肝功能化驗(yàn)異常的分析與解釋

1,肝功能化驗(yàn)異常的分析與解釋,趙新顏,2,肝臟具有那些功能?,代謝功能膽汁生成和排泄 凝血功能解毒作用,3,肝臟分類檢測(cè),Enzyme testsAminotransferasesAlkaline phosphataseGamma glutamyl transpeptidase Tests of synthetic function Albumin Prothrombin time Tests of hepatic transport capabilitySerum bilirubin,4,丙氨酸氨基轉(zhuǎn)移酶Alanine Aminotransferase (ALT),Serum Glutamic-pyruvic Transaminase (SGPT)組織來源:肝細(xì)胞胞漿,丙氨酸,酮戊二酸,丙酮酸,谷氨酸,5,天冬氨酸氨基轉(zhuǎn)移酶Aspartate Aminotransferase (AST),Serum Glutamic-oxaloacetic Transaminase (SGOT)組織來源:心臟,肌肉,腎臟,腦,胰腺,紅細(xì)胞肝細(xì)胞胞漿(20%)及線粒體(80%),天門冬氨酸,酮戊二酸,草酰乙酸,谷氨酸,AST,6,ALT與AST,Severe ( 20 times, 1000 U/L) 急性病毒性肝炎,藥物或毒物損傷,休克肝Moderate (3-20 times )慢性肝炎,藥物性肝炎,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,7,ALT: AST ratio,AST：ALT2酒精性肝病AST：ALT1肝硬化,8,堿性磷酸酶Alkaline Phosphatase (ALP),組織來源: 肝臟,骨骼,腸道,胎盤機(jī)制:膽汁酸增加ALP脂溶性,刺激ALP合成,9,堿性磷酸酶Alkaline Phosphatase (ALP),意義:肝臟相關(guān)的:肝內(nèi)膽汁淤積部分或完全膽道梗阻肝臟腫瘤肉芽腫性病變非肝臟因素:骨腫瘤妊娠,10,谷酰轉(zhuǎn)肽酶 Gamma-glutamyl transferase (GGT),組織來源: membrane of cells (liver, kidney, pancreas, intestine, prostate)意義:膽汁淤積原發(fā)性或轉(zhuǎn)移性肝癌酒精性肝病胰腺癌,壺腹周圍癌,11,肝功能異常類型,12,膽紅素代謝示意圖,13,膽紅素Bilirubin (BIL),間接膽紅素增高血癥:生成過多肝臟攝取受損葡萄糖醛酸化受損,14,間接膽紅素增高血癥(例1),李霞，女，27歲非洲工作（08-4-18至08-10-7）稽留熱5天（08-10-18至08-10-22）血圖片：可見瘧原蟲（外院）服用氯奎3日，青蒿琥酯片及蒿甲醚5日熱退（08-10-20至08-10-27）入院前3日再次高熱伴陣發(fā)中上腹絞痛（08-10-28）血色素9.1g/dl降至3.9g/dl伴醬油色尿，網(wǎng)織紅2.53%ALT 30U/L,AST 57U/L,TBIL 40.3umol/L,IBIL 27.43umol/L,LDH863U/L,15,間接膽紅素增高血癥(例2),中年女性。膽結(jié)石擬手術(shù)，發(fā)現(xiàn)間接膽紅素增高請(qǐng)會(huì)診。Hb正常網(wǎng)織紅細(xì)胞比例增高。外周血圖片,16,間接膽紅素增高血癥(例3),劉壯飛 ，男性，12歲反復(fù)皮膚黃染伴乏力6年 父親自18歲起發(fā)現(xiàn)膽紅素升高，以間接膽紅素為主ALT 16U/L，AST 27 U/L正常TBIL 46.2umol/L，IBIL 30.0umol/L。組織病理學(xué)最終診斷：Gilbert綜合征,17,膽紅素Bilirubin (BIL),直接膽紅素增高血癥:肝外膽管梗阻肝內(nèi)膽汁淤積,18,肝外膽管梗阻,李彥紅，女性，77歲突然皮膚鞏膜黃染10天ALT，AST 正常ALP 302U/L，GGT361U/LTBIL 250.60umol/L, DBIL 233.60umol/L,19,肝外膽管梗阻,20,正常胰膽管系統(tǒng),21,膽汁分泌障礙、流速減慢或停滯，可發(fā)生在從肝細(xì)胞、 毛細(xì)膽管直至Vater壺腹各水平。 臨床：以瘙癢、黃疸、ALP、GGT增高等為特征。 病理：肝細(xì)胞及/或膽道系統(tǒng)膽汁成分蓄積。,肝內(nèi)膽汁淤積的概念,22,肝內(nèi)各級(jí)膽管及其命名,Hering管,總膽管,右肝管,左肝管,400-800um 段膽管,300 -400um 區(qū)膽管,100um 隔膽管,15-100um 葉間小膽管,15um 細(xì)膽管,毛細(xì)膽管,肝細(xì)胞,23,肝內(nèi)毛細(xì)膽管小葉間膽管,ductule,Bile canaliculus,自Scheuer P J ， Live Biopsy Interpretation. 