肝脏疾病本科彭涛2011

个人简历,Liver Diseases肝脏疾病,彭涛 教授、博士生导师外科学教研室（肝胆血管外科） 2011-10-17,3,肝脏解剖生理概要-1,The liver lies in the right upper quadrant of the abdomen, under the protective rib cage, beneath the diaphragm and connected to the digestive tract by means of portal vein and biliary drainage system.Gilssons capsule, bare area, falciform lig., coronary lig., gastrohepatic lig., hepatoduodenal lig. foramen,1: liver; 2: rib cage; 3: spine; 4: pelvis,4,肝脏解剖生理概要-2,The American (lobar) system & the French (Couinaud segmental) system.,5,肝脏解剖生理概要-3,6,肝脏解剖生理概要4-Cauinaud segmentation,7,肝脏解剖生理概要5-left hepatic vein,8,肝脏解剖生理概要6-middle hepatic vein,9,肝脏解剖生理概要7- hepatic vein & portal vein,10,肝脏解剖生理概要8- portal vein plane,11,“精准肝脏外科时代”保留肝中静脉的左半肝切除,12,“精准肝脏外科时代” 保留肝右静脉的右后叶肝切除,13,双重血供 (75% via 门静脉 & 25% via 肝动脉)肝动脉携氧量占50门静脉两端是毛细血管网，无功能性静脉瓣门静脉不可结扎或切断肝脏血流阻断时间15-20min,肝脏解剖生理概要9- circulation,14,代谢: bilirubin, carbohydrate, lipid, protein, vitamin, drugs & toxins, ect.凝血免疫调节再生肝功能指标: 转氨酶: aspartate phosphatase (AST), alanine phosphatase (ALT)Alkaline phosphatases (ALP), Gamma-glutamyl transpeptidase (GGT)AlbuminChild-Pugh肝功能分级; ICG15min渚留率,肝脏解剖生理概要10,Hepatic Trauma 肝脏创伤,16,Hepatic trauma -Classification and characteristics,Penetrating hepatic-traumaDue to bullets, knives etc.less devitalization of liver parenchymaDue to missiles shatter massive parenchymaBlunt hepatic-traumaDue to direct blow to the upper abdomen or lower right rib cage, or sudden deceleration.Might be explosive bursting wounds or linear lacerations.The posterior superior segment (SVII) is mostly vulnerable due to its location.Damage to the hepatic veins is catastrophic and difficult to expose during exploration. (The staging system is for your reference only, but pls pay attention to by what index it score the damage),17,Symptoms and signs: hypovolemic shock (hypotension, decreased urinary output, low central venous pressure)Laboratory findings: no detectable anemia due to rapid blood loss. Leukocytosis is common.Imaging findings: CT scan is prior to other techniques among stable patients. It can estimate the type and severity of the injury, which is useful information for both triaging and exploration if necessary.Sonography is of limited value; angiography is diagnostic in hemobilia.,Hepatic trauma -Clinical findings,18,Hepatic trauma -imaging findings,19,Hepatic trauma -imaging findings,Hydrops at the adrenal gland,Hepatic trauma with fracture of left rib,20,Hepatic trauma -Treatment,In a review of 1842 liver injuries from 1975-1999 in USA, nonsurgical therapy is used in more than 80% of blunt injuries.The death rates from both blunt and penetrating trauma have improved significantly due to decreased death from hemorrhage.,J. David Richardson, et al. ANNALS OF SURGERY, 232( 3): 324330.,21,Hepatic trauma -Treatment Nonoperative management for patients with stable minor injuries,Contained