肝脏疾病(本科)彭涛2011.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,*,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,*,个人简历,起止年月,地点,学习、工作单位,任职,1987.91993.6.,1993.71999.12,1994.91997.6.,1999.122003.12,2000.92003.6.,2003.102005.10,2003.122006.12,2006.12,1998.81998.12,2001.92001.10,2001.112002.7,2005.92006.10,2006.112008.6,北京大学医学部,广西南宁市,广西南宁市,广西南宁市,四川成都市,广西南宁市,广西南宁市,广西南宁市,日本九州市,日本九州市,新加坡,美国纽约市,美国华盛顿,DC,北京大学医学部,广西医科大学第一附属医院普外科,广西医科大学,广西医科大学第一附属医院肝胆外科,四川大学华西医学中心,广西医科大学,广西医科大学第一附属医院肝胆外科,广西医科大学第一附属医院肝胆外科,日本产业医科大学生态科学研究所,日本产业医科大学生态科学研究所,新加坡国立大学医学系,美国纽约哥伦比亚大学医学中心,美国国立健康研究院国立癌症研究所,本科（六年制）,住院医师,硕士,(,肿瘤外科学,),讲师,博士（外科学）,博士后,(,临床医学,),副教授,教授,访问学者,访问学者,访问学者,博士后,博士后,美国癌症协会（,American Association of Cancer Research,AACR,）,Associate Member,（会员号,127245,）,Carcinogenesis,杂志特约审稿人（,IF2007=5.366,）,Liver INT,杂志特约审稿人（,IF2004=2.344,）,研究方向：肝癌生物反应标志物与大分子损伤,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,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.,Gilsson,s capsule,bare area,falciform lig.,coronary lig.,gastrohepatic lig.,hepatoduodenal lig.foramen,1:liver;2:rib cage;3:spine;4:pelvis,3,肝脏解剖生理概要,-2,The,American,(lobar)system&the,French,(Couinaud segmental)system.,4,肝脏解剖生理概要,-3,5,肝脏解剖生理概要,4,-Cauinaud segmentation,6,肝脏解剖生理概要,5,-left hepatic vein,7,肝脏解剖生理概要,6,-middle hepatic vein,8,肝脏解剖生理概要,7,-hepatic vein&portal vein,9,肝脏解剖生理概要,8,-portal vein plane,10,“,精准肝脏外科时代,”,保留肝中静脉的左半肝切除,11,“,精准肝脏外科时代,”,保留肝右静脉的右后叶肝切除,12,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,13,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),Albumin,Child-Pugh,肝功能分级,;ICG15min,渚留率,肝脏解剖生理概要,10,14,Hepatic Trauma,肝脏创伤,Hepatic trauma,-,Classification and characteristics,Penetrating,hepatic-trauma,Due to bullets,knives etc.,less devitalization of liver parenchyma,Due to missiles,shatter massive parenchyma,Blunt,hepatic-trauma,Due 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(S,VII,)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),16,Symptoms and signs,:hypovolemic shock(hypotension,decreased urinary outputlow 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,17,Hepatic trauma,-,imaging findings,18,Hepatic trauma,-,imaging findings,Hydrops at the adrenal gland,Hepatic trauma with fracture of left rib,19,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.,20,Hepatic trauma,-,Treatment,Nonoperative,management for patients with stable minor injuries,Contained subcapsular or intrahepatic hemotoma,Unilobar fracture,Absence of devitalized liver,Minimal intraperitoneal blood,Absence of injuries to other intra-abdominal organs.,However,repeatedly examination should be carried out during the observation!,21,Hepatic trauma,-,Treatment,Exploration,for patients with active bleeding or a major injury,Techniques include:,Drainage,for wounds without hemorrhage,Suture,for bleeding vessels,Massive injury may require,lobectomy,Subcapsular 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.,22,Hepatic trauma,-,Complications and prognosis,Rebleeding,Subhepatic,sepsis,Hemobilia,-selective angiography and embolization,Stress ulcers,H2 receptor antagonists(Cimetidine,Ranitidine,Omeprazole etc),Mortality,depends on the type and severity of injuries.,23,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,24,原发性肝癌,Primary Liver Cancer,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%,26,ICC,即使病理诊断也要小心谨慎,27,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%.,28,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 deficiency,Hemochromatosis,Plant alkaloid,Oral contraceptives,Androgens,Vinyl chloride,Trace elements(?):Cu,Zn,Ni and Co,Parasites:Clonorchis sinensis,29,20/100,000,40/100,000,NPC,HCC,30,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),31,背景,中国流行病学,1995,全国肿瘤普查,死亡率,20.40/100,000,29.07,/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,32,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,33,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,34,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.,35,Hepatocellular carcinoma,liver,gross,Nodule of hepatocellular carcinoma in chronic,hepatitis C,;the pale golden yellow color is