肝功能化验异常的分析和解释课件.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,*,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,肝脏具有那些功能?,代谢功能,胆汁生成和排泄,凝血功能,解毒作用,1,肝脏分类检测,Enzyme tests,Aminotransferases,Alkaline phosphatase,Gamma glutamyl transpeptidase,Tests of synthetic function,Albumin,Prothrombin time,Tests of hepatic transport capabilitySerum bilirubin,2,丙氨酸氨基转移酶,Alanine Aminotransferase(ALT),Serum Glutamic-pyruvic Transaminase(SGPT),组织来源:,肝细胞胞浆,丙氨酸,酮戊二酸,丙酮酸,谷氨酸,3,天冬氨酸氨基转移酶,Aspartate Aminotransferase(AST),Serum Glutamic-oxaloacetic Transaminase(SGOT),组织来源:,心脏,肌肉,肾脏,脑,胰腺,红细胞,肝细胞胞浆(20%)及线粒体(80%),天门冬氨酸,酮戊二酸,草酰乙酸,谷氨酸,AST,4,ALT,与,AST,Severe(20 times,1000 U/L),急性病毒性肝炎,药物或毒物损伤,休克肝,Moderate(3-20 times),慢性肝炎,药物性肝炎,酒精性肝炎,自身免疫性肝炎,Mild(1-3 times),脂肪肝,非酒精性脂肪性肝炎,肝硬化,5,ALT,:,AST ratio,AST：ALT,2,酒精性肝病,AST：ALT,1,肝硬化,6,碱性磷酸酶,Alkaline Phosphatase(ALP),组织来源:,肝脏,骨骼,肠道,胎盘,机制:,胆汁酸增加ALP脂溶性,刺激ALP合成,7,碱性磷酸酶,Alkaline Phosphatase(ALP),意义:,肝脏相关的:,肝内胆汁淤积部分或完全胆道梗阻,肝脏肿瘤,肉芽肿性病变,非肝脏因素:,骨肿瘤,妊娠,8,谷酰转肽酶,Gamma-glutamyl transferase,(GGT),组织来源:,membrane of cells(liver,kidney,pancreas,intestine,prostate),意义:,胆汁淤积,原发性或转移性肝癌,酒精性肝病,胰腺癌,壶腹周围癌,9,肝功能异常类型,化验,肝细胞损伤,胆汁淤积,转氨酶,8倍正常值,3 倍正常值,ALP,8倍正常值,BIL,增高,增高,PT,延长，对维生素K治疗反应差,延长，对维生素K治疗反应好,腹痛,不常见,常见（肝外梗阻时）,发热，WBC增高,不常见常见（肝外梗阻时）,10,胆红素代谢示意图,11,胆红素,Bilirubin(BIL),间接胆红素增高血症:,生成过多,肝脏摄取受损,葡萄糖醛酸化受损,12,间接胆红素增高血症(例1),李霞，女，27岁,非洲工作（08-4-18至08-10-7）,稽留热5天（08-10-18至08-10-22）,血图片：可见疟原虫（外院）,服用氯奎3日，青蒿琥酯片及蒿甲醚5日热退,（08-10-20至08-10-27）,入院前3日再次高热伴阵发中上腹绞痛（08-10-28）,血色素9.1g/dl降至3.9g/dl伴酱油色尿，网织红2.53%,ALT 30U/L,AST 57U/L,TBIL 40.3umol/L,IBIL 27.43umol/L,LDH863U/L,13,间接胆红素增高血症(例2),中年女性。,胆结石拟手术，发现间接胆红素增高请会诊。,Hb正常,网织红细胞比例增高。,外周血图片,14,间接胆红素增高血症(例3),刘壮飞，男性，12岁,反复皮肤黄染伴乏力6年,父亲自18岁起发现胆红素升高，以间接胆红素为主,ALT 16U/L，AST 27 U/L,正常,TBIL 46.2umol/L，IBIL 30.0umol/L。,组织病理学,最终诊断：,Gilbert,综合征,15,胆红素,Bilirubin(BIL),直接胆红素增高血症:,肝外胆管梗阻,肝内胆汁淤积,16,肝外胆管梗阻,李彦红，女性，77岁,突然皮肤巩膜黄染10天,ALT，AST,正常,ALP 302U/L，GGT361U/L,TBIL 250.60umol/L,DBIL 233.60umol/L,17,肝外胆管梗阻,18,正常胰胆管系统,19,胆汁分泌障碍、流速减慢或停滞，可发生在从肝细胞、,毛细胆管直至,Vater,壶腹各水平。,临床：以瘙痒、黄疸、,ALP,、,GGT,增高等为特征。,病理：肝细胞及,/,或胆道系统胆汁成分蓄积。,肝内胆汁淤积的概念,20,肝内各级胆管及其命名,Hering管,总胆管,右肝管,左肝管,400-800um 段胆管,300 -400um,区胆管,100um,隔胆管,15-100um 叶间小胆,管,15um 细胆管,毛细胆管,肝细胞,21,肝内毛细胆管小叶间胆管,ductule,Bile canaliculus,自Scheuer P J，Live Biopsy Interpretation.2006，53,22,肝内胆汁淤积,Viral hepatitis,Etoh hepatitis,EBV,CMV,Anabolic,steroids,Contraceptives,TPN,Primary biliary sclerosis,Primary sclerosing cholangitis,23,肝内胆汁淤积,24,肝内胆汁淤积,25,肝内胆汁淤积,26,甘氨酸,，,牛磺酸总胆汁酸 TBA,27,28,肝脏合成功能,白蛋白,Malnutrition,Nephrotic syndrome,Protein losing enteropathy(Sprue,Crohns),凝血酶原活动度,60%,4060%,3.5,2.8-3.5,6,胆红素mg/dl,2,2-3,3,腹水,无,少量,中量,肝性脑病,无,12,34,Grade A 1-6;Grade B 7-9;Grade C 1015,Child CG,Turcotte JG.Surgery and portal hypertension.In:The liver and portal hypertension.Edited by CG Child.Philadelphia:Saunders 1964:50-64.,Pugh RN,Murray-Lyon IM,Dawson JL,Pietroni MC,Williams R(1973).The British journal of surgery 60(8):6469.,31,肝功能储备,Child-Pugh,Points,Class,One year survival(%),Two year survival(%),5-6,A,100,85,7-9,B,81,57,10-15,C,45,35,32,肝功能储备,MELD,The Model for End-Stage Liver Disease,MELD=3.78Ln serum,bilirubin,(mg/,dL,)+11.2Ln INR+9.57Ln serum,creatinine,(mg/,dL,)+6.43,Interpretation(3 month),40 or more-100%mortality,30-39-83%mortality,20-29-76%mortality,10-19-27%mortality,10-4%mortality,Malinchoc M,Kamath PS,Gordon FD,et al.