肝癌肝昏迷医学知识讲座优质PPT课件.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,肝癌肝昏迷医学知识讲座,Overview,Definition,Heaptocellular carcinoma(HCC),originated in the liver cells or,intrahepatic bile duct cells.,Incidence rate,14.5846/,100,000,.,HCC,is up to 2,5times more common in,men than women and usually arises in a,cirrhotic liver.,Overview,Chronic liver disease,Aflatoxin,Drinking Water Pollution,Other factors,Etiology and pathogenesis,Chronic liver disease,viral hepatitis,1.HBV:,HBV-DNA,may,be integrated into the host,DNA of liver cells,and c,hanges gene,expression in liver cells,.,2.HCV,Etiology and pathogenesis,Cirrhosis,About 50 90%of HCC accompanied cirrhosis.,Acute and chronic hepatitis,Cirrhosis,HCC,Etiology and pathogenesis,Aflatoxin B1,Drinking Water Pollution:,Algae toxin,could contaminate water sources,Chemical carcinogens:nitrite,organic,chlorine pesticides,Parasite:liver fluke,Etiology and pathogenesis,Pathology,Morphological typing,Block type,(5,cm),Nodular type,(5,cm,),Diffuse type,Small,hepatocarcinoma,(,3,cm),Cell classification,Hepatocellular,Bile duct cell type,metastasis,1.Intrahepatic metastasis,2.Extrahepatic metastasis,（,1,）,Hematogenous metastasis,（,2,）,Lymphatic metastasis,（,3,）,implantation metastasis,Pathology,Subclinical hepatocellular carcinoma:,Without any signs and symptoms,AFP,clinical manifestation,hepatic region pain:,Persistent pain or dull pain,Progressive enlarge liver:,Quality hard,uneven surface,nodule or,giant blocks,ragged edge,tenderness,vascular murmur,clinical manifestation,Jaundice,Cirrhosis symptoms and signs,:,liver dysfunction and Portal,hypertension:,Such as,Splenomegaly,ascites,collateral,circulation,clinical manifestation,Systemic manifestations of malignant,tumors:,Fatigue,weight loss,cachexia,fever,anorexia,Metastasis features:,the lung,bone,chest,Paraneoplastic syndrome:,such as hypoglycemia,、,Erythrocytosis,and so,on,clinical manifestation,Table 2.Prevalence of Clinical Features of Hepatocellular Carcinoma,clinical manifestation,Complications,Hepatic encephalopathy,Upper gastrointestinal bleeding,Rupture of liver carcer nodules,Secondary infection,（一）,Detection of liver cancer,markers,1.,Alpha-fetoprotein(AFP),Clinical Significance:liver cancer census(high-,risk groups),diagnosis,Judging,treatment and,relapse,Laboratories and equipment inspection,AFP,diagnostic criteria for liver cancer,AFP 500g/L 4W,AFP:From low to high,AFP200g/L 8W,False positive:,Pregnancy,chronic,hepatitis,cirrhosis,Gonadal blastoma,False-negative:,Detection of AFP heterogeneity,Laboratories and equipment inspection,2.,Other liver cancer marker,r-glutamyl transferase isoenzyme peptide,（,r-GT）,abnormal prothrombin,（,APT）,serum a-l-fucosidase(AFU),ALP isoenzyme,（,ALP-I,）,Laboratories and equipment inspection,（二）,Imaging examination,Ultrasound:2cm or more substantial mass,X ray computer tomography,（,CT）,X-hepatic angiography,Magnetic resonance imaging(MRI),（三）,Liver puncture biopsy,Laboratories and equipment inspection,Clinical manifestations,coupled with AFP,liver B-Ultrasound,CT etc.,Diagnosis,Clinical diagnostic criteria for hepatocellular carcinoma,(,一）,Non-invasive diagnostic criteria,1.,Imaging,：,Two kinds of imaging studies have shown more than 2cm liver mass.,2.Imaging with AFP:A kind of imaging examination showe more than 2cm liver mass a,ccompanied,AFP 400g/L.,Diagnosis,（二）,Histological diagnostic,criteria,Less than 2cm of intrahepatic nodules that,maging can not determine shoud be,punctured to confirm histological,characteristics of liver cancer.,Diagnosis,1.Active hepatitis and cirrhosis,Differential Diagnosis,（一）,D,ifferential diagnosis,in,AFP-positive,liver,cancer,Active liver disease,Liver Cancer,Differential Diagnosis,Active liver disease ALT,AFP,curve,Time,density,AFPchange,ALT,change,Differential Diagnosis,density,时间,ALTchance,AFPchance,HCC ALT,AFP curve,Differential Diagnosis,2.Pregnancy,3.Embryonic gonad tumors,4.Other gastrointestinal tumors,such as gastric cancer,pancreatic cancer and malignant insulinoma and so on.,Differential Diagnosis,Differential Diagnosis,（,二）,Identification of AFP-negative,hepatocellular carcinoma,Metastatic,hepatic,carcinoma.,Hepatic,hemangioma.,Intrahepatic liquid space-occupying lesions:live cyst,liver abscess and liver hydatid.,4.,Other benign