2006 ，53,24,肝內(nèi)膽汁淤積,Viral hepatitisEtoh hepatitisEBV,CMVAnabolic, steroids,Contraceptives,TPNPrimary biliary sclerosisPrimary sclerosing cholangitis,25,肝內(nèi)膽汁淤積,26,肝內(nèi)膽汁淤積,27,肝內(nèi)膽汁淤積,28,甘氨酸，?；撬?總膽汁酸 TBA,29,30,肝臟合成功能,白蛋白MalnutritionNephrotic syndromeProtein losing enteropathy (Sprue,Crohns)凝血酶原活動(dòng)度60%4060%40%膽堿脂酶,31,膽堿脂酶Acetylcholinesterase,真性膽堿脂酶紅細(xì)胞和腦灰質(zhì)運(yùn)動(dòng)神經(jīng)節(jié)終板 有機(jī)磷中毒假性膽堿酶（擬膽堿脂酶）肝臟合成反應(yīng)肝功能儲(chǔ)備孕婦及口服避孕藥可降低,32,肝功能儲(chǔ)備 Child-Pugh,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.,33,肝功能儲(chǔ)備 Child-Pugh,34,肝功能儲(chǔ)備 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.,35,女性，54歲主訴：上腹不適、惡心2天入院日期：20080821,高球蛋白血癥,36,治療前后肝功能,37,高球蛋白血癥,中年女性,急性起病.轉(zhuǎn)氨酶顯著增高,輕度黃疸.明顯高球蛋白血癥.ANA陽(yáng)性.肝組織病理學(xué)符合自身免疫性肝炎的表現(xiàn).激素治療基本有效!,38,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,39,Hyperglobulinemia,Hyperglobulinemia: Polyclonal Gammopathy Chronic bacterial diseases Pneumonia Chronic fungal diseases Chronic protozoal 原蟲的 / rickettsial diseases,40,Hyperglobulinemia,Hyperglobulinemia: Polyclonal GammopathyChronic viral diseases Neoplasia Lymphoma Mast cell tumor Other tumors Autoimmune disorders Systemic lupus erythematosus Chronic polyarthritis Others,41,Hyperglobulinemia,Hyperglobulinemia: Monoclonal Gammopathy Neoplasia Multiple myeloma Lymphoma Chronic lymphocytic leukemiaInflammation/infection Leishmaniasis Idiopathic Waldenstrom macroglobulinemia Benign monoclonal gammopathy,42,Serum Protein Electrophoresis-Normal Pattern,43,Serum Protein Electrophoresis-Polyclonal Gammopathy,sarcordosis,The sequential increase of the globulin fractions illustrated sarcoid stepping.,44,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,45,Serum Protein Electrophoresis-Cirrhotic Pattern,beta-gamma bridge pattern,end stage liver disease secondary to chronic alcohol abuse,46,Serum Protein Electrophoresis-Acute inflammatory pattern,pneumonia and pyelonephritis,albumin and gamma globulin are decreased and alpha-2-globulin becomes very prominent,47,Serum Protein Electrophoresis-Alpha 1 anti-trypsin deficiency,alpha-1-anti-trypsin deficiency,48,Serum Protein Electrophores