(April 2000).,Hepatology,31(4):86471.,33,女性,，54岁,主诉：上腹不适、恶心2天,入院日期：20080821,高球蛋白血症,34,治疗前后肝功能,ALT,AST,ALP,GGT,ALB,GLO,CHE,TBIL,DBIL,08-20,804,705,31.8,72.4,81.11,61.01,08-22,515,450,133,291,26.3,74,3.26,80.38,62.09,08-28,155,93,143,343,23,62.7,3.22,31.35,24.08,09-03,90,79,161,352,22.5,64.3,3.17,37.47,27.06,09-10(,),97,112,193,363,22.4,62.4,2.95,47.94,34.26,09-16,70,65,192,389,24.1,64.5,3.33,26.51,17.92,09-24,128,114,183,444,32.8,67.8,4.51,44.36,25.77,10-2,145,89,136,402,30.1,64.8,4.9,26.69,15.09,10-15,58,42,107,252,31.8,54.6,5.15,16.7,9,35,高球蛋白血症,中年女性,急性起病.,转氨酶显著增高,轻度黄疸.,明显高球蛋白血症.,ANA阳性.,肝组织病理学符合自身免疫性肝炎的表现.,激素治疗基本有效!,36,Globulin,is one of the two types of,serum,proteins,the other being,albumin,.,Protein electrophoresis,:,Alpha 1 globulins,Alpha 2 globulins,Beta globulins,Gamma globulins,(one group of gamma globulins are,immunoglobulins,that function as,antibodies,),Globulin,37,Hyperglobulinemia,Hyperglobulinemia:Polyclonal Gammopathy,Chronic bacterial diseases Pneumonia Chronic fungal diseases,Chronic protozoal 原虫的/rickettsial diseases,38,Hyperglobulinemia,Hyperglobulinemia:Polyclonal Gammopathy,Chronic viral diseases,Neoplasia Lymphoma Mast cell tumor Other tumors,Autoimmune disorders Systemic lupus erythematosus Chronic polyarthritis Others,39,Hyperglobulinemia,Hyperglobulinemia:Monoclonal Gammopathy,Neoplasia,Multiple myeloma Lymphoma Chronic lymphocytic leukemia,Inflammation/infection,Leishmaniasis,Idiopathic,Waldenstrom macroglobulinemia Benign monoclonal gammopathy,40,Serum Protein Electrophoresis-Normal Pattern,41,Serum Protein Electrophoresis-Polyclonal Gammopathy,sarcordosis,The sequential increase of the globulin fractions illustrated sarcoid stepping.,42,Serum Protein Electrophoresis-Nephrotic Pattern,alpha-2-macroglobulin,Loss of lower molecular weight proteins(Examples:albumin,IgG),Retention of higher molecular weight proteins(example alpha-2-macroglobulin.),SLE,43,Serum Protein Electrophoresis-Cirrhotic Pattern,beta-gamma bridge pattern,end stage liver disease secondary to chronic alcohol abuse,44,Serum Protein Electrophoresis-Acute inflammatory pattern,pneumonia and pyelonephritis,albumin and gamma globulin are decreased and alpha-2-globulin becomes very prominent,45,Serum Protein Electrophoresis-Alpha 1 anti-trypsin deficiency,alpha-1-anti-trypsin deficiency,46,Serum Protein Electrophoresis-Monoclonal(M)Protein Present,IgG kappa,multiple myeloma,47,Serum Protein Electrophoresis-Biclonal Gammopathy,IgG-k and IgA-lambda,multiple myeloma,48,总结,转氨酶增高敏感性高,特异性差。,肝脏合成功能可反应肝脏功能储备。,胆红素增高首先明确肝前、肝性、肝后。,如为肝前性首先除外溶血。,如为肝后性明确是肝外还是肝内胆汁淤积。,球蛋白高首先区分是单克隆性还是多克隆性。,49,