内科学-培训课件PPT
内科学-培训课件PPT,内科学,培训,课件,PPT
Hemorrhagic DisordersHuang Zhen-qian,ProfessorDept.of Hematology The First Affiliated Hospital,Guangzhou Medical U1ContentSummaryCauses and Mechanism of DiseaseCauses and Mechanism of DiseaseClinical FeaturesClinical FeaturesInvestigation of LabInvestigation of LabCriterion of DiagnosisCriterion of DiagnosisManagementManagement2DefinitionvWhen the normal hemostatic mechanism fails,major hemorrhage may follow minor trauma or may arise apparently spontaneously.3Mechanism of normal hemostasisVascular mechanismPlatelet mechanismBlood coagulation mechanism4Normal hemostasis567red thrombus8Anticoagulation and fibrinolystic mechanismvAnticoagulation systemAT-Protein C system:PC,PS,TMTFPIHeparin910Anticoagulation and fibrinolystic mechanismvFibrinolysis systemPlasminogenTissue-type plasminogen activator(t-PA)Urokinase-type plasminogen activator(u-PA)Inhibitors:2-plasmin inhibitor(2-PI),plasminogen activator inhibitor-1(PAI-1)11Anticoagulation and fibrinolystic mechanismPlasminogenActivatorInhibitorKallekrein (intrinsic)t-PA,u-PA PAI(extrinsic)2-PI plasmin fibrinogen(fibrin)FDP1213Classificationvvascular disordersvplatelet disordersvdisorders of blood coagulationvdisorders of anticoagulation system and fibrinolytic systemvComplex disorders of hemostatic mechanism14Classification:Vascular disordersvHereditary or congenital:Hereditary hemorrhagic telangiectasia(遗传性出血性毛细血管扩张症)遗传性出血性毛细血管扩张症),hereditary disorders of connective tissue such as Ehlers-Danlos syndrome.vSecondary:infections,chemical factors or drugs,disorders of metabolism(Vitamin C or P deficiency),pathological changes of vascular wall(atherosclerosis),connective tissue diseases.vAllergy:allergic purpura.vOther purpuras:purpura simplex,senile purpura,mechanic purpura,paraproteinemia.15Classification:platelet disordersThrombocytosisThrombocytopathyThrombocytopenia16Classification:platelet disorders17Classification:platelet disordersvThrombocytosisPrimary:essential thrombocythemiaSecondary:infections,injury,post-splenectomy,chronic myelocytic leukemia,other myeloproliferative