肝疾病(外科学第八版课件).pptx

肝疾病肝疾病 Liver DiseaseLiver Disease 学习要求学习要求 1.1. 掌握掌握肝脓肿、肝癌的诊断和外肝脓肿、肝癌的诊断和外 科治疗。科治疗。 2.2. 熟悉肝脏的解剖特点，细菌性熟悉肝脏的解剖特点，细菌性 和阿米巴性肝脓肿的鉴别诊和阿米巴性肝脓肿的鉴别诊 断。断。 3.3. 了解肝了解肝囊肿、肝海绵状血管瘤囊肿、肝海绵状血管瘤 的诊断和治疗的诊断和治疗原则。原则。 Surgical Anatomy 标志标志 血管血管 肝门肝门 分分叶叶 分段分段 Liver functions 1.1. 分泌胆汁分泌胆汁 2.2. 代谢功能代谢功能 3.3. 凝血功能凝血功能 4.4. 解毒作用解毒作用 5.5. 吞噬和免疫作用吞噬和免疫作用 再生能力再生能力强强 缺氧耐受力差缺氧耐受力差 肝脓肿肝脓肿 Liver abscessLiver abscess Pathogenesis 1.1. Biliary Biliary tree tree 2.2. Hepatic artery Hepatic artery 3.3. Portal Portal vein vein 4.4. Nearby infection Nearby infection 5.5. Trauma Trauma Clinical Features 1.1. Fever and chillsFever and chills 2.2. RUQ RUQ pain and pain and tenderness tenderness 3.3. Hepatomegaly Hepatomegaly 4.4. JaundiceJaundice 5.5. Nonspecific Nonspecific symptoms symptoms Lab. and imaging 1.1. WBCWBC, ,HGB HGB 2.2. Ultrasound, X-Ray, CTUltrasound, X-Ray, CT 3.3. FNAFNA Differential diagnosis 1.1. Amebic live abscessAmebic live abscess 2.2. Intrahepatic biliary infectionsIntrahepatic biliary infections 3.3. Cancer of the liverCancer of the liver 4.4. Subphrenic abscessSubphrenic abscess Treatment 1.1. Supportive therapySupportive therapy Energy and nutritionEnergy and nutrition Electrodes and fluidElectrodes and fluid Blood transfusionBlood transfusion Treatment 2.2. AntibioticsAntibiotics A ASAP, if suspectedSAP, if suspected Broad spectrum, covering GBroad spectrum, covering G + + ,G,G - - and and anaerobesanaerobes Duration Duration 2w, recommended2w, recommended Treatment 3.3. DrainageDrainage PercutaneousPercutaneous LaparotomyLaparotomy L Laparoscopicaparoscopic Treatment 4.4. HepatectomyHepatectomy 5.5. Traditional medicineTraditional medicine 肝囊肿(Cyst of the liver) 肝囊肿 非寄生虫性 先天性 单发性 多发性 创伤性 炎症性 肿瘤性 寄生虫性 肝棘球坳病 Echinococcosis of the liver 肝包虫病肝包虫病 （HydatidHydatid ） 1.1.牧区生活史牧区生活史 2.2.血清学血清学+ +影像学影像学 3.3.手手术治疗为首术治疗为首选选 先天性肝囊肿 congenital cyst of liver p 囊壁内层附有内皮细胞 p 液体清亮，多不含胆汁 p 大而有症状者需适当治疗 p 腹腔镜下开窗术首选，也可选穿 刺。 p 注意：与胆道相通囊肿、病变广泛 的多囊肝。 肝肿瘤 （tumor of liver) 肝肿瘤 良性 恶性 原发性 继发性 肝海绵状血管瘤 Cavernous hemangioma of liver p 生长缓慢 p 较小时多无症状 p CT、MRI不难诊断 p 小而无症状者随访 p 手术切除适应证 小 结 pp 肝脏解剖肝脏解剖 pp 肝脓肿肝脓肿 临床表现临床表现 与阿米巴性肝脓肿的鉴别与阿米巴性肝脓肿的鉴别 治疗方法治疗方法 原发性肝癌原发性肝癌 Primary Primary l liver canceriver cancer Epidemiology pp CommonCommon pp 600000 new cases found annually600000 new cases found annually pp 55% occurs in China55% occurs in China pp M MF F pp High incidence in the age of High incidence in the age of 40s, and a tendency to develop 40s, and a tendency to develop earlierearlier Etiology pp Liver cirrhosisLiver cirrhosis pp HBVHBV pp AflatoxinAflatoxin (AFT) (AFT) pp Chronic alcohol abuse Chronic alcohol abuse pp HCVHCV pp Chemicals: Chemicals: nitrites, hydrocarbonsnitrites, hydrocarbons, , solvents, pesticides, solvents, pesticides, vinyl vinyl chloridechloride Pathology pp CategoriesCategories Cancer cellsCancer cells MorphologyMorphology SizeSize pp MetastasisMetastasis intrahepaticintrahepatic extrahepaticextrahepatic Clinical Presentation pp RUQ abdominal painRUQ abdominal pain pp Nonspecific symptomsNonspecific symptoms pp HepatomegalyHepatomegaly Diagnosis pp HCC markersHCC markers Alpha fetoprotein (AFP)Alpha fetoprotein (AFP) Serum Serum enzymologyenzymology pp ImagingImaging UltrasoundUltrasound CT and MRICT and MRI DSADSA X-raysX-rays pp FNA and BiopsyFNA and Biopsy Diagnosis Treatment pp 治疗原则治疗原则 早期诊断，早期治疗，根据不同病早期诊断，早期治疗，根据不同病 进行综合治疗进行综合治疗 pp 首选方法首选方法 早期施行手术治疗早期施行手术治疗 Treatment 1.1. Surgical treatmentSurgical treatment ResectableResectable Hepatectomy (Radical, Palliative)Hepatectomy (Radical, Palliative) UnresectableUnresectable (op. in procedure) (op. in procedure) HALHAL, EI, RFA, MWA, , EI, RFA, MWA, CryotherapyCryotherapy RecurrentRecurrent PerforatedPerforated Liver transplantationLiver transplantation 肝切除术 Treatment 2.2. Percutaneous ablationPercutaneous ablation RFARFA MWAMWA PEIPEI Treatment 3.3. ChemotherapyChemotherapy TACE: TACE: recoreco- - General chemotherapy: not General chemotherapy: not recoreco- - Sustained Sustained release release agentagent 4.4. RadiotherapyRadiotherapy 5.5. Biological treatment Biological