{"id":6629,"date":"2020-05-04T18:06:31","date_gmt":"2020-05-04T17:06:31","guid":{"rendered":"https:\/\/euromedic.rs\/pregledi\/gastroenterologija-virusne-bolesti-jetre-copy\/"},"modified":"2020-10-07T10:53:02","modified_gmt":"2020-10-07T09:53:02","slug":"gastroenterologija-zutica","status":"publish","type":"post","link":"https:\/\/euromedic.rs\/pregledi\/specijalisticki-pregledi\/gastroenterologija\/gastroenterologija-zutica\/","title":{"rendered":"Gastroenterologija – \u017dutica"},"content":{"rendered":"

\u017dutica (lat. Icterus, eng. Jaundice)<\/strong><\/p>\n

\u017dutica predstavlja prebojenost beonja\u010da i ko\u017ee \u017eutom bojom.Porast vrednosti bilirubina u krvi je uzrok\u00a0\u017eutice. Prvo se mo\u017ee primetiti na beonja\u010dama jer sloj tkiva koje prekriva beonja\u010de poseduje protein retikulin za\u00a0koji se bilirubin lako i brzo vezuje i potom se mo\u017ee primetiti i prebojenost ko\u017ee.Istovremeno se javlja tamnije\u00a0prebojen urin, u zavisnosti od uzroka, i svetlija stolica od svetlo \u017eute do belo-sive boje.\u00a0Normalne vrednosti bilirubina su do 20,5 \u03bcM\/l. Do 35 \u03bcM\/l smatra se da je u pitanju sindrom subikterus, a\u00a0preko 35 \u03bcM \/ l ikterus. Klini\u010dki se ikterus manifestuje kad se vrednosti u plazmi uve\u0107aju 3 do 4 puta (50 do\u00a070 \u03bcM\/l).<\/p>\n

Patofiziolo\u0161ki aspekt:<\/strong> pove\u0107ano optere\u0107enje jetrine \u0107elije bilirubinom, poreme\u0107aj u preuzimanju i transportu\u00a0bilirubina unutar jetrine \u0107elije, defekt u konjugaciji bilirubina,defekt u izlu\u010divanju bilirubina na nivou\u00a0kanalikularne membrane ili opstrukcija \u017eu\u010dnih puteva.<\/p>\n

Mo\u017ee se podeliti na:<\/strong>
\n1) prehepati\u010dku (hemoliti\u010dku)
\n1) hepatocelularnu
\n2) opstruktivnu (hirur\u0161ku).<\/p>\n

Mo\u017ee se definisati kao poreme\u0107aj lu\u010denja \u017eu\u010di od sinusoidalne membrane jetrine \u0107elije do ampule Vateri ( mesto\u00a0izlivanja \u017eu\u010di u duodenum).<\/p>\n

Klasifikacija:<\/strong>
\n1) izolovani porast bilirubina (hemoliza i uro\u0111eni poreme\u0107aji )
\n2) holestatski ikterus sa dilatacijom ili bez dilatacije \u017eu\u010dnih puteva koja opet mo\u017ee biti akutna i hroni\u010dna
\n3) hapatocelularni ikterus.<\/p>\n

1) Hemoliti\u010dka nastaje zbog skra\u0107enog veka eritrocita i mo\u017ee biti nasledna (poreme\u0107aj membrane\u00a0eritirocita,hemoglobinopatije,deficit eritrocitnih enzima) kao i ste\u010dena hemoliza (imuna i neimuna).\u00a0Kod hemoliti\u010dkog ikterusa bilirubin je obi\u010dno blago povi\u0161en do 50 \u03bcM \/ l i nekonjugovani \u010dini 90 % ukupnog\u00a0bilirubina.Pove\u0107an je urobilinogen u urinu (nema bilirubina) a pove\u0107an je i urobilinogen u fecesu.<\/p>\n