disorders(such as polycythemia vera 真性红细胞增多症)真性红细胞增多症))18Classification:platelet disordersvFunctional abnormalities of plateletsHereditary:giant platelet syndrome(Bernard-Soulier syndrome),thrombasthenia(血小板无力症血小板无力症),Acquired:due to drugs,uremia,liver diseases,dysproteinemias.19Classification:disorders of blood coagulationvHereditary or congenital:hemophilia A(F deficiency),hemophilia B(F deficiency),factor deficiency(formerly hemophilia C),hypothrombinogenemia,hypofibrinogenemia,von Willebrands disease,other coagulation factors deficiency,including deficiency of activated-protein C inhibitor structural abnormalities.vAcquired:Vitamin K deficiency,severe liver diseases,disseminated intravascular coagulation(DIC)etc.20Classification:disorders of anticoagulation system and fibrinolytic systemvdisorders of anticoagulation system and fibrinolytic systemoverdose of heparin or dicumarol,liberation of tissue plasminogen activator into the circulation,antibodies against F,thromboplastin,thrombin,heparinoid anticoagulant,DIC.21Classification:Complex disorders of hemostatic mechanismvHereditary or congenitalvWDvAcquiredDICLiver disease22Etiological diagnosis:HistoryvWhoAge SexFamily history vWhenPredisposing cause Drug ingestion?Nutrition statusany concomitant diseases Frequency of the bleeding event 23Etiological diagnosis:Symptoms and signsvWhere:The site of bleeding(skin,mucous membrane,GI tract,solid organ,joint or muscle?)vWhat:The physical characteristics of the bleeding(petechial瘀点瘀点?Purpura紫癜紫癜?Ecchymoses瘀斑瘀斑?hematoma?)vOther concomitant symptoms and signsvVital signs:HR,RR,BP,etc.2425hemophilia26Differential diagnosisTable.The clinical distinction between disorders of vessels and platelets and disorders of blood coagulation 27Etiological diagnosis:Laboratory examinationsvScreening testsFor the Vascular disorders and platelet disorders capillary frangibility test bleeding time(BT)platelet countclot retraction test(CRT)28Etiological diagnosis:Laboratory examinationsFor the disorders of blood coagulationactivated partial thromboplastin time(APTT)prothrombin time(one stage