subcapsular or intrahepatic hemotoma, Unilobar fractureAbsence of devitalized liverMinimal intraperitoneal bloodAbsence of injuries to other intra-abdominal organs. However, repeatedly examination should be carried out during the observation !,22,Hepatic trauma -Treatment Exploration for patients with active bleeding or a major injury,Techniques include: Drainage for wounds without hemorrhageSuture for bleeding vesselsMassive injury may require lobectomySubcapsular hematomas requie thoroughly exploration.Temporary clamping the inflow vessels in the hilum helps ligating bleeding vessels. Ancillary bypass, packing or absorbable gauze mesh may help in some cases.,23,Hepatic trauma -Complications and prognosis,RebleedingSubhepatic sepsisHemobilia-selective angiography and embolizationStress ulcersH2 receptor antagonists (Cimetidine, Ranitidine, Omeprazole etc)Mortalitydepends on the type and severity of injuries.,24,肝脏肿瘤的分类,良性肿瘤：肝腺瘤，肝血管瘤 原发性肝癌 恶性肿瘤： 继发性肝癌：转移性,原发性肝癌Primary Liver Cancer,26,原发性肝癌,组织病理类型:肝细胞癌： Hepatocellular carcinoma (HCC);约91%；胆管细胞癌： Cholangiocellular carcinoma (cholangiocarcinoma); 7%8%；混合细胞型肝癌： Mixed form (hepatocholangioma). 1%2%,27,ICC即使病理诊断也要小心谨慎,28,背景 （肝细胞癌，HCC）,西方国家少见, 有地理分布特异性（非洲撒哈拉地区、东南亚、日本、太平洋岛国、希腊、意大利） 曾被认为是“癌肿之王”、“不可治愈”临床症状隐匿，发现多已晚期近2030年诊断和治疗获得了长足的进步根治性切除后5-yrs存活率 3070%.,29,背景 - 病因一览,病毒性肝炎 (HBV, HCV et al.)真菌毒素 (黄曲霉毒素aflatoxins)饮水污染 (池塘或沟渠水)Other causes遗传酗酒Alpha-antitrypsin deficiencyHemochromatosisPlant alkaloidOral contraceptivesAndrogensVinyl chlorideTrace elements(?): Cu, Zn, Ni and CoParasites: Clonorchis sinensis,30,20/100,00040/100,000,NPCHCC,31,中国是HCC高发地区,Global Cancer Statistics, 2002. CA Cancer J Clin 2005;55;74-108,2002年全球新发病例 626,162中国病例占55，约344,000男性高发于女性 (2.67 : 1),32,背景 中国流行病学,1995 全国肿瘤普查死亡率 20.40/100,00029.07/100 000 (男) 11.23/100,000 (女)自1990s, NO 2. 肿瘤杀手 (城市次于肺癌，农村次于胃癌；15 34岁国人的头号肿瘤杀手）中国的地理分布特征：东南沿海高发区( 30/100 000) ：广西扶绥、江苏启东、浙江舟山、福建同安,33,病理要点,大体病理类型:巨块型: 结节型:弥漫型: 分化程度: 包膜：（+）预后相对较好 (Fibrolamellar hepatoma)转移:淋巴结 (hilar, celiac)肺腹腔门静脉、肝静脉,34,早期肝癌和小肝癌的概念,早期肝癌是指没有临床症状和体征的肝癌，亦即亚临床肝癌。 微小肝癌：2.0cm小肝癌：2.0cm 5.0cm大肝癌：5.0cm 10.0cm,35,Hepatocellular carcinoma, liver, gross,A 2.0 cm HCC arising in a chronic viral hepatitis; the tumor, which had a predominant acinar architecture, produced abundant bile.,36,Hepatocellular carcinoma, liver, gross,Nodule of hepatocellular carcinoma in chronic hepatitis C; the pale golden yellow color is common.,37,Hepatocellular carcinoma, liver, gross,The neoplasm is large and bulky and has a greenish cast because it contains bile. To the right of the main mass are smaller satellite nodules.,The satellite nodules of this hepatocellular carcinoma represent either intrahepatic spread of the tumor or multicentric origin of the tumor.,38,Hepatocellular carcinoma, liver, gross,Another hepatocellular carcinoma with a greenish yellow hue. Such masses may