肝脏疾病本科彭涛2011.ppt

个人简历,LiverDiseases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,Theliverliesintherightupperquadrantoftheabdomen,undertheprotectiveribcage,beneaththediaphragmandconnectedtothedigestivetractbymeansofportalveinandbiliarydrainagesystem.Gilssonscapsule,barearea,falciformlig.,coronarylig.,gastrohepaticlig.,hepatoduodenallig.foramen,1:liver;2:ribcage;3:spine;4:pelvis,4,肝脏解剖生理概要-2,TheAmerican(lobar)systemangiographyisdiagnosticinhemobilia.,Hepatictrauma-Clinicalfindings,18,Hepatictrauma-imagingfindings,19,Hepatictrauma-imagingfindings,Hydropsattheadrenalgland,Hepatictraumawithfractureofleftrib,20,Hepatictrauma-Treatment,Inareviewof1842liverinjuriesfrom1975-1999inUSA,nonsurgicaltherapyisusedinmorethan80%ofbluntinjuries.Thedeathratesfrombothbluntandpenetratingtraumahaveimprovedsignificantlyduetodecreaseddeathfromhemorrhage.,J.DavidRichardson,etal.ANNALSOFSURGERY,232(3):324330.,21,Hepatictrauma-TreatmentNonoperativemanagementforpatientswithstableminorinjuries,Containedsubcapsularorintrahepatichemotoma,UnilobarfractureAbsenceofdevitalizedliverMinimalintraperitonealbloodAbsenceofinjuriestootherintra-abdominalorgans.However,repeatedlyexaminationshouldbecarriedoutduringtheobservation!,22,Hepatictrauma-TreatmentExplorationforpatientswithactivebleedingoramajorinjury,Techniquesinclude:DrainageforwoundswithouthemorrhageSutureforbleedingvesselsMassiveinjurymayrequirelobectomySubcapsularhematomasrequiethoroughlyexploration.Temporaryclampingtheinflowvesselsinthehilumhelpsligatingbleedingvessels.Ancillarybypass,packingorabsorbablegauzemeshmayhelpinsomecases.,23,Hepatictrauma-Complicationsandprognosis,RebleedingSubhepaticsepsisHemobilia-selectiveangiographyandembolizationStressulcersH2receptorantagonists(Cimetidine,Ranitidine,Omeprazoleetc)Mortalitydependsonthetypeandseverityofinjuries.,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PrimaryLiverCancer,26,原发性肝癌,组织病理类型:肝细胞癌：Hepatocellularcarcinoma(HCC);约91%；胆管细胞癌：Cholangiocellularcarcinoma(cholangiocarcinoma);7%8%；混合细胞型肝癌：Mixedform(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,HCVetal.)真菌毒素(黄曲霉毒素aflatoxins)饮水污染(池塘或沟渠水)Othercauses遗传酗酒Alpha-antitrypsindeficiencyHemochromatosisPlantalkaloidOralcontraceptivesAndrogensVinylchlorideTraceelements(?):Cu,Zn,NiandCoParasites:Clonorchissinensis,30,20/100,00040/100,000,NPCHCC,31,中国是HCC高发地区,GlobalCancerStatistics,2002.CACancerJClin2005;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20.40/100,00029.07/100000(男)11.23/100,000(女)自1990s,NO2.肿瘤杀手(城市次于肺癌，农村次于胃癌；1534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(30/100000)：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(Fibrolamellarhepatoma)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：2.0cm10.0cm,35,Hepatocellularcarcinoma,liver,gross,A2.0cmHCCarisinginachronicviralhepatitis;thetumor,whichhadapredominantacinararchitecture,producedabundantbile.,36,Hepatocellularcarcinoma,liver,gross,NoduleofhepatocellularcarcinomainchronichepatitisC;thepalegoldenyellowcoloriscommon.,37,Hepatocellularcarcinoma,liver,gross,Theneoplasmislargeandbulkyandhasagreenishcastbecauseitcontainsbile.Totherightofthemainmassaresmallersatellitenodules.,Thesatellitenodulesofthishepatocellularcarcinomarepresenteitherintrahepaticspreadofthetumorormulticentricoriginofthetumor.,38,Hepatocellularcarcinoma,liver,gross,Anotherhepatocellularcarcinomawithagreenishyellowhue.Suchmassesmayalsofocallyobstructthebiliarytractandleadtoanelevatedalkalinephosphatase,39,HCC(fibrolamellarcarcinoma),gross,Welldemarcatedfibrolamellarcarcinomawithcentralscar;thesurroundingliverisnormal.,Coarselamellarfibrosisischaracteristichistologically;notethepalebodyinthelargeeosinophilicmalignanthepatocyte(X40).,40,Hepatocellularcarcinoma,liver,microscopic,ThemalignantcellsofthisHCC(seenmostlyontheright)arewelldifferentiatedandinterdigitatewithnormal,largerhepatocytes(seenmostlyattheleft),ThisHCCiscomposedoflivercordsthataremuchwiderthanthenormalliverplatethatistwocellsthick.Thereisnodiscernablenormallobulararchitecture,thoughvascularstructuresarepresent.,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,Serumbilirubin:nonspecificAlkalinephosphatase: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-Imagingfindings(DSA),45,HCC-Imagingfindings,介入前,介入后,46,HCC-ImagingfindingsCTscan,Arterialphase,Portalveinphase,47,肝癌MRI表现,48,活检atoneendthetissueappearsquitefragmented(X8).,ThepresenceofmacrotrabeculararchitectureinthisfragmentedareaallowedforestablishingthediagnosisofHCC(X40).,50,原发性肝癌的诊断,高危人群:男性,40yrs,HBV/HCV(+),酗酒,肝硬化,家族史症状早期HCC5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：Percutaneousethanolinjection(PEI)orradiofrequencyablation(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,Multiplecavernoushemangiomasinayoungwomanwithepisodicabdominalpain;whitetissueinthelargestlesionrepresentsfibrosisindicatingsomedegreeofinvolution.,Thehoneycombappearanceandvascularnatureofthisgiantcavernoushemangiomaarereadilyapparentfromthecapsularsurface.,76,Hemangiomas,Sequentialchangesduringangiograpgy:avascularlesionwithdelayedclearingofthecontrastmedium.,77,Hemangiomas,Hemangiomashowingcharacteristicsharpdemarcationfromthesurroundingliverandspongytexture.,Thecutsurfaceofthishemangiomavariesfromhoneycombtospongytofibrotic(photographcourtesyofS.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,Hepaticcysts,Multiplecystsarevisibleoncutsurfaceofliver;thecystwallsarethin,translucent,andgrey.Thisisfromacasewithpolycysticdisease;notethesmallgreenbileducthamartomasinthesurroundingliver.,Polycysticliverandkidneydiseaseatautopsy;theliverwascompletelynormalfunctionally(photographcourtesyofChrisReuter,M.D.).,81,Hepaticcysts-imagingfindings,Hepaticcystswithintra-abdominalhydrops,82,Thewallofthissimplecystiscomposedofathinlayeroffibrousconnectivetissue;thesurroundingliverisunremarkable(X10).,Hepaticcysts,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,Liveradenoma,86,Hepaticadenoma,Attheupperrightisawell-circumscribedneoplasmthatisarisinginliver.Thisisanhepaticadenoma.,Thecutsurfaceoftheliverrevealsthehepaticadenoma.Notehowwellcircumscribeditis.Theremainingliverisapaleyellowbrownbecauseoffattychangefromchronicalcoholism.,87,Sharplydemarcatedhepaticadenoma,whichissomewhatpalerthanthesurroundingliver;thereisanareaoffreshhemorrhage,aswellassomefibrosisfromearlierepisodeofhemorrhage.,Hepaticadenoma,Hepaticadenomascanbecomesolargeastobelife-threatening.Thisestrogenrelatedadenoma,benignhistologically,replacedmuchoftheliver,leadingtothepatientsdemise.,88,Hepaticadenoma,Normallivertissuewithaportaltractisseenontheleft.Thehepaticadenomaisontherightandiscomposedofcellsthatcloselyresemblenormalhepatocytes,buttheneoplasticlivertissueisdisorganizedhepatocytecordsanddoesnotcontainanormallobulararchitecture.,Thehemorrhagicarearepresentsthepeliosislikechangecommonlyseeninestrogenrelatedadenomas(X3.3).,局灶性结节性增生Focalnodularhyperplasia(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,Focalnodularhyperplasia,Aclassicfocalnodularhyperplasia,palerthanthesurroundingliver,andwithadistinctcentralstellatescar.,Thebandsoffibrosisimpartanappearancemimickingthatofmacronodularcirrhosis(Klatskin,X5).,肝脓肿HepaticAbscess,93,肝脓肿,病原菌：细菌、寄生虫、真菌原发灶：腹腔内或隐匿性感染灶胆道门静脉肝动脉淋巴引流,94,肝脓肿-症状&体征,一般情况差（不适、疲乏）、寒战、弛张热、黄疸右上腹痛、右肩牵涉痛、肝肿大、触痛、胸膜渗出,95,肝脓肿-实验室检查,白细胞升高见于绝大多数病例贫血、HematocritBilirubin,ALP,96,肝脓肿-影像学,平片(右胸):基底段不张、胸膜渗出、右膈上抬、