肝臟病理_ppt課件

Welcome,肝臟疾病病理學(xué)診斷,OutlineofGuidelines,Classificationofliverdiseases,LIVER,LiverBiopsy,LiverBiopsy,ConfirmthediagnosisSerologicalbloodtestsEstablishdegreeoffibrosisSerologyBiopsynotrepresentativeIdentifycirrhosisDetermineoptimumtherapy,Liverbiopsyadequacy,“Mosthepatopathologistsaresatisfiedwithabiopsyspecimencontainingatleastsixtoeightportaltracts”.BravoAAetalNEJM344,495;2001.Weshouldnotbeprimarilyconcernedwiththesizeofbiopsythat“satisfies”thepathologist.Thecorrectquestionis:Whatsizeofbiopsywillprovideareliableassessmentforthepatientsmanagement?,Liverbiopsyadequacy,GuidoMandRuggeM.SeminLivDis24,89;2004.Inmostdiffuseliverdiseasesexaminationof12-15completeportaltractsisnecessary.20mmofa1.4mmdiameter(17gauge)needlebiopsy.Progressivelylongersamplesofthinnerbiopsiesareneeded.,36-1肝臟活檢標本的評價,整體情況-低倍鏡匯管區(qū)中、高倍鏡肝小葉中、高倍鏡中央靜脈中、高倍鏡,LOBULEVSACINUS,肝小葉,肝板、肝竇,肝臟,EM,肝臟,EM(cont.),匯管區(qū)和中央靜脈,36-2常用診斷名詞的定義,嗜酸性小體氣球樣變性Ductule葉間膽管碎宵狀壞死,灶狀壞死帶狀壞死融合性壞死大片壞死橋接壞死,Acidophilbody,BallooningDegeneration,FattyDegenerationAlcoholicliverdisease,Ductule,Interlobularbileduct,Necrosis,piecemeal,Necrosis,focal,Necrosis,Zonal,Necrosis,Confluent,Necrosis,Massive,Necrosis,Bridging,DrugandToxin-InducedLiverDisease,36-3肝小葉淋巴細胞浸潤伴有或不伴有肝細胞變性或壞死,急性醫(yī)源性急性病毒性(HAV,HBVB,HCV,CMV,EBVetc)自身免疫性癌髓外造血白血病/淋巴瘤原發(fā)性膽管性肝硬化,36-4肝小葉多形核細胞浸潤伴有或不伴有肝細胞變性或壞死,酒精性肝炎細菌/真菌感染醫(yī)源性反應(yīng)敗血癥“手術(shù)性”肝炎病毒感染（CMV),AutoimmuneHepatitis,36-5肝細胞壞死伴輕微炎癥反應(yīng),急性病毒感染纖維化性膽汁淤積性肝炎肝靜脈血液外溢缺血嗜肝病毒引起的大片壞死醫(yī)源或毒素反應(yīng)創(chuàng)傷腫瘤,36-6匯管區(qū)淋巴細胞或和漿細胞浸潤,急性病毒性肝炎自身免疫性肝炎膽管阻塞移植物抗宿主反應(yīng)淋巴瘤/白血病,肝小葉炎癥或變性或壞死輕微,肉芽腫或腫瘤原發(fā)性膽汁性肝硬化原發(fā)性硬化性膽管炎排斥反應(yīng)病毒性肝炎Wilson病,Primarybiliarycirrhosis,Antimitochondrialantibody,36-7匯管區(qū)多形核細胞浸潤-,肝小葉炎癥或變性或壞死輕微,順行性膽管炎膽道阻塞高營養(yǎng)醫(yī)源性病毒性肝炎,“膽管溶解性”,36-8匯管區(qū)嗜酸性粒細胞浸潤,自身免疫性肝炎髓外造血醫(yī)源反應(yīng)寄生蟲感染原發(fā)性膽汁性肝硬化原發(fā)性硬化性膽管炎排斥反應(yīng),Liverbiopsyfroma25y-oLaotianshowingagranulomatousreactionagainsttheovum(HE).,36-9肉芽腫性炎癥,兒童慢性肉芽腫病克隆氏病異物反應(yīng)原發(fā)性肝臟肉芽腫病免疫性膽管炎細菌、真菌、立克次氏體、病毒感染脂肪性肉芽腫惡性腫瘤醫(yī)源性反應(yīng)原發(fā)性膽汁性肝硬化肉瘤樣病,36-10肝纖維化,淀粉樣橋接性纖維化中央透明變性纖維化先天性肝纖維化先天性梅毒囊性纖維化灶性