method)(PT)thrombin time(TT)clotting time(CT)293031323334Etiological diagnosis:Laboratory examinationsvConfirmatory testsFor vascular disordersvWFEndothelin-1(ET-1)TM35Etiological diagnosis:Laboratory examinationsvConfirmatory testsFor platelet disordersmegakaryocytes in marrowmorphology of plateletsplatelet adhesion testaggregation test induced by ADP,adrenaline collagen,arachidonic acidanalysis of platelet glycoproteins etc.36Etiological diagnosis:Laboratory examinationsvConfirmatory testsFor disorders of blood coagulation measurement of different factor antigens and coagulant activities37Etiological diagnosis:Laboratory examinationsvConfirmatory testsFor disorders of anticoagulationAT-antigen and activity,TATPCFactor:C antibodyLupus-type anticoagulant,cuorin-type anticoagulant38Etiological diagnosis:Laboratory examinationsvConfirmatory testsFor disorders of fibrinolysis3P testFDPD-dimerPlasminogent-PA39Etiological diagnosis:Laboratory examinationsvSpecial testsFor hereditary disorders or some special disordersProtein structural analysisAmino acid sequencingGene analysisimmunopathology40Etiological diagnosis:diagnostic procedurehemorrhagic disorder?classification(vessel?BPC?Coagulation?)Which factor?quantity or quality?Congenital?Hereditary?Acquired?Gene and molecular biology analysis41TreatmentvEtiological treatment and preventionAcquired diseasesDrugs that impair platelet functions should be avoided.Vigorous treatment of the underlying diseases,such as liver disease.42TreatmentvEtiological treatment and preventionHereditary diseasesNo radical treatment.Avoid intramuscular injections,surgical operation and trauma.Plan surgical procedures carefully,if the operation is inevitable.Antenatal diagnosis43TreatmentvTreatment according to pathophysiologyDrugs decreasing the capillary fragility:Rutin,Vitamin C,adrenosem.Drugs used in thrombocytopenia:adrenal corticosteroid for immunothrombocytopenia.Replacement therapy in coagulation factors deficiencies:Vitamin K in acquired deficiency of Vitamin K dependent factors,coagulation factor transfusion.Antifibrinolysis