common.,36,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.,37,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,38,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).,39,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.,40,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,41,临床表现,实验室检查,Serum bilirubin:nonspecific,Alkaline phosphatase:nonspecific,HBsAg,HCV-Ab:nonspecific,AFP,(,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.,42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,2cm,CT,(,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,12cm,HCC,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.,43,HCC-Imaging findings(DSA),44,HCC-Imaging findings,介入前,介入后,45,HCC-Imaging findings,CT scan,Arterial phase,Portal vein phase,46,肝癌,MRI,表现,47,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,48,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).,49,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-AFP,400ng/ml,8weeks,exclusion of pregnancy,active hepatitis,embryonic tumors,影像学,:B-US,CT,MRI,DSA,活检,:,50,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。,51,极早期,(0),PS 0,CPA,早期,(A),PS 0,CPA-B,中期,(B),PS 0,CPA-B,晚期,(C),PS 1-2,CPA-B,终末期,(D),PS 2,CPC,HCC,随机对照试验（,50%,）,中位生存时间,11-20,月,对症,(20%),生存期,3,月,HCC,BCLC staging and treatment,Sem Liv Dis 1999 to J Hepatol 2008;48:S20-S37,治愈性治疗（,30,）,5,年生存率,40%-70%,肝移植,RF/PEI,切除术,伴随疾病,有,无,3,个结节,3cm,上升,正常,单发结节,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,55,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.,56,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,57,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,CECT,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,74,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.,75,Hemangiomas,Sequential changes during angiograpgy:,a vascular lesion with delayed clearing of the contrast medium.,76,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.).,77,肝囊肿,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,79,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.).,80,Hepatic cysts-,imaging findings,Hepatic cysts with intra-abdominal hydrops,81,The wall of this simple cyst is composed of a thin layer of fibrous connective tissue;the surrounding liver is unremarkable(X10).,Hepatic cysts,82,肝脏腺瘤,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,.,84,Liver adenoma,85,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.,86,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.,87,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).,88,局灶性结节性增生,Focal nodular hyperplasia(FNH),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,.,90,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(Klatskin,X5).,91,肝脓肿,Hepatic Abscess,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,93,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,94,肝脓肿,-,实验室检查,白细胞升高见于绝大多数病例,贫血、,Hematocrit,Bilirubin,ALP,95,肝脓肿,-,影像学,平片,(,右胸,):,基底段不张、胸膜渗出、右膈上抬、运动度,平片,(,腹,):,肝肿大、气液平面、胃形态改变,US,CT scans,:,提供病灶位置、大小、数目的准确信息,96,A case Hepatic Abscess from,Streptococcis Milleri,A 58-year-old male complained about rash over the legs and lower back,arthralgias and soaking night sweats which had started about one week before his clinic visit.An ultrasound examination demonstrated multiple,hypoechoi,c lesions in the liver measuring up to 4.3x3.3 cm with increased blood flow to the periphery.On contrast-enhanced CT scan,these lesions appeared,hypodense.,(Klaus Bielefeldt,et al.),97,肝脓肿,鉴别诊断,其他引起不适、消瘦、贫血、发热的疾病,阿米巴肝脓肿,（,Amebic abscess,）,:,流行区旅居史,A history to endemic area,单发,Solitary abscess,疼痛、触痛、腹泻、肝肿大、血清学,amebiasis(+).,细菌性肝脓肿,（,Pyogenic abscess,）,:,常见于老年患者,黄疸、搔痒、脓毒血症、包块、,bilirubin,ALP,98,肝脓肿,并发症,肝内播散（多发脓肿）,破裂（胸腔、腹腔）,败血症,感染中毒性休克,肝功能衰竭,胆道出血,99,肝脓肿,治疗,抗生素：,usually aminoglycoside,clindamycin or metronidazole and ampicilin,应覆盖,E Coli,K pneumoniae,Bacteroides,enterococcus,and anaerobic streptococci,and be modified according to,cultures,.,US or CT,引导下经皮穿刺置管引流适用于大多数病例,部分病人需要开腹引流或肝叶切除,100,Thank You,！,Questions,？,1,、字体安装与设置,如果您对PPT模板中的字体风格不满意，可进行批量替换，一次性更改各页面字体。,在,“,开始”,选,项卡,中,，点击“,替,换”按,钮右,侧箭,头,，,选,择“,替,换,字,体,”。（如下,图）,在图“替换”下拉列表中选择要更改字体。（如下图）,在“替换为”下拉列表中选择替换字体。,点击“替换”按钮，完成。,102,2,、替换模板中的图片,模板中的图片展示页面，您可以根据需要替换这些图片，下面介绍两种替换方法。,方法一：更改图片,选中模版中的图,片,（,有些图片与其他,对象,进行了组合，,选,择,时,一定要选中图,片 本身，而不是组合）。,单击鼠标右键，选择“更改图片”，选择要替换的图片。（如下图）,注意：,为防止替换图片发生变形，请使用与原图长宽比例相同的图片。,102,赠送精美图标,