Direktni pokazatelj je skra\u0107en vek eritrocita a indirektni pove\u0107an broj retikulocita, povi\u0161ena aktivnost izoenzima\u00a0LDH1, smanjena koncentracija haptoglobina, bilirubinski kalklusi u \u017eu\u010dnoj kesi i uve\u0107anje slezine –\u00a0splenomegalija.\u00a0Primarna tzv. \u0161antna hiperbilirubinemija nastaje zbog pove\u0107ane produkcije bilirubina u ko\u0161tanoj sr\u017ei zbog\u00a0neefektivne eritocitne sinteze.\u00a0Familijarne hiperbilirubinemije su Gibertov sindrom kao naj\u010de\u0161\u0107i i zahvata 2 do 5 %populacije a \u017eutica je blaga\u00a0od 17 do 85 \u03bcM \/ l , povremena i to naj\u010de\u0161\u0107e se javi u infekcijama gladovanju i u fizi\u010dkom naporu, a testovi\u00a0funkcije jetre su normalni kao i histologija jetre.\u00a0Dijagnoza se mo\u017ee postaviti testom gladovanja kada vrednosti bilirubina rastu i fenobarbitonskim testom kada
\npri uzimanju ovog leka vrednosti bilirubina padaju.\u00a0Pacijenti sa ovim sindromom ne treba da uzimaju paracetamol, jer se lek metaboli\u0161e preko glukuronil transferaze.<\/p>\n

Redje se mo\u017ee raditi vrlo retko o Crigler – Najjarovom sindromu sa dva tipa i to tip 1 gde postoji potpuni\u00a0deficit enzima za konjugaciju bilirubina a koji se nasledjuje autozomno recesivno i ima lo\u0161u prognozu, i tip 2\u00a0gde je smanjena aktivnost enzima \u00a0odgovornih za konjugaciju bilirubina za 10 % i gde se le\u010denje uspe\u0161no\u00a0sprovodi lekom fenobarbitonom i fototerapijom.\u00a0Retko se mo\u017ee javiti i Dubin Johnsonov sindrom koji se lako dijagnostifikuje brom sulfo ftaleinskim testom\u00a0ima dobru prognozu i \u0107e\u0161\u0107e se manifestuje u trudno\u0107i i kod uzimanja oralnih kontraceptiva.\u00a0Rotorov sindrom je familijarna konjugovana hiperebilirubinemija isto se nasledjuje autozomno recesivno, a radi\u00a0se o poreme\u0107aju organskih anjona u hepatocitu a histolo\u0161ki jetra izgleda normalno.<\/p>\n

2) Holestaza se mo\u017ee podeliti na intrahepati\u010dnu, hepatocelularnu i kanalikularnu ekstrahepati\u010dnu\u00a0Intrahepati\u010dna hepatocelularna mo\u017ee biti izazvana virusima, alkoholom, lekovima, androgenim\u00a0hormonima,kanalikularna primarnom bilijarnom \u00a0cirozom, autoimunom holangiopatijom, bilijarnom\u00a0atrezijom, lekovima i trudno\u0107om.\u00a0Retki uzroci intrahepati\u010dke holestaze su: septiikemija, benigna rekurentna holestaza, Morbus Caroli, M Hodgin,\u00a0amiloidoza i kriptogena (nepoznatog uzroka) makronodularna ciroza.<\/p>\n

