肝脏疾病本科彭涛2011 ppt课件.ppt

个人简历,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） 2011-10-17,3,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. Gilssons capsule, bare area, falciform lig., coronary lig., gastrohepatic lig., hepatoduodenal lig. foramen,1: liver; 2: rib cage; 3: spine; 4: pelvis,4,肝脏解剖生理概要-2,The American (lobar) system & the French (Couinaud segmental) system.,5,肝脏解剖生理概要-3,6,肝脏解剖生理概要4 -Cauinaud segmentation,7,肝脏解剖生理概要5 -left hepatic vein,8,肝脏解剖生理概要6 -middle hepatic vein,9,肝脏解剖生理概要7 - hepatic vein & portal vein,10,肝脏解剖生理概要8 - portal vein plane,11,“精准肝脏外科时代” 保留肝中静脉的左半肝切除,12,“精准肝脏外科时代” 保留肝右静脉的右后叶肝切除,13,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,14,代谢: bilirubin, carbohydrate, lipid, protein, vitamin, drugs ICG15min渚留率,肝脏解剖生理概要10,Hepatic Trauma 肝脏创伤,16,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 (SVII) 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),17,Symptoms and signs: hypovolemic shock (hypotension, decreased urinary output, low 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,18,Hepatic trauma -imaging findings,19,Hepatic trauma -imaging findings,Hydrops at the adrenal gland,Hepatic trauma with fracture of left rib,20,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.,21,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 !,22,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.,23,Hepatic trauma -Complications and prognosis,Rebleeding Subhepatic sepsis Hemobilia-selective angiography and embolization Stress ulcersH2 receptor antagonists (Cimetidine, Ranitidine, Omeprazole etc) Mortalitydepends on the type and severity of injuries.,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 Primary Liver Cancer ,26,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%,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, 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,30,1/100,000 5/100,000,背景 流行病学,全球发病率在上升 发病有地理特征 非洲: 164.6/100 000 (莫桑比克) 美国：标化发病率 1-7/100 000 /年 男性多于女性：49 :1（1:1 in group without preexistent liver disease） 移民美国的东方人发病率6倍高于白人,20/100,000 40/100,000,NPC HCC,31,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),32,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,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 (Fibrolamellar hepatoma) 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：2.0cm 10.0cm,35,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.,36,Hepatocellular carcinoma, liver, gross,Nodule of hepatocellular carcinoma in chronic hepatitis C; the pale golden yellow color is common.,37,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.,38,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,39,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).,40,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.,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,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.,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.,44,HCC-Imaging findings (DSA),45,HCC-Imaging findings,介入前,介入后,46,HCC-Imaging findings CT scan,Arterial phase,Portal vein phase,47,肝癌MRI表现,48,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,49,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).,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 & 体征: 甲胎蛋白: RI-AFP400ng/ml, 8weeks, exclusion of pregnancy, active hepatitis, embryonic tumors 影像学: B-US, CT, MRI, DSA 活检:,51,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。,52,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,TACE,多个肿瘤,门脉转移,N1,M1,PS: performance status，ECOG体能状态评分 CP: Child-Pugh 评级,新药治疗,索拉非尼,53,原发性肝癌的综合治疗原则,早期诊断，早期治疗； 早期病人手术切除是治疗的最有效方法。 根据不同病情进行综合治疗，是提高疗效的关键； 肝癌术后复发的积极再治疗可进一步提高肝癌术后的生存率。