drugs:para-aminomethylbenzoic acid(PAMBA 氨甲苯酸氨甲苯酸),tranexamic acid(t-AMCHA 氨甲环酸氨甲环酸),-aminocaproic acid(EACA 氨基己酸氨基己酸).Anticoagulants:immunosuppressive drugs for antibodies,protamine sulfate for heparinoid anticoagulants.44TreatmentvOther treatmentAnticoagulation and anti-platelet drugsPlasmapheresissurgery45复习思考题复习思考题v临临床床上上如如何何鉴鉴别别血血小小板板及及血血管管性性疾疾病病、凝凝血血性性疾疾病病所所致致出血?出血?v狼疮性抗凝物的检测及临床意义。狼疮性抗凝物的检测及临床意义。vATAT与肝素在抗凝血中的作用机理。与肝素在抗凝血中的作用机理。v出血性疾病的诊断思路。出血性疾病的诊断思路。v应用肝素抗凝血时,需要监测凝血功能,请问是监测应用肝素抗凝血时,需要监测凝血功能,请问是监测APTTAPTT还是还是PTPT,为什么?,为什么?46肝癌HepaticCancer广州医科大学附属第一医院消化内科陈学清1概念l肝癌可能起源于肝脏肝癌可能起源于肝脏,如肝细胞、胆管上皮或间质组织,或如肝细胞、胆管上皮或间质组织,或者从远处或邻近器官肿瘤转移而来者从远处或邻近器官肿瘤转移而来lPRIMARYMALIGNANTTUMORSHepatocellularCarcinoma(肝细胞癌)FibrolamellarHepatocellularCarcinoma(纤维板层肝细胞癌)纤维板层肝细胞癌)IntrahepaticCholangiocarcinoma(肝内胆管癌)Angiosarcoma(血管肉瘤)Hepatoblastoma(肝母细胞瘤)lPrimarycarcinomaoftheliverPrimaryhepaticcarcinoma:PHC2原发性肝癌l我国常见的恶性肿瘤之一l死亡率仅次于胃癌和食管癌,消化肿瘤第三l发病率呈上升趋势l 全世界25万/年死亡,中国占45%l多见于中年男性,男:女=5:134肝脏的大体解剖5胆总管肝固有动脉 肝门静脉Posteriorviewoftheliver.Theshapeoftheliverisdeterminedbymoldingagainstadjacentorgans6肝脏的解剖(胆管)7小叶内胆小管胆小管门脉周小胆管(Hering管)肝(血)窦胆管A.肝门静脉-肝动脉B.窦周(Disse腔)间隙C.肝细胞间毛细胆管肝脏的解剖8肝(血)窦 中央静脉 Disse腔 小叶下静脉(流入肝静脉)下腔静脉肝门静脉分支 分配静脉 输入微静脉肝动脉分支 门管小动脉 小叶内动脉 门管周小动脉 Figure69-1Thespatialrelationshipamongthedifferentcelltypesoftheliver.SinusoidalplasmacomesindirectcontactwithhepatocytesinthespaceofDisse.Theendothelialcellsarefenestratedandlackabasementmembrane.Kupffercellsarelocatedinthelumenofthesinusoid,wheretheyareindirectcontactwiththesinusoidalendothelialcellsandportalblood.Stellatecellsaresituatedbetweentheendothelialcellsandhepatocytesandcomeindirectcontactwithbothcelltypes.Thehepatocytesarejoinedwitheachotherbytightjunctionsandthegapjunctions.Thecanaliculardomainoftheplasmamembraneoftwoadjacenthepatocytesenclosesthebilecanaliculus.9星形细胞从解剖学上体会的l任何肝细胞损伤:引起肝功能改变 毛细胆管和肝(血)窦的改变的 l肝细胞不正常修复 肝细胞血供受影响 门静脉的压力会增大 进一步损害肝功能10原发性肝癌:病因l病毒性肝炎l肝硬化(多种病因所致)l食物和水:酒精、食物霉变(黄曲霉毒素)或含亚硝胺、缺乏微量元素、藻类污染l毒物与寄生虫:亚硝胺、偶氮芥类华支睾吸虫感染与胆管癌等l遗传因素:饮食习惯及环境。