例黃疸原因待查患者臨床表現(xiàn)及肝穿病理特點(diǎn)分析

1718中國(guó)現(xiàn)代醫(yī)學(xué)雜志Vol.17No.20079Sep.文章 1005-8982(2007)18-2181-

ysisof214casesofclinicalmanifestationandhistopathologicalfeaturesinpercutaneousliverbiopsyfortheictericwithunrecognized(1.DepartmentofSynthetic,YouanHospital,CapitalMedicalUniversity,Beijing100069,P.R.China;2.DepartmentofClinicalMedicine,ChaoyangHospital,CapitalMedicineUniversity,Beijing100020,P.R.China):Objective】Tostudytheclinicalandhistopathologicalspecialityof214ictericpatientswhoseviralindexeswerenegativewhenadmittedtothehospital. Methods】214patientswithjaundicewhoseviralindexeswerenegativewereselected.Webothwrotedownandyzedtheirsymptomsandphysicalsigns,resultsofliverfunction,immunodetectionandbloodroutine.Results】Thepatientssufferedfromthesediseasesincludingviralhepatitis,thedrug-inducedliverdisease,autoimmuneliverdisease,obstructivejaundice,unknownreason,acuiv-erfailure,cholestatichepatitisandacuteadiposishepaticaongestationalperiodwhohavemoresymptomsthanotherdiseases(﹥60%).ThepatientssufferedfromthesediseasesincludingPBC,alcoholicliverdisease,unknownreasondiseasesandacuiverfailurewhohadmorephysicalsignsthanotherdiseases.Viralhepatitis,drug-inducedliverdisease,unknownreasondiseases,acuiverfailureandacuteadiposishepaticaongestationalperiodhadsignifi-cantabnormalliverfunction.ThemeanvaluesofESR(erythrocytesedimentationrate)ofthesediseasessuchasviralhepatitis,alcoholicliverdisease,hepatolenticulardegeneration,pancreaticcancer,acuteadiposishepaticaongesta-tionalperiodwerehigherthanotherdiseases;themeanvaluesofAFP(alphafetoprotein)ofthepatientssufferedfromhepatomawerehigherthanotherpatients.Conclusions】Somekindsofdiseaseswhicharecommonlyseenareau-toimmuneliverdisease,viralhepatitis,drug-inducedliverdisease,obstructivejaundice,alcoholicliverdisease,con-genitaldisease,theunknownreasondiseaseinsequence.Nospecialcomplaintsbelongtothesediseasesrespective-ly,exceptobstructivejaundicewithpotteryclaysedes.Sometimesageandsexareimportantfactors.Percutaneousneedlebiopsyoftheliverisakindofpotentialexamination,butisnotalmighty,andultrasound(SUV),CT(computedinsomecases.:jaundice;clinicalmanifestation;percutaneousneedlebiopsyoftheliver;correlationCLCNumber:R575 code:A214例黃疸原因待查患者臨床表現(xiàn)龍1,2,(1.首都醫(yī)學(xué)附屬佑安醫(yī)院綜合科,12.首都醫(yī)學(xué)附屬朝陽(yáng)醫(yī)院臨床藥理,1:目的 研究214例入院時(shí)學(xué)指標(biāo)是的黃疸原因待查患者的臨床表現(xiàn)和肝穿病理特點(diǎn)方法選擇學(xué)指標(biāo)的黃疸待查患者 將他們的癥狀體征肝功能免疫學(xué)以及血常規(guī)依據(jù)病種分列成表并加以分析結(jié) 性肝炎藥物性肝病自身免疫性肝病梗阻性黃疸原因不明黃疸暴發(fā)性肝衰竭以及Receiveddate:Sep.14,中國(guó)現(xiàn)代醫(yī)學(xué)雜 第17。妊娠急性脂肪肝患者的不適主訴較多(>60)。PC性肝病原因不明黃疸和暴發(fā)性肝衰竭患者的陽(yáng)性體征較多(>60) 性肝炎藥物性肝病原因不明黃疸暴發(fā)性肝衰竭以及妊娠急性脂肪肝患者的肝功能明顯異常。性肝炎性肝病肝豆?fàn)詈俗冃砸群腿焉锛毙灾靖位颊叩难林得黠@升高,P的明顯升高僅見(jiàn)于肝癌患者結(jié)論 依據(jù)疾病出現(xiàn)的頻率,從高到低依次是自身免疫性肝病性肝炎藥物性肝病梗阻性黃疸性肝病性疾病不明原因黃疸除梗阻性黃疸有陶土樣便以外,消化系統(tǒng)常見(jiàn)的不適癥狀多數(shù)是非特異的和有時(shí)是重要的因素肝穿活檢是一項(xiàng)重要的檢查,超聲CT肝血管造影、RCP(逆行膽胰管造影)同樣是必要的檢查。。 黃疸;臨床表現(xiàn);經(jīng)皮肝穿活檢;相關(guān)性號(hào): R575 文獻(xiàn)標(biāo)識(shí)碼: JaundiceistheresultthatTBIL(totalbilirubin)concentrationinserumisabove1mg/dl,whiakestheworldseeskinandalbugineaoculiturningyellow.Itiseasytoconfuseclinicalworkbecausetherearetoomanyfactorsthatinfluencethelevelofjaundice.Weselectedthepatientsappearedictericwhoserea-sonsofdiseasewereunrecognized,andthenstudytheirclinicalandhistopathologicalspecialities.MaterialsandCasesselectionandWecollected214patientsappearedictericwhoseviralindexeswerenegative,whileadmittedtothe

