NH LNG BILIRUBIN HUYT THANH

1. Khi nim v Bilirubin:

Bilirubin cn gi l sc t mt, l sn phm thoi ho ca nhn porphyrin trong Hem ca hng
cu.
i sng trung bnh ca hng cu l 120 ngy. Khi hng cu cht hemoglobin c gii phng.
Hemoglobin tip tc thoi ho to thnh bilirubin t do.
Mi ngy c khong 50mmol bilirubin t do c to thnh. Bilirubin ny c c im l c,
khng ho tan trong nc nn khng c mt trong nc tiu. Bilirubin t do (cn gi l bilirubin
gin tip), vo mu, nh albumin vn chuyn ti gan. Ti gan bilirubin t do kt hp vi acid
glucoronic to thnh bilirubin lin hp (cn gi l bilirubin trc tip).
Bilirubin lin hp c c im l khng c, tan trong nc nn c mt trong nc tiu
Gan l c quan duy nht c kh nng chuyn bilirubin t do thnh bilirubin lin hp.
Bilirubin lin hp to ra s c d tr ti mt do kch thch ca thc n s xung rut v
tip tc thoi ho to thnh cc sn phm urobilin v stercobilin, c mu. Phn ln chng c
o thi qua phn. Mt phn nh bilirubin lin hp c thu phn bi vi khun rut to thnh
bilirubin t do qua chu trnh Gan-Rut ti hp thu tr v gan. S t c o thi qua nc
tiu di dng bilirubin lin hp.
Bilirubin ton phn trong mu gm bilirubin t do (bilirubin gin tip) v bilirubin lin hp
(bilirubin trc tip)
2. Nguyn tc k thut:
Trong ho sinh lm sng, thng xt nghim Bilirubin trc tip v Bilirubin ton phn sau
tnh ra bilirubin gin tip.
Nguyn tc k thut nh lng bilirubin trc tip: Bilirubin trc tip trong huyt thanh c kh
nng tham gia phn ng trc tip vi axit Sulphanilic v axit Nitr (trong thuc th Diazo) to
thnh phc hp azo mu hng tm.
Bilirubin ton phn trong huyt thanh cng c phn ng to phc hp azo mu hng tm nh
bilirubin trc tip nhng cn c mt ca cetrimid.
Phc hp mu hng tm t l thun vi nng Bilirubin trong huyt thanh c xc nh
bc sng 546nm.
3. Nhn nh kt qu:
Bnh thng: Bilirubin ton phn < 17 mmol/l
Bilirubin trc tip < 4,3 mmol/l.
Bilirubin gin tip 12,7 mmol/l
S tng bilirubin trong mu gy hin tng vng da. Vng da c chia thnh 3 loi chnh nh
sau:
3.1.Vng da do nguyn nhn trc gan: Nguyn nhn: cc bnh l lm tng ph hu hng cu,
c th c 2 loi sau: -Vng da tan huyt do di truyn gp trong cc bnh v mu nh bnh
thalassemi, bnh do hng cu thiu enzym G6PD. -Vng da tan huyt mc phi nh sinh trng
st nhim k rt, do truyn nhm nhm mu hoc do bt ng nhm mu gia m v con.... Kt
qu xt nghim: bilirubin ton phn tng ch yu tng bilirubin t do, bilirubin lin hp bnh
thng.
3.2. Vng da do nguyn nhn ti gan: Nguyn nhn: cc bnh l ti gan nh vim gan, abces
gan, x gan, ung th gan... Kt qu xt nghim: bilirubin ton phn tng trong tng c
bilirubin t do v bilirubin lin hp.

3.3. Vng da do nguyn nhn sau gan: Nguyn nhn l tc nghn ng dn mt nh trong
bnh si ti mt, u ti mt, vim ti mt, u u tu... Kt qu xt nghim bilirubin ton phn
tng cao m ch yu l tng bilirubin lin hp cn bilirubin t do bnh thng.