also focally obstruct the biliary tract and lead to an elevated alkaline phosphatase,39,HCC (fibrolamellar carcinoma ), gross,Well demarcated fibrolamellar carcinoma with central scar; the surrounding liver is normal.,Coarse lamellar fibrosis is characteristic histologically; note the pale body in the large eosinophilic malignant hepatocyte (X40).,40,Hepatocellular carcinoma, liver, microscopic,The malignant cells of this HCC (seen mostly on the right) are well differentiated and interdigitate with normal, larger hepatocytes (seen mostly at the left ),This HCC is composed of liver cords that are much wider than the normal liver plate that is two cells thick. There is no discernable normal lobular architecture, though vascular structures are present.,41,临床表现 症状、体征,早期无明显症状：即亚临床肝癌（无症状和体征）肝区疼痛：常见的首发症状，持续性钝痛、刺痛、胀痛；可伴牵涉痛肝肿大：中、晚期肝癌常见消化道症状：腹胀、食欲减退、恶心呕吐、腹泻、出血全身症状：乏力、消瘦、低热晚期肝癌症状：贫血、黄疸、腹水、浮肿、恶液质癌肿转移部位的相应症状：肺、骨、脑伴癌综合症：低血糖症、红细胞增多症、女性男性化,42,临床表现 实验室检查,Serum bilirubin: nonspecificAlkaline phosphatase: nonspecificHBsAg, HCV-Ab: nonspecificAFP (甲胎蛋白): 7080% HCCs升高; 假阳性 见于慢活肝、急性肝炎、生殖腺肿瘤、妊娠. 术后复发监测(半衰期约67天). 正常上限 20ng/ml; 200ng/ml 拟诊 HCC.,43,临床表现 影像学,要点：大小、数量、位置、毗邻、门静脉癌栓、肝硬化、门静脉高压X线：肝影增大、膈肌升高、胃横结肠受压超声：适于筛查；分辨率2cmCT (平扫+增强) ：分辨率 12cm；有助于鉴别血管瘤MRI：分辨率 12cm；有助于鉴别血管瘤.选择性腹腔动脉或肝动脉造影：分辨率 12cmHCC较相邻肝实质血管丰富胆管细胞癌相对乏血供血管瘤有特征性的血管池动态影像静脉期可显示门静脉占位CT碘油造影可显示微小HCC.,44,HCC-Imaging findings(DSA),45,HCC-Imaging findings,介入前,介入后,46,HCC-Imaging findingsCT scan,Arterial phase,Portal vein phase,47,肝癌MRI表现,48,活检 & 筛查,肝活检:经皮细针肝穿刺活检 (出血？针道种植？)筛查: US+AFP 高危人群筛查可发现早期 HCC，提高治疗效果,49,HCC is amenable to biopsy by percutaneous needle biopsy,The architectural distortion due to cirrhosis is evident; at one end the tissue appears quite fragmented (X8).,The presence of macrotrabecular architecture in this fragmented area allowed for establishing the diagnosis of HCC (X40).,50,原发性肝癌的诊断,高危人群: 男性, 40yrs, HBV/HCV(+), 酗酒, 肝硬化, 家族史症状 & 体征:甲胎蛋白: RI-AFP400ng/ml, 8weeks, exclusion of pregnancy, active hepatitis, embryonic tumors影像学: B-US, CT, MRI, DSA活检:,51,原发性肝癌的鉴别诊断,继发性肝癌：寻找原发灶；肝硬化：肝局限性增生结节；肝的良性肿瘤：最常见的是肝海绵状血管瘤；肝非肿瘤性良性占位：肝脓肿、肝囊肿肝毗邻器官肿瘤：胃癌、结肠癌、肾癌、胰腺癌。,52,随机对照试验（50%）中位生存时间11-20月,对症(20%)生存期50yrs并存肝硬化血管侵犯门静脉癌栓位置深在包膜侵犯跨肝叶播散 多结节,56,治疗 部分肝切除,预后: 5yrs 复发率70%, 单中心或多中心起源. US+AFP 随访可早期发现复发灶，再次手术可使部分病人获益. 中国：总体5年生存率30%; 早期HCC 5年生存率60% *许多病人死于肝硬化而非肿瘤复发（肝功能衰竭、出血）.,* 中华医学杂志, 2003 , 83 (12):1053-7.,57,治疗 肝脏移植,优点:适用于巨大或多结节肝癌适用于肝硬化病人适用于肝炎病毒感染者可保证肝硬化患者的术后生活质量对早期HCCs, 肝移植与肝切除生存率相仿,58,治疗 辅助治疗,经皮消融治疗：Percutaneous ethanol injection (PEI) or radiofrequency ablation (RFA): 物理或化学方法造成HCC坏死。