space-occupying diseases:inflammatory pseudotumor,liver adenoma,liver and partial fatty infiltration,liver nodules and liver sarcoma and so on.,surgical treatment,Local treatment,1.Hepatic artery embolization,chemotherapy,2.,Ethanol injection,3.Physiotherapy,Treatment,Radiotherapy,Biological and immunotherapy,Systemic chemotherapy,Comprehensive treatment,Treatment,Table 5.Treatment Options for Hepatocellular Carcinoma,Prognosis,The better prognosis as following,：,1.,Tumor less than 5cm,early operation.,2.,Cancer capsule integrity,and there is,no cancer plug formation.,3.,Normal,immune.,Chapter 14,Hepatic Encephalopathy,Internal Medical Teaching and Research Section,First,Clinical Medical College of Guangxi Medical University,2005undergraduat courseware,Professor XingHuo-Tang,Definition,Hepatic encephalopathy is a state of disordered central nervous system function resulting from failure of the liver to detoxify noxious agents of gut origin because of hepatocellular dysfunction and portosystemic shunting.,Etiology and pathogenesis,Etiology,:,cirrhosis,severe hepatitis,hepatocellular carcinoma,fatty liver of pregnancy,et al,.,Common,incentive,ing factors of hepatic encephalopathy,Glutamine,NH,3,+Glutamate,Urea,protein,NH,3,+CO,2,Intestinal ammonia:,Ammonia,liver,Etiology and pathogenesis,（一）,Neurotoxin,NH,3,+H,+,NH,4,+,pH,6,pH,6,urea,glutamine,Interfere with brain cells TCA cycle.,2.,Increased brain neutral amino acids such as tyrosine,phenylalanine,tryptophan.,3,.,Astrocytes increased glutamate and neuronal cell swelling.,Ammonia can also directly interfere with the electrical activity of neurons.,Etiology and pathogenesis,Ammonia inhibited the central nervous system:,Etiology and pathogenesis,（二）,Changes in neurotransmitter,Normal neurotransmitter:dopamine,norepinephrine.,1.False neurotransmitter:,Tyrosine,Tyramine,hydroxyl tyramine,Phenylalanine,Phenylethylamine Phenylethanolamine,Etiology and pathogenesis,2,.GABA/BZ,3.,Tryptophan,Tryptophan,Brain,5-hydroxytryptamine,5-HIAA,Inhibited brain function,Pathology,Acute,HE patients no obvious anatomical,abnormalities in brain,mainly secondary,brain edema,Clinical manifestations,The manifestations of the primary disease,.,The manifestations of the central nervous system.,Phases,The level of consciousness,Pounce-like tremor,EEG,NO.1 phases,mild changes in,normal,precursor personality and behavior,phases,NO.2 phases,consciousness disorders,sleep disorders.,+,abnormal,pre-coma,orientation and computing,abnormal,NO.3 phases,drowsiness,mental disorder,+,abnormal,sleeping,period neurological signs postive,NO.4 phases complete loss of consciousness _,abnormal,coma,deep coma,Clinical manifestations,Minimal hepatic encephalopathy:,None of the symptoms and signs.,Psychological aptitude test unresponsive,.,Laboratories and equipment inspection,Ammonia,Electrolyte acid-base imbalance,hypokalemia,metabolic alkalosis,Evoked Potentials,EEG,Psychological Aptitude Test,Imaging,Diagnosis,Serious liver disease,+,precipitating factors,+,Neuropsychiatric symptoms,+,Exclude other diseases,Differential diagnosis,Cerebrovascular accident:,Age,high blood,pressure,Hemiplegia,Diabetic coma:glucose,urine glucose,urine,ketone(+),Uremia:History of kidney disease,edema,anemia,high blood pressure,urinary,changes,renal function damaged,Poisoning,Treatment,一、,The elimination of incentives and treatment,of primary disease,:,1,.,Avoid sedatives and drugs which damaged liver,function.,2,.,Hemostasis,removal of intestinal hemorrhage.,3,.,Correct water and electrolyte acid-base,disturbance.,4,.,Prevention and control,infection.,5,.,Improve liver function.,Treatment,二、,Reducing intestinal ammonia production,and absorption:,1,.Restricted protein diet,2.Intestinal cleansing,3.Lactulose,lactitol,4.Inhibited bacterial growth,5.Probiotic preparations,Treatment,三、,To promote metabolism of ammonia in vivo,:,1.L-ornithine-L-aspartate(OA),2.Ornithine-ketoglutarate,3,.Sodium benzoate,4,.Glutamate,5,.Arginine,四、,GABA/BZ receptor antagonist flumazenil,composite.,五、,Antagonist to false neurotransmitter,Treatment,六、,other treatment,1,.Artificial liver.,2,.Liver transplantation.,3,.Prevention and treatment of cerebral,edema,and protecting brain cells function.,4,.To maintain airway.,小 肝 癌,大 肝 癌,大 肝 癌,大 肝 癌,大 肝 癌,结 节 型 肝 癌,