不同种族不同11我国原发性肝癌中1/3有慢性肝炎史流调HBsAg阳性率90%HBV与肝癌高发有关肝细胞癌中,5-8%抗HCV抗体阳性提示丙肝与肝癌发病有关12IncidenceofhepatocellularcarcinomaindifferentpartsoftheworldHigh,age-adjustedrate15cases/100,000/yr;intermediate,age-adjustedrate=5-15cases/100,000/yr;low,age-adjustedrate5CM,10CM者称巨块易发生肝坏死引起肝破裂。多呈圆形,质硬,可见包膜。位于肝包膜者易破裂结节型 癌块直径 5CM,常伴有肝硬化。瘤结节多个散在,圆形或椭圆形,大小不等,直径由数毫米至数厘米,有的相互融合形成较大的结节弥漫型 米粒黄豆大小结节散布全肝。常因肝衰死亡。小癌型 癌块直径3CM,或相邻二癌结节之和400g/L AFP由低浓逐渐升高不降 APF200g/L持续8周应排除妊娠和生殖胚胎瘤及活动性慢性肝病AFP异质体:肝癌血清中LCA结合型25%,良性肝病结合型25%,有助于提高PHC诊断率,且不受AFP浓度、肿瘤大小和病情早晚影响AFP单克隆克抗体28实验室检查肿瘤标记物检测-谷氨酰转移酶同工酶谷氨酰转移酶同工酶II(GGT2)原发和转移阳性率达90%,特异性达97.1%,与AFP无关。异常疑血酶原(异常疑血酶原(AP)肝癌阳性率达67%-l-l岩藻糖苷酶岩藻糖苷酶 (AFUAFU)诊断敏感性为75%,特异性为90%其他其他 酸性同工铁蛋白(AIF)、醛缩酶A(ALD-A)、5-核苷酸磷酸二酯酶同工酶V(5-NPD 5)29AFP和AFP异质体检测:针对原发性肝细胞癌有助于AFP阴性的原发性肝癌的诊断和鉴别诊断肿瘤标记物检测-谷氨酰转移酶同工酶谷氨酰转移酶同工酶IIII(GGTGGT2 2)原发和转移阳性率达90%,特异性达97.1%,与AFP无关。异常疑血酶原(异常疑血酶原(APAP)肝癌阳性率达67%-l-l岩藻糖苷酶岩藻糖苷酶 (AFUAFU)诊断敏感性为75%,特异性为90%其他其他 酸性同工铁蛋白(AIF)、醛缩酶A(ALD-A)、5-核苷酸磷酸二酯酶MarkerSensitivity(%)Specificity(%)CommentsAlpha-fetoproteinHigh-incidencepopulations:80-9090Relativelyquickandeasytomeasure;mostextensivelystudiedLow-incidencepopulations:50-70RelativelyexpensiveDes-carboxyprothrombin58-9184QuickandeasytomeasureMuchmoreexpensivethana-fetoprotein-L-Fucosidase7570-90Quickandeasytomeasure;relativelyinexpensiveTableTumorMarkersofHepatocellularCarcinomaNotethatsensitivityandspecificityratesvarybothwiththepopulationunderstudyandwiththeabsolutelevelofthemarker.Thus,thespecificityofamarkedlyelevatedalpha-fetoproteinlevelinpatientswithcirrhosisgreatlyexceedsthesensitivityofmildlyelevatedlevelsinpersonswithoutcirrhosis.30影像学检查超声显像目前筛查首选方法。查出直径为1CM以上的肿瘤,利用多谱勒或超声造影,了解供血状态。结合AFP用于普查,有利于早期诊断增强CT/磁共振显像(MRI)CT更客观和敏感是,是诊断和确定治疗策略的重要手段,直径1CM的肿瘤80%,结合肝动脉造影,可检出直径1CM的肿瘤,是诊断小肝癌和微小肝癌的最佳方法。MRI为非放射性,可短期可重复进行X线肝血管造影在B超或CT/MRI检查不满意时进行。对直径12cm的小肝癌,可做出精准诊断,达90%其它:内镜下逆行性胰胆管造影(ERCP)放射性核素肝显像用99得-红细胞作血池显影有助于肝癌与肝浓疡、囊肿、血管瘤等良性病变的鉴别。31正常肝声像正常肝声像包膜整齐、光滑,呈强回声。实质内分布均匀,弥漫细小回声。32肝癌肝癌直接征象:直接征象:肝内实质性占位,回声可由低中高(由小到大),内部可呈“互相融合”、“卫星”状。33间间接接征征象象:肝大,包膜凹凸不平,管道走向失常,门脉内异常团块回声。CDFICDFI:周边丰富高速低阻血流34Figure:超声检查显示肝细胞癌结节性高回声区伴散在低回声区,边界超声检查显示肝细胞癌结节性高回声区伴散在低回声区,边界不清不清Ultrasonograminapatientwithhepatocellularcarcinomashowinganodularhyperechoicpatternwithscatteredhypoechoicareas.Theedgesofthetumorareill-defined.35影像学检查超声显像目前筛查首选方法。