Intra i ekstrahepati\u010dna holestaza se javlja kod primarnog skleroziraju\u0107eg holangitisa \u2013 PSC, sarkoidoze i
\nhistiocitoze X.\u00a0Ekstrahepati\u010dka holestaza kod koje se javlja visok konjugovani bilirubin, pove\u0107an bilirubin u urinu, a\u00a0urobilinogen u urinu i fecesu su odsutni ili se povremeno jave u zavisnosti od opstrukcije koja mo\u017ee biti\u00a0intermitentna a naj\u010de\u0161\u0107i uzok su joj : holedoholitijaza, Ca glave pankreasa, Ca papile Vateri, holangio karcinom, benigne strikture \u017eu\u010dnih puteva, i parazitoza naj\u010de\u0161\u0107e akutna.\u00a0U serumu je nejasan porast ALP GGT holesterola i fosfolipida konjugovanih \u017eu\u010dnih kiselina, lipoproteina\u00a0X (LDL frakcija), a transaminaze ALT i AST obi\u010dno budu ispod 100 IU\/l.\u00a0Pacijent ima svrab ko\u017ee, masnu stolicu (steatoreju) ,deficit vitamina A, D, E, K, ksantome, ulkusnu bolest.\u00a0Dijagnoza se postavlja na osnovu ultrazvu\u010dnog pregleda prvo, te ako se vide pro\u0161ireni \u017eu\u010dni putevi dalje se\u00a0mo\u017ee raditi ERCP, MRCP, PTC a ako nisu dijagnoza se postavlja na osnovu klini\u010dke slike, imunolo\u0161kih analiza,\u00a0biopsijom jetre, prednizolonskim testom i virusolo\u0161kim analizama.\u00a0PBC primarna bilijarna ciroza se javlja \u0107e\u0161\u0107e kod \u017eena i u 95% su pozitivna antimitohondrijalna antitela – AMA\u00a0\/AMA- M 9 najranije se detektuju a AMA – M4 i M8 uvek uz AMA -M 2 znak su lo\u0161ije pognoze i br\u017ee\u00a0evolucije.\u00a0ANA kod pacijenata sa negativnim AMA -M 2 su zna\u010dajna.\u00a0Dijagnoza se postavlja biopsijom jetre ali postoji jo\u0161 specifi\u0107nih imunolo\u0161kh markera koji odredjuju da li treba\u00a0raditi biopsiju jetre ( kod AMA nagativnih pacijenata a sa sumnjom na PBC).\u00a0Obratiti pa\u017enju na autoimuni holangitis kod pacijenata sa negativim AMA jer se javljaju visoke vrednosti\u00a0ANA(visok titar).<\/p>\n

Kada se koristi prednizolonski test?<\/strong><\/p>\n

Kod hepatitisa A holestatskog tipa ako su hepatitisi B i C isklju\u010deni, i alkoholnog holestatskog hepatitisa.\u00a0U dozi 30 mg u toku 5 dana trebalo bi da se smanji vrednost bilirubina za 40%.<\/p>\n

Terapija se sprovodi isklju\u010divo pod nadzorom lekara i to ursodeoksiholnom kiselinom 15 do 25 mg po kg telesne\u00a0te\u017eine u tri dnevne doze i to je lek izbora za PBC, PSC, autoimunu holangiopatiju i lekovima uzrokovanu\u00a0holestazu, a kao pomo\u0107no sredstvo od koristi je kod M.Caroli i benignih striktura \u017eu\u010dnih puteva.\u00a0Svrab se le\u010di holestiraminom koji vezuje \u017eu\u010dne soli u crevima, i za 4 do 5 dana daje pobolj\u0161anje a daje se 12
\ngrama na dan.<\/p>\n

3) Hepatocelularni ikterus kada je hiperebilirubinemija konjugovanog tipa mo\u017ee biti u akutnim i hroni\u010dnim
\nbolestima.\u00a0Akutni hepatocelularni ikterus javlja se kod : akutnih hepatitisa (bilirubin u urinu se pojavljuje pre \u017eutice i\u00a0urobilinogena u urinu ali i uz visoke vrednosti ALT i AST), kod ne\u017eeljenih dejstva lekova ili toksi\u010dnih\u00a0supstanci, ishemijskog hepatitisa, akutnog Budd Chiary sindroma , M.Wilson, akutne masne jetre u trudno\u0107i,\u00a0masivne maligne infiltracje jetre.\u00a0Hroni\u010dni hepatocelularni ikterus se javlja kod hroni\u010dnog hepatitisa i ciroze, autoimunog hepatitisa,\u00a0medikamentoznog hepatitisa, metaboli\u010dkih bolesti, M.Wilson.<\/p>\n

Zaka\u017eite Va\u0161 specijalisti\u010dki pregled gastroentetologa.\u00a0<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

\u017dutica (lat. Icterus, eng. Jaundice) \u017dutica predstavlja prebojenost beonja\u010da i ko\u017ee \u017eutom bojom.Porast vrednosti bilirubina…<\/p>\n","protected":false},"author":1,"featured_media":6631,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[479],"tags":[78,443],"class_list":["post-6629","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-gastroenterologija","tag-gastroenetrologija","tag-zutica"],"yoast_head":"\nGastroenterologija - \u017dutica - Dijagnostika i le\u010denje u Euromediku<\/title>\n<meta name=\"description\" content=\"\u017dutica predstavlja prebojenost beonja\u010da i ko\u017ee \u017eutom bojom.Porast vrednosti bilirubina u krvi je uzrok\u00a0\u017eutice. 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