适用于周边男性(6:1). （雌激素） 绝大多数无症状，偶然发现 (4cm) 可能出现腹痛或包块；自发性出血罕见 核素显像, CE-CT, MRI, 血管造影有典型的影像学特点：“早出晚归” 疑诊血管瘤禁忌穿刺活检 有症状、5cm、婴幼儿病例可以考虑结扎、肝叶切除、栓塞、放疗等措施 避免服用口服避孕药,75,Hemangiomas,Multiple cavernous hemangiomas in a young woman with episodic abdominal pain; white tissue in the largest lesion represents fibrosis indicating some degree of involution.,The honeycomb appearance and vascular nature of this giant cavernous hemangioma are readily apparent from the capsular surface.,76,Hemangiomas,Sequential changes during angiograpgy: a vascular lesion with delayed clearing of the contrast medium.,77,Hemangiomas,Hemangioma showing characteristic sharp demarcation from the surrounding liver and spongy texture.,The cut surface of this hemangioma varies from honeycomb to spongy to fibrotic (photograph courtesy of S. Goetz, M.D.).,肝囊肿,79,肝囊肿,通常单发、无症状牧区旅居史者需与肝包虫病鉴别多囊肝病常合并多囊肾病（常染色体显性遗传病）临床表现: 上腹不适、包块、梗阻性黄疸有症状者：开腹或腔镜下囊壁切除或去顶减压,80,Hepatic cysts,Multiple cysts are visible on cut surface of liver; the cyst walls are thin, translucent, and grey. This is from a case with polycystic disease; note the small green bile duct hamartomas in the surrounding liver.,Polycystic liver and kidney disease at autopsy; the liver was completely normal functionally (photograph courtesy of Chris Reuter, M.D.).,81,Hepatic cysts-imaging findings,Hepatic cysts with intra-abdominal hydrops,82,The wall of this simple cyst is composed of a thin layer of fibrous connective tissue; the surrounding liver is unremarkable (X10).,Hepatic cysts,肝脏腺瘤,84,肝脏腺瘤,口服避孕药是危险因素绝大多数是女性；半数无症状症状 & 体征: 右上腹痛、自发性瘤内出血（伴随月经）、包块实验室: 肝功能、AFP 正常影像学: US, CT-局部占位; angiography-乏血供富血供; biopsy 有助于诊断但有风险治疗: 难以绝对除外恶性，切除几乎是唯一选择. 避免服用口服避孕药.,85,Liver adenoma,86,Hepatic adenoma,At the upper right is a well-circumscribed neoplasm that is arising in liver. This is an hepatic adenoma.,The cut surface of the liver reveals the hepatic adenoma. Note how well circumscribed it is. The remaining liver is a pale yellow brown because of fatty change from chronic alcoholism.,87,Sharply demarcated hepatic adenoma, which is somewhat paler than the surrounding liver; there is an area of fresh hemorrhage, as well as some fibrosis from earlier episode of hemorrhage.,Hepatic adenoma,Hepatic adenomas can become so large as to be life-threatening. This estrogen related adenoma, benign histologically, replaced much of the liver, leading to the patients demise.,88,Hepatic adenoma,Normal liver tissue with a portal tract is seen on the left. The hepatic adenoma is on the right and is composed of cells that closely resemble normal hepatocytes, but the neoplastic liver tissue is disorganized hepatocyte cords and does not contain a normal lobular architecture.,The hemorrhagic area represents the peliosis like change commonly seen in estrogen related adenomas (X3.3).,局灶性结节性增生Focal nodular hyperplasia (FNH),90,局灶性结节性增生,良性病变；女性多于男性口服避孕药是危险因素.大多数病人无症状：右上腹包块或不适；生长缓慢，出血罕见.肝功能、AFP 正常.CT：星芒状的斑痕；动脉相富血供.治疗: 难以绝对除外恶性，切除几乎是唯一选择. 避免服用口服避孕药.,91,Focal nodular hyperplasia,A classic focal nodular hyperplasia, paler than the surrounding liver, and with a distinct central stellate scar.,The bands of fibrosis impart an appearance mimicking that of macronodular cirrhosis (Klats