查出直径为1CM以上的肿瘤,利用多谱勒或超声造影,了解供血状态。结合AFP用于普查,有利于早期诊断增强CT/磁共振显像(MRI)CT更客观和敏感是,是诊断和确定治疗策略的重要手段,直径1CM的肿瘤80%,结合肝动脉造影,可检出直径1CM的肿瘤,是诊断小肝癌和微小肝癌的最佳方法。MRI为非放射性,可短期可重复进行X线肝血管造影在B超或CT/MRI检查不满意时进行。对直径12cm的小肝癌,可以更准确诊断其它:内镜下逆行性胰胆管造影(ERCP)放射性核素肝显像用99得-红细胞作血池显影有助于肝癌与肝浓疡、囊肿、血管瘤等良性病变的鉴别。36正常腹部CT检查结果NormalanatomicrelationoftheLIVERwithotherintra-abdominalstructuresasshownbycomputedtomography.A,aorta;C,venacava;G,incidentalgallstone;I,smallintestine;K,leftkidney;L,liver;P,portalvein;S,stomach;V,vertebra37FigureComputedtomographicscanofapatientwithhepato-cellularcarcinomainvolvingmuchoftheleftlobeandtheadjacentpartoftherightlobeoftheliver38394041大肠癌肝转移42MultiphasicmRimagingofthelivershowinghepatocellularcarcinomawithcharacteristicfeatures,includinghyperintensity(arrow)onT2-weightedimage(top left panel)butnotonT1-weightedimage(top right panel43影像学检查超声显像目前筛查首选方法。查出直径为1CM以上的肿瘤,利用多谱勒或超声造影,了解供血状态。结合AFP用于普查,有利于早期诊断增强CT/磁共振显像(MRI)CT显示直径1CM以上的肿瘤,结合肝动脉造影,可检出直径1CM的肿瘤,是诊断小肝癌和微小肝癌的最佳方法。MRI为非放射性,可短期可重复进行X线肝血管造影在B超或CT/MRI检查不满意时进行。对直径12cm的小肝癌,可以更准确诊断其它:内镜下逆行性胰胆管造影(ERCP)放射性核素肝显像用99得-红细胞作血池显影有助于肝癌与肝浓疡、囊肿、血管瘤等良性病变的鉴别。44PHC肝内多发转移介入前CT扫描45EED影像学检查超声显像目前筛查首选方法。查出直径为1CM以上的肿瘤,利用多谱勒或超声造影,了解供血状态。结合AFP用于普查,有利于早期诊断增强CT/磁共振显像(MRI)CT显示直径1CM以上的肿瘤,结合肝动脉造影,可检出直径2cm肝癌特征性占位性病变影像学结合AFP标准:肝脏活检阳性 诊断标准(1)一项典型的影像学检查均显示有2cm肝癌特征性占位性病变血清AFP400g/L(无排除性条件)51组织学标准:金标准ERCP检查:胆管癌可能通过ERCP行胆汁脱落细胞学 检查,甚至在胆道镜下行组织活检诊断标准(2)对影像学检查不能确定诊断的2cm肝内结节应通过 肝穿刺激活检以证实52鉴别诊断(1)继发性肝癌病情轻AFP阴性多为多发,可找到原发灶必要时病理确诊肝硬化53原发性肝癌通常发生在肝硬化的基础上,二者的鉴别常有困难如果肝硬化病例有明显的肝大、质硬的大结节,或肝萎缩变形而影像检查又发现占位性病变,则肝癌的可能性很大方法:反复检测血清AFP或AFP异质体,密切随访,最终能做正确诊断鉴别诊断(1)继发性肝癌病情轻、AFP阴性多为多发,可找到原发灶必要时病理确诊肝硬化:增强CT/MRI动脉强化快进快出诊断肝癌,无强化考虑肝硬化结节AFP400ng/ml有助于肝癌诊断活动性肝病AFP和ALT动态曲线平衡 多支持活动肝病AFP和ALT曲线分离 多支持肝癌肝脓肿发热、肝区疼痛、白细胞高,超声检查见脓肿液性暗区必要时US引导诊断穿刺,或诊断性治疗肝包虫病:相关的生活史非常重要54鉴别诊断(2)肝局部脂肪浸润:多见肝硬化早期或糖尿病脂肪浸润,CT检查肝局部密度减低。但肝A造影病灶血管无扭曲可鉴别。必要时活检。