結(jié)節(jié)狀增生肝臟門脈區(qū)纖維化肝臟靜脈性血液外溢，慢性阻塞性代謝性疾病中央靜脈周圍纖維化腫瘤,肝纖維化,肝硬化=肝細胞再生+纖維化,36-11膽汁淤積,良性家族性膽汁淤積妊娠性膽汁淤積醫(yī)源性手術(shù)后性膽汁淤積敗血癥,細胞內(nèi)淤膽,IntrahepapticCholestasis,ExtrahepapticCholestasis,36-12淤血或出血伴有肝竇擴張,肝靜脈血外溢靜脈阻塞性疾病心力衰竭醫(yī)源反應(yīng)腫瘤壓迫結(jié)節(jié)性再生性增生和回管區(qū)硬化門脈阻塞,肝淤血,肝出血,36-13色素沉積,膽色素鐵脂褐素其它外源性色素福爾馬林色素,膽色素bilepigment,Hemochromatosis,Prussianblueironstain,Lipofuscin,36-14細胞內(nèi)包含體,腺病毒抗胰靡蛋白酶缺乏支鏈淀粉血癥大泡脂肪變微泡脂肪變“糖原性”胞核巨線粒體“毛玻璃”細胞HSVMalloryhyaline,ALPHA-1-ANTITRYPSINSTORAGE,MEGAMITOCHONDRIA,GROUNDGLASSCELLS,Alpha-1-antitrypsindeficiency,CMVhepatitis,GlycogenNuclei,A30-year-oldwomaninthe30thweekofpregnancywithFulminanthepaticfailure,herpessimplexvirus,Malloryhyaline,36-15脂肪變顯著不伴有或輕微壞死,酒精性脂肪性肝炎妊娠脂肪肝灶性脂肪變肝細胞腺瘤、癌醫(yī)源、毒素反應(yīng)代謝性疾病非酒精性脂肪性肝炎非特異性脂肪變Wilson病,36-16組織中出現(xiàn)不常見細胞,髓外造血巨核細胞轉(zhuǎn)移瘤儲備細胞（肝、Kupffer或Ito),髓外造血,36-17“幾乎正?！钡母位顧z,肝匯管區(qū)纖維化醫(yī)源性反應(yīng)Missedlesion結(jié)節(jié)狀再生或增生蓄積或代謝性疾病,36-18缺少(觀察不到)正常結(jié)構(gòu),膽管中央靜脈肝細胞匯管區(qū)匯管靜脈肝竇,36-19肝臟代謝性疾病的光鏡診斷,36-20肝臟代謝性疾病的電鏡和非特異性光鏡診斷,36-21肝臟代謝性疾病非診斷的光鏡和電鏡特點,高酪氨酸血癥肝臟,Glycogenstorage,Liver,LM,Glycogenstorage,Liver,EM,肝臟疾病診斷,病因?qū)W形態(tài)（LM&EM)組化和免疫組化血清學(xué)、酶學(xué)檢查臨床表現(xiàn),AlcoholicFattyLiver,AlcoholicFattyLiver,Cirrhosis,FibrosisRegeneratingNodule,Micronodularcirrhosis,Micronodularcirrhosis:,HepaticAdenoma,HepatocellularCarcinoma,Hepaticmetastasis:,Hepaticmetastasis:,AmoebicLiverAbscess:,HeparLobatum(cong.Syphilis):,HCC-TheGlobalPerspectiveTheBigFiveCancers,TheMajorEtiologicalFactors,Chronichepatitis-typesBorCCirrhosis/chronicliverdiseaseofanytypeAflatoxinexposureMales,increasingage,8%-High,2-7%-Intermediate,2%-Low,DatafromCDC,ChronicHBVInfection-GeographicDistribution,ProspectiveStudyofHCCDevelopmentinHBsAgSeropositiveMaleChinese,HCCDEVELOPMENT19,223(HBsAg-ve)922,707Meanfollow-up=8.9yearsMaleChinese3,454(HBsAg+ve)152Relativerisk=98.4(50.2-193),Beasley,1982,Beasley1986,“ThelifetimeriskofdevelopingHepatocellularcarcinomaInaChinesemalecarrierOfthehepatitisBvirusIsbetween40and50%”,ChronicViralHepatitis&HCC,Okuda,1999,Anti-HCVPrevalence,5%-High,1.1-5%-Intermediate,0.2-1%-Low,0.2