XT NGHIM BILIRUBIN P DNG TRONG LM SNG

NHC LI SINH L
Bilirubin (sc t mt) c ngun gc ch yu t qu trnh ph hy cc hng cu v mt mc t
hn t cc cytochrom v myoglobin.
Qu trnh ph hy cc hng cu c th c tin hnh:
1. Trong ty xng (qu trnh to hng cu khng hiu qu).
2. Trong mu tun hon (c cc t khng th).
3. Trong lch (sau mt thi gian sng trung bnh 120 ngy).
Nh vy, Hb c gii phng t cc hng cu s to ra Hem, st v globin:
1. Globin s c haptoglobin gi li.
2. St c gn vi tranferrin.
3. Hem c chuyn ha thnh biliverdin nh enzym oxydase ca microsom, sau thnh
bilirubin di tc dng ca biliverdin reductase.
Nh vy, bilirubin khng lin hp (bilirubin t do) c to thnh:
- Chim 80% bilirubin ton phn lu hnh trong mu.
- Gn vi albumin v v vy khng c lc qua thn.
- Thng c gi l bilirubin gin tip do cn s dng phng php gin tip nh lng
loi bilirubin ny (phi hp thm mt c cht lm gia tc phn ng o mu).
gan, bilirubin khng lin hp (gin tip) chu mt qu trnh chuyn ha gm 3 giai on :
1. c cc t bo gan gi li.
2. Lin hp vi glucuronid nh enzym glucuronyltransferare cu gan.
3. Bi xut vo trong ng mt.
Bilirubin lin hp c to thnh:
- Chim 20% bilirubin ton phn trong mu.
- Khng gn vi protein, tan trong nc, v vy c lc qua thn.
- Thng c gi l bilirubin trc tip do nh lng loi bilirubin ny c thc hin mt
cch trc tip khng cn phi phi hp thm cht gy gia tc phn ng.
20% bilirubin lin hp c ti hp thu vo mu, trong khi 80% c thi tr trong ng mt
ri vo rut. rut, di tc ng ca cc vi khun, bilirubin c chuyn ha thnh
Urobilinogen ri thnh stercobilin v c thi tr trong phn.
Ch mt phn nh urobilinogen c ng tiu ha s c ti hp thu vo h thng tnh mch
ca thc hin chu trnh gan-rut, v c th c thy trong nc tiu (urobilinogen khng
gn vi protein).
C th tm tt cc qu trnh trn nh sau:

Bilirubin t do (hay khng lin hp)

Bilirubin lin hp
Ngun gc
Ph hy cc hng cu, cytocrome hay myoglobin Gan hay ng mt
Gn vi protein
+++
Thi qua nc tiu
+++
ng ngha
bilirubin gin tip
bilirubin trc tip
Ghi ch:
1. Bnh thng, kt qu xt nghim ch tr li nng bilirubin ton phn. Nu c tnh trng
tng bilirubin ton phn, phng xt nghim s tin hnh thm cc test xc nh nng
bilirubin trc tip v gin tip.
2. Trong cc bnh l ca t bo gan (vd: x gan, vim gan), qu trnh lin hp bilirubin t b tc
ng. Ngc li, qu trnh bi xut bilirubin lin hp rt d b bin i, iu ct ngha ti sao
c tng lng bilirubin lin hp (hay trc tip) trong cc bnh l k trn.
3. Khi lng bilirubin lin hp tng cao trong cc t bo gan, s gy tro ngc bilirubin lin
hp vo dng tun hon v gy vng da.
MC CH V CH NH XT NGHIM

 chn on cc bnh l gan mt v tnh trng tan mu.

CCH LY BNH PHM
- Xt nghim c thc hin trn huyt thanh. Yu cu bnh nhn nhn n t 4-8h trc khi ly
mu lm xt nghim song bnh nhn c th ung nc bnh thng.
- Cn phi tch nhanh hng cu, do tan mu c th lm sai kt qu xt nghim.
- Trnh bnh phm tip xc vi nh sng.
GI TR BNH THNG
1. Bilirubin ton phn:
- Tr s sinh: < 10mg/dL hay < 17mol/L.
- 1 thng: 0,3 1,2 mg/dL hay 5,1 20,5 mol/L.
- Ngi ln: 0,2 1,0 mg/dL hay 3,4 17,1 mol/L.
2. Bilirubin trc tip: 0,0 0,4 mg/dL hay 0 - 7 mol/L.
3. Bilirubin gin tip: 0,1 1 mg/dL hay 1- 17 mol/L.
4. T l bilirubin trc tip/bilirubin ton phn: < 20%.
TNG NNG BILIRUBIN TON PHN
Cc nguyn nhn chnh thng gp l:
1. C thai.
2. Tr s sinh v tr non.
3. Hot ng th lc mnh.
4. Cc nguyn nhn gy tng bilirubin t do.
5. Cc nguyn nhn gy tng bilirubin lin hp.
TNG NNG BILIRUBIN T DO (BILIRUBIN GIN TIP)
Cc nguyn nhn chnh thng gp l:
1. Tng ph hy hng cu qu mc:
- Tan mu (vd: st rt, bnh do khng tng hp Rh ca tr s sinh).
- To hng cu khng hiu qu (vd: bnh thiu mu Biermer).
- Cng lch.
2. Suy gim qu trnh lin hp bilirubin ti gan:
- Bnh Gilbert.
- Suy tim mt b.
- Thuc rifampicin
- Khim khuyt qu trnh lin hp bilirubin.
- Tr s sinh v tr non.
- Hi chng Crigler Najjar (do thiu ht enzym glucuronyl transferase).
TNG NNG BILIRUBIN LIN HP (BILIRUBIN TRC TIP)
Cc nguyn nhn chnh thng gp l:
1. Bnh l t bo gan:
- Vim gan do virus.
- Vim gan do thuc:
+ INH.
+ Rifampicin.
+ Halothan.

