脂肪肝治疗课件

脂肪肝诊治进展1什么是脂肪肝？2肝细胞内脂质积聚超过肝湿重的5%称之脂肪肝。正常人肝脏内脂质含量占肝湿重的2%～4%，其中2/3为磷脂，此外尚有胆固醇、中性脂肪，主要是构成细胞膜及其他细胞器的膜。大多数脂肪肝属于三酰甘油含量异常增高，根据脂肪含量，可将脂肪肝分为轻型(含脂肪5%～10%)，中型(含脂肪10%～25%)，重型(含脂肪25%～50%或>30%)三型。病理切片：每个视野下脂肪变的细胞>33%称为脂肪肝33%-67%中度脂肪肝；>67%重度脂肪肝3中国脂肪肝有何特点？45Prevalenceofnon-alcoholicfattyliverdiseaseinvarioushigh-riskgroupscomparedwiththegeneraladultpopulation.DigestiveandLiverDisease47(2015)997–10066导致脂肪肝的原因和危害因素？789脂肪肝分几大类？10酒精性脂肪肝（酒精）非酒精性脂肪肝（遗传环境与代谢）其他脂肪肝（病因明确）11非酒精性脂肪性肝病（即脂肪肝）是如何发生的？12Figure1:OverlapinPathogenesisinNAFLDandALDHepatology.2017Jan18.

13MultiplehitInthefirsthit,thereisanaccumulationoftriglycerideaslipiddropletswithinthecytoplasmofhepatocytes(steatosis)inmorethan5%ofhepatocytes.Insulinresistancecontributestothishepaticsteatosis.Thisphaseofbenignhepaticsteatosisisreversibleandcanbeself-limitedbutmakestheliversusceptibletothesecondhitwhichadvancesthelivertoanecroinflammatorystage,i.e.,NASH.14MultiplehitThesecondhitincludesoxidativestress(freeradicalformationduetoexcessivefattyacidoxidation),cardiolipin(presentoninnermitochondrialmembrane)peroxidationleadingtomitochondrialdysfunctionandmorereactiveoxygenspeciesformation,pro-inflammatorycytokineformation,apoptosisandgut-derivedbacterialendotoxinemia.15MultiplehitThethirdhitincludespalatine-likephospholipase3(PNPLA3)geneinvolvement,andimpairedhepatocyteregeneration.Certainsinglenucleotidepolymorphisms(SNPs)havebeenfoundtobeassociatedwithhigherfrequency,severehistologicchangesandmoreprogressionofNAFLD.VariantSNPsinPZPandPNPLA3geneswerefoundtobeindependentriskfactorsforthedevelopmentofNAFLD.HencegeneticsplayanimportantrolealongwithmetabolicfactorsinthedevelopmentofNAFLD.16Atotalof7observationalstudiesmetcriteriaforinclusion(oneforcardiovascularendpointsand6for

liver

endpoints).TherewasapositiveassociationbetweenmoderatealcoholuseanddecreasedNASHandfibrosis,howeverheavyepisodicdrinkingmayacceleratefibrosisprogressionandinpatientswithadvancedfibrosismoderatealcoholusemayincreasetheriskofhepatocellularcarcinoma.Hepatology.2017Jan18.

酒精对脂肪肝的影响17脂肪肝的结局18Progressionofnon-alcoholicfattyliverdisease(NAFLD)tonon-alcoholicsteatohepatitis(NASH)withorwithoutfibrosis,cirrhosis,andhepatocellularcarcinoma.J.Hepatol.

2015;62:1148–1155.Hepatol.

2015;13:643–654.

192021脂肪肝的必要检查22人体学血压、脉搏、呼吸、身高、体重、腰围、臀围病史：年龄性别、文化程度、职业；饮酒史、肥胖史、疾病史、用药史；饮食结构、运动方式

和程度化验检查：肝功能、血脂、血常规、尿常规、尿酸、病毒学、胰岛功能、血糖（0和120min）、肾功能2324Simplesteatosis→NASH→cirrhosis.NASHclassification:type1:Simplesteatosis;type2:steatosis+inflammation(lobularandportal)→NASH;type3:steatosis+balloonedhepatocytes→NASH;type4:steatosis+fibrosis→NASH.25CTMRIMRS

DSAB超HR

PRIORITIES安全、准确、标准量化、无创？影像检查影像检查262728脂肪肝的对策29302.药物治疗策略31抗炎保肝药物的分类分类作用机制抗炎类抗炎：抗抑制炎症因子、免疫性因子；免疫调节：刺激单核-巨噬细胞系统、诱生γ-干扰素，增强NK细胞活性；可抗过敏、抑制钙离子内流代表药物异甘草酸镁注射液（天晴甘美）、天晴甘平、其它甘草制剂、双环醇修复肝细胞膜类与肝细胞膜及细胞器膜相结合，增加膜的完整性、稳定性和流动性，使受损肝功能和酶活性恢复正常，调节肝脏的能量代谢，促进肝细胞再生代表药物多烯磷脂酰胆碱解毒类参与体内三羧酸循环及糖代谢，激活多种酶，促进糖、脂肪及蛋白质代谢，减轻组织损伤，促进修复代表药物为GSH（还原型谷胱甘肽）、硫普罗宁抗氧化类抗脂质过氧化，增强肝细胞膜对多种损伤因素的抵抗力代表药物为水飞蓟素类利胆类促进胆汁酸转运，达到退黄，降酶的作用代表药物为熊去氧胆酸（UDCA）、S-腺苷蛋氨酸.王宇明.抗炎保肝药物的作用机制及地位.中华肝脏病杂志