邻近肝区的肝外肿瘤腹膜后软组织或肾、肾上腺、胰腺、结肠等影像学和AFP检查有利于鉴别其它肝脏良恶性肿瘤或病变肝血管瘤、肝囊肿、肝包虫病、肝腺瘤及局灶结节增生、肝内炎性假瘤等定期行超声、CT、MRI等检查帮助诊断,必要时超声引导下肝诊断性穿刺55肝癌的治疗随着医学技术的进步,以及人群体检的普及,早期肝癌和小肝癌的检出率逐年提高早发现、早治疗早期肝癌手术根治切除不能切除应采取综合治疗模式56治 疗手术治疗手术治疗:根治原发性肝癌的最好手段,肝癌对化疗和放疗不敏感肝癌对化疗和放疗不敏感局部治疗局部治疗 肝动脉化疗栓塞(TACE、非手术者首选)、无水酒精注射、射频等物理治疗肝移植:如肝癌合并肝硬化肝移植:如肝癌合并肝硬化药药物物治治疗疗:HBVHBV感感染染者者在在手手术术、局局部部治治疗疗或或肝肝移移植植后后,均均需需坚坚持持口口服服抗抗病病毒毒治治疗疗,肝肝移移植植患患者者需需要要终终生生使使用用免免疫疫抑抑制制剂剂患患者者教教育育:休休息息、严严格格禁禁酒酒及及乱乱用用药药物物、注注意意饮饮食食、有有肝肝硬硬化化低低盐盐限限水水钠钠、避避免免感感染染、有有轻轻微微肝肝性性脑脑病病者者避避免免开开车车等等5758凡有手术指征者均应积极争取手术切除 手术适应证:诊断明确,估计病变局限于一叶或半叶,未侵及第一、二肝门和下腔静脉肝功代偿好、凝血酶原时间不低于正常的50%无明显黄疸、腹水或远处转移心、肺、肾功能良好,能耐受手术术后复发,病变局限于肝的一侧者经肝动脉栓塞化疗或肝动脉结扎、插管化疗后,病变明显缩小,估计有手术切除者对大肝癌可采用二步切除术肝癌的手术治疗治 疗手术治疗:手术治疗:根治原发性肝癌的最好手段,肝癌对化疗和放疗不敏感肝癌对化疗和放疗不敏感局部治疗局部治疗 肝动脉化疗栓塞(TACE、非手术者首选)、无水酒精注射、射频等物理治疗肝移植:如肝癌合并肝硬化肝移植:如肝癌合并肝硬化药药物物治治疗疗:HBVHBV感感染染者者在在手手术术、局局部部治治疗疗或或肝肝移移植植后后,均均需需坚坚持持口口服服抗抗病病毒毒治治疗疗,肝肝移移植植患患者者需需要要终终生生使使用用免免疫疫抑抑制制剂剂患患者者教教育育:休休息息、严严格格禁禁酒酒及及乱乱用用药药物物、注注意意饮饮食食、有有肝肝硬硬化化低低盐盐限限水水钠钠、避避免免感感染染、有有轻轻微微肝肝性性脑脑病病者者避避免免开开车车等等5960TACE为原发性肝癌非手术治疗的首选方案 疗效好,可提高患者3年生存率 步骤:经皮穿刺股动脉,在X线透视将将导管插至肝固有动脉或其分支,注射抗肿瘤药或栓塞剂 常用的栓塞剂有明胶海绵碎片和碘化油 碘化测能栓塞0.05mm口径血管,甚至可填塞肝血窦,可持久阻断血流。目前多用碘化油混合化疗 TACE可反复多次治疗,一般每4-6周重复一次,经2-5次后许多肝癌明显缩小,可进行手术切除不足:对播散卫星灶和门静脉癌栓的疗效有限,更难控制病灶的远处转移肝癌肝动脉化疗栓塞治疗PHC肝内多发转移介入治疗后6162原发性肝癌无水酒精注射治疗(PEI)步骤:在B超引导下,将无水酒精直接注入肝癌组织内,使癌细胞脱水、变性,产生凝固性坏死,属于一种化学治疗肝癌的方法。PEI对小肝癌可使肿瘤明显缩小,甚至可以达到肿瘤根治的程度 对晚期肝癌可以控制肿瘤生长的速度,延长患者的生存期推建对象:肿瘤直径小于3cm,结节数在3个以内伴有肝硬化而不能手术治疗的主要方法肝癌无水酒精注射治疗63原发性肝癌物理治疗包括:射频消融治疗、微波组织凝固、高功率聚焦超声治疗,激光等 局部高温疗法不仅可以使肿瘤细胞变性、坏死,还可以增强肿瘤对放疗的敏感性 另外,冷冻疗法和直流电疗法也可以达到杀伤肝癌细胞的作用。冷冻治疗还可能有免疫增强的疗效肝癌的物理治疗治 疗手术治疗:手术治疗:根治原发性肝癌的最好手段,肝癌对化疗和放疗不敏感肝癌对化疗和放疗不敏感局部治疗局部治疗 肝动脉化疗栓塞(TACE、非手术者首选)、无水酒精注射、射频等物理治疗肝移植肝移植:如肝癌合并肝硬化:如肝癌合并肝硬化药药物物治治疗疗:HBVHBV感感染染者者在在手手术术、局局部部治治疗疗或或肝肝移移植植后后,均均需需坚坚持持口口服服抗抗病病毒毒治治疗疗,肝肝移移植植患患者者需需要要终终生生使使用用免免疫疫抑抑制制剂剂患患者者教教育育:休休息息、严严格格禁禁酒酒及及乱乱用用药药物物、注注意意饮饮食食、有有肝肝硬硬化化低低盐盐限限水水钠钠、避避免免感感染染、有有轻轻微微肝肝性性脑脑病病者者避避免免开开车车等等64肝移植的适应症65米兰(Milan)标准:肿瘤直径 5cm,或肿瘤少于3个,每个直径 3 cm;无大血管浸润;无淋巴结或肝外转移。UCSF标准:单个肿瘤6.15cm,或肿瘤少于3个,最大的不超过4.15cm,总直径和不超过8cm,无肉眼可见的血管侵犯,无淋巴结或肝外转移。Pittsburgh标准:按照肿瘤有无血管浸润,有无两叶受累,最大肿瘤直径,淋巴结情况以及有无转移等分成、A、B、A、B共6期,认为至B 期适合肝移植,即匹兹堡标准肿瘤复发是影响的肝癌肝移植术后的主要危险因素主要影响因素为:肿瘤的大小、个数,肿瘤的分布,有无血管侵犯,有无淋巴结转移,以及甲胎蛋白(AFP)的水平;术后危险因素为肿瘤的组织学分级,是否有微血管侵犯目前被普遍接受的标准主要有三个米兰(Milan)标准、UCSF标准以及Pittsburgh标准肝移植的适应症66复旦标准单发肿瘤直径9厘米,或多发肿瘤3个,且最大直径5厘米,全部肿瘤直径总和9厘米,无大血管转移、淋巴结转移及肝外转移。