,54,治疗 部分肝切除,根治性部分肝切除提供了几乎唯一的治愈机会 根治性切除的标准: 无远处转移或肝静脉/门静脉侵犯; 肿瘤限于所切除的肝段或肝叶.,55,治疗 部分肝切除,术后预后不良的指证: 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,56,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.,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：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3cm病灶，可能获得相当于外科切除的效果。 经动脉化疗栓塞(Arterial chemoembolization): 理论依据: HCC主要是肝动脉供血，栓塞剂造成肿瘤缺血及延缓化疗药清除 理论缺陷: 周边肿瘤细胞肝动脉/门静脉双重血供 实际效果：对选择性的病例可造成肿瘤坏死、延长生存.,59,口服药物：最新研究结果在重要医学杂志先后发表,SHARP研究 New England Journal Medicine,Llovet JM et al，2008;359:378-90.,Oriental研究 Lancet Oncology,Cheng AL et al，2008年12月在线发表,Llovet JM et al. N Engl J Med 2008;359:378-90. Cheng AL et al. Lacnet Oncoligy 2008 Dec 17 online publish .,课外阅读参考文献：,2009 中国原发性肝癌规范化诊治专家共识,转移性肝癌,62,转移性肝癌-背景,发生率较HCC高20倍 约50%来自消化系统 分型：同时性转移，异时性转移 常见原发灶: 乳腺、肺、胰腺、胃、大肠、肾、卵巢、子宫 途径: 体循环、门静脉、淋巴、邻近肿瘤侵犯,63,Metastatic neoplasms of the liver,The numerous mass lesions that are of variable size. Some of the larger ones demonstrate central necrosis. The masses are metastases to the liver.,This large solitary metastatic nodule was from a colon primary; the glairy cut surface represents a high mucin content.,64,Metastatic neoplasms of the liver,Here are liver metastases from an adenocarcinoma primary in the colon, one of the most common primary sites for metastatic adenocarcinoma to the liver,Multiple confluent nodules with central umbilication and peripheral hyperemia are classic for metastasis to liver; the primary here was a breast carcinoma.,65,转移性肝癌-临床表现,症状 & 体征: 乏力、消瘦、厌食 上腹疼痛、腹水、黄疸、发热、白细胞升高 PE: 肝脏肿大、肿块、触痛、脾大、腹壁静脉曲张,66,转移性肝癌-临床表现,实验室检查： Hematocrit 3036% bilirubin, ALP 肿瘤标志物：CEA,CA125,19-9 活检,67,转移性肝癌-临床表现,影像学： 超声: 初筛 CE-CT: MRI：,68,This computed tomographic (CT) scan without contrast of the abdomen in transverse view demonstrates multiple mass lesions resulting in a markedly enlarged liver extending from right to nearly the left side of the upper abdomen. These are metastases from a colonic adenocarcinoma. A normal sized spleen is seen at the lower left,69,This computed tomographic (CT) scan with contrast of the abdomen in transverse view demonstrates multiple mass lesions representing metastases from a colonic adenocarcinoma. A normal spleen appears at the lower right in the image (on the patient's left).,70,转移性肝癌-治疗,手术切除的指证 无肝外转移 技术可行 对以下疾病可能达到根治性切除的效果: 结肠、胰岛细胞癌、类癌、邻近肿瘤侵犯. 对以下疾病可能效果有限: 乳腺、胰腺、胃、女性盆腔脏器、肺.,71,转移性肝癌-化疗,经肝动脉插管化疗：优于全身化疗 肝动脉结扎或栓塞,课外阅读参考文献：,2010年 结直肠癌肝转移诊断和综合治疗指南-中华胃肠外科杂志2010，Vol 13(6):457,肝血管瘤,74,肝血管瘤,最常见的肝脏良性肿瘤 女性男性(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,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.,76,Hemangiomas,Sequential changes during angiograpgy: a vascular lesion with delayed clearing of the contrast medium.,77,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.).,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,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.).,81,Hepatic cysts-imaging findings,Hepatic cysts with intra-abdominal hydrops,82,The wall of this simple cyst is composed of a thin layer of fibrous connective tissue; the surrounding liver is unremarkable (X10).,Hepatic cysts,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,Liver adenoma,86,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.,87,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 patient's demise.,88,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).,局灶性结节性增生 Focal nodular hyperplasia (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,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).,肝脓肿 Hepatic Abscess,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、Hematocrit Bilirubin, 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、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,97,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 hypoechoic 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.),98,肝脓肿 鉴别诊断,其他引起不适