+ Methyldopa.
+ Chlopromazin.
+ Paracetamol.
+ Salicylat.
- Vim gan nhim c:
+ CCL4 (tetraclorua carbon).
+ Amanit phalloide.
- Suy tim mt b.
- X gan.
- Xm nhim gan (bnh l khi u, nhim thit huyt t, bnh Wilson).
- Thiu alpha1- Antitrypsin.
- Bnh Dubin Jonson (ri lon bi xut bilirubin).
2. Tc mt
- Trong gan:
+ Si mt.
+ Vim ty cp hau mn tnh.
+ Nang gi ty trong vim ty cp.
+ Ung th ty.
+ Ung th bng Vater.
+ Ung th biu m (carcinoma) ng mt.
+ Cht hp hay tc ng mt.
CC YU T GP PHN LM THAY I KT QU XT NGHIM
- xy ra tnh trng v hng cu ca mu bnh phm c th lm thay i kt qu xt nghim.
- mu bnh phm tip xc trc tip vi nh sng mt tri hay nh sng nhn to > 1h s lm
gim nng bilirubin ca bnh phm.
- Tip xc trong vng 24h trc vi thuc cn quang s lm thay i kt qu xt nghim.
- Cc thuc c th lm tng nng bilirubin ton phn: Adrenalin, allopurinol, cc steroid lm
tng chuyn ha, thuc iu tr st rt, vitamin C, azathiopin, chlorpropamid, thuc cng
cholin, codein, dextran, thuc li tiu, isoproterenol, levodopa, thuc c ch MAO, mepridin,
methyldopa, methotrexat, morphin, thuc nga thai ung, phenazopyridin, phenothiazin,
quinidin, rifapin, streptomycin, theophyllin, tyrosin, vitamin A.
- Cc thuc c th lm gim nng bilirubin ton phn: barbituric, caffein, citrat,
corticosteroid, ethanol, penicillin, protein, salicylat, sulfonamid, urea.
- nh lng bilirubin niu c th cho kt qu dng tnh gi bnh nhn dng phenothiazin,
tri li xt nghim ny c th cho kt qu m tnh gi khi c nitrit trong nc tiu hay bnh nhn
ang dng vitamin C.
LI CH CA XT NGHIM NH LNG BILIRUBIN MU
Xt nghim hu ch:
1. trong thm d cc thiu mu (khi phi hp ng thi vi nh lng haptoglobin, cc LDH,
hng cu li v st huyt thanh) xc nh cn nguyn l do tan mu hay do to hng cu
khng hiu qu.
2. nh gi mc nng ca mt bnh l gan.
3. Trong thm d cc tc mt ( trong v ngoi gan).

4. Theo di bnh nhn c iu tr bng thuc khng lao (INH, rifampicin).

5. Gia tng n l v tng lc bilirubin khng lin hp (gin tip) xong khng c bng chng
tan mu c gp 2-5% dn s (bnh Gilbert).
LI CH CA XT NGHIM NH LNG BILIRUBIN TRONG NC TIU
Bilirubin c tm thy trong nc tiu l bilirubin lin hp (trc tip), loi khng gn vi
protein. V vy, XT NGHIM cho php chn on phn bit:
1. Cc vng da do tan mu: khng thy c bilirubin trong nc tiu.
2. Cc vng da do bnh gan hay do mt: c bilirubin trong nc tiu.
CC HNG DN THC HNH LM SNG DA TRN Y HC BNG CHNG
- Cc nh gi ban u i vi tnh trng tng bilirubin mu l cn xc nh xem tnh trng tng
bilirubin huyt thanh thuc loi tng thanh phn trc tip (tng bilirubin lin hp) hay tng
thnh phn gin tip (tng bilirubin khng lin hp).
- Cc bnh nhn ngi ln khng c triu chng lm sng b tng bilirubin mu loi khng lin
hp, n c mc nh cn c tm kim cc chn on: hi chng Gilbert b tan mu v
tng bilirubin do thuc.
- Nu c tng bilirubin mu loi lin hp, cn nh gi c tnh trng tng phosphatase kim i
km hay khng loi tr tnh trng tc mt.