杭州标准累计肿瘤直径8厘米,或累计肿瘤直径8厘米,但术前血清甲肝蛋白400ng/ml且肿瘤组织学分级为高或中分化。相比较Milan和Pittsburgh标准,我国肝移植标准显著扩大了肝癌肝移植的适应症范围。治 疗手术治疗:手术治疗:根治原发性肝癌的最好手段,肝癌对化疗和放疗不敏感肝癌对化疗和放疗不敏感局部治疗局部治疗 肝动脉化疗栓塞(TACE、非手术者首选)、无水酒精注射、射频等物理治疗肝移植:如肝癌合并肝硬化肝移植:如肝癌合并肝硬化药药物物治治疗疗:HBVHBV感感染染者者在在手手术术、局局部部治治疗疗或或肝肝移移植植后后,均均需需坚坚持持口口服服抗抗病病毒毒治治疗疗,肝肝移移植植患患者者需需要要终终生生使使用用免免疫疫抑抑制制剂剂患患者者教教育育:休休息息、严严格格禁禁酒酒及及乱乱用用药药物物、注注意意饮饮食食、有有肝肝硬硬化化低低盐盐限限水水钠钠、避避免免感感染染、有有轻轻微微肝肝性性脑脑病病者者避避免免开开车车等等67其它治疗措施68放射治疗放射治疗:常规放疗常规放疗,或种植放射性粒子、标记同位素钇等或种植放射性粒子、标记同位素钇等全身化疗全身化疗:常用药物阿霉素常用药物阿霉素,5-FU,5-FU,丝裂霉素等丝裂霉素等,联合用药联合用药生物和免疫治疗生物和免疫治疗常用干扰素、肿瘤坏死因子、白细胞介素2(1L-2)单抗、酪氨酸激酶抑制剂(靶向),基因治疗,肿瘤疫苗等综合治疗综合治疗:一种或多种方法联合一种或多种方法联合,中晚期主要的治疗方法中晚期主要的治疗方法尽可能除去肿瘤,修复机体免疫功能,保护重要器官功能ModalityCommentsSurgicalresectionOffersbestchanceforcurebutisseldompossiblewhenthetumorissymptomaticMaybetechnicallydifficultHighrecurrencerateafterresectionLivertransplantationMaybesuccessfulinselectedpatientsRequirestransfertoatransplantationcenterand,postoperatively,lifelongimmunosuppressionHighrecurrencerateExpensiveAlcoholinjectionorradiofrequencyablationPalliativeforsmall(usuallymultiple)tumorsthatcannotberesectedConfirmationthatallthemalignantcellshavebeendestroyedmaybedifficultChemoembolizationMayshrinkselectedtumorstothepointthattheymaybecomeresectableEffectispalliativeforlocalizedbutunresectabletumorsChemotherapyPalliativeonly;canbeusedasanadjuncttosurgicalresectionortransplantationDrugtoxicityiscommonTreatmentOptionsforHepatocellularCarcinoma69转移性肝癌的治疗70根据转移性肝癌与原发灶临床表现之间的时间关系,分为三型:早发型:临床尚未有原发癌时,转移性肝癌已有明显的临床表现同步型:临床上发现原发癌的同时,也了现有肝转移迟发型:原发癌经手术切除后,隔一段时间才发生肝转移一致认为,手术切除是使病人有可能获得治愈的惟一方法肝癌的并发症的治疗上消化道出血:区分门脉和非门脉肝癌结节破裂出血:外科手术肝性脑病:早识别,减少肠内氮 源性生成和吸收,促进体内氨代谢,人工肝等继发感染:化疗、放疗,肠道感染,褥疮等7172预 后预后的估计:1、瘤体小于5cm,能早期手术者则预后好 2、癌肿包膜完整,尚无癌栓形成者预后好 3、机体免疫状态良好者预后好 4、合并肝硬化或有肝外转移者预后较差 发生消化道出血、肝癌破裂者预后很差73预 防l 防治病毒性肝炎l 注意食物清洁、粮食霉变l 改进饮用水质l 减少各种有害物的接触74 男,40岁,腹胀5年,加重1年,近一周发热,伴腹痛,有慢性乙型肝炎史。查体:巩膜黄染,全腹膨隆,压痛、反跳痛阳性,脾肋下4cm,移动性浊音阳性。最可能的诊断:A.肝硬化并发原发性腹膜炎B.结核性腹膜炎C.肝癌并癌性腹水D.溃疡病穿孔E.急性化脓性腹膜炎病例一75 男,40岁,有慢性肝炎史15年,近来腹胀消瘦,体格检查:巩膜黄染,上腹部触到拳头大质硬、表面不光滑包块,最可能的诊断是:A.原发性肝癌B.转移性肝癌C.慢性肝炎D.肝脓疡E.肝硬化病例二76谢谢大家!77
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