hospital.Allmaterialswerein-patientsfromJune1st,2004toJuly1st,2005inourhospital.Malewas113andfemalewas101.Age:2～89years,themeanage:MethodofsamplesWebothwrotedownandyzedtheirsymp-toms,physicalsigns,resultsofliverfunction,immun-odetectionandbloodroutine.StatisticalFtestwasusedtocomparethemeansofindexesamongthedifferentdiseases.StatisticalysesweredonebySPSS11.5software.Table1Comparisonof214cases′symptoms Jaundice Jaundice NauseaVomitingBellyacheAbdominal Viral60Drug-inducedliver40033980690Obstructive060Alcoholicliver0600636700Unknown77409940Acuiver886622468640330100032320Overlap440200022220Buddy-Chiari220000212220SS-550300032530Dubin-Johnson440000003100Gilbert550000001420Hepatolenticular330100111200Cholestatic662300023430Pancreatic551221022330Malformationofhepatic 11000011100Acuteadiposishepatica 31321122100

vo-gestationalNote:aboutmorethan7kindsofsymptomscouldturnoutinthesediseaseswith*.AIH(autoimmunehepatitis),PBC(primarybiliarycirrhosis),PSC第18 江,等:214例黃疸原因待查患者臨床表現(xiàn)及肝穿病理特點(diǎn)分Table2Comparisonof214cases′conventionalliverfunctions Viralhepatitis#183426±7683171640±972019060±46303589±37019060±54105905 ±44509748±2930963±42127420±78Thedrug-induced97640±3024263480±3261010400±44203670±94027503±98424012 ±58208505±17231044±57813920±64 14767±448313400±810011267±43333899±84116576±70164964 ±531010240±2380446±19722325±178 20680±974014310±743012700±36903540±113019695±7344432970±12042233040±1128013382±5613838±49265260±384

25225±1434115680±342029520±48403875±91324294±11784543040±11064025950±685012962±47532065±167317450±83 9427±37 8530±294118620±59703371±86214620±3921413270±12096019420±673011720±3850491±14329480±92Alcoholicliver23476±1275127248±1436110630±32403670±74116720±54304176 ±732013940±5780324±13382126±384

84740±524607860±294013129±22303587±69311899±6943570450±24178015240±427012740±2360594±3328371±45243740±86320124070±3844016750±26504297±56816840±54705680 ±35603218±567665±23814825±36 15525±47 9890±324018450±34603272±54115685±6824245650±8045022740±592012961±32452861±112416750±54sonGilbertlarAcuteadiposis

12573±732410427±432526017±84564213±124316512±6952349000±6390016670±393010420±2750387±12535850±17610270±349272±263417450±55803720±3184640±19704892±34909640±2130346±12310420±297640±386840±367211740±45203460±49516245±48613604±43608792±2934397±1364732±149650±31 6820±275010420±35803970±82205420±1560413400±8267021740±396010420±1850814±30611530±399470±35 7790±25409740±28603750±4607250±2140408700±4965020450±45709850±1430427±18914720±4512160±48 8750±297013240±47503850±6706720±2250397400±4542019430±436011470±3650659±23424780±7646270±1348028540±895028430±57203920±38023153±9417381600±3682024270±498012760±3580971±32426140±5724720±874018420±673031450±47203820±43021783±7946378420±3953021740±345010750±24801356±47326780±7456 94 520 34 28 4045 154 72 2 283aticaon 30±9464018530±64203950±41012620±5360421640±8737017830±41907460±32701060±32013640±54Note:Suchdiseaseswith#comparedwithotherdiseaseshavesignificantvariantPGeneralTherewere28patientswhosufferedfromhep-atitisE infection,and14patientssufferedfromhepatitisA infection.Intotal,itsratiois42/214.Among51patients,therewere11 swhoseim-munodetectionwereallnegative.Andtheirdiagnosisresultfromhistopathologicalfeatures.ysisof214Fromtable1,wecouldlearnthat:thepatientssufferedfromthesediseasesincludingviralhepatitis,drug-inducedliverdisease,autoimmuneliverdisease(AIH,PBC,SS-syndromeandOverlapsyndrome)[1~3],obstructivejaundice,unknownreason,acu iverfail-ure,cholestatichepatitis,pancreaticcancerandacuteadiposishepaticaongestationalperiodwhohadmoresymptomsthanotherdiseases(≥7/11).Weshouldthinkofobstructivejaundiceifwemeettheelderpa-tientswithfeverandbellyache.Onthecontrary,con-gentaldiseasewilloccurtouswhenthepatientswere

ysisof214casesconentionalliverfunc-Fromtable2,wecouldlearnthat:thepatientssufferedfromthesediseasesincludingviralhepatitis,drug-inducedliverdisease,theunknownreason,a-cuteliverfailureandacuteadiposishepaticaonges-tationalperiodhavesignificantabnormalliverfunc-ysisof214cases′resultsofbloodroutineandAFPFromtable3(omitted),havingcomparedthere-sultsofbloodroutineandAFP,wecouldlearnthat:ThemeanvaluesofESRofthesediseasessuchasvi-ralhepatitis,alcoholicliverdisease,hepatolenticulardegeneration,pancreaticcancer,acuteadiposishepat-icaongestationalperiodwerehigherthanotherdis-eases(AccordingtothemeanvalueofESR,above-mentioneddiseasescomparedwithotherdiseaseshad1717中國(guó)現(xiàn)代醫(yī)學(xué)雜志Table3Correlationbetweendefinitediagnosisandliver CasenumberLiverbiopsynumber9632Overlap42SS-50NotViral4Thedrug-inducedliver8Obstructive0Not0NotAlcoholicliver0Not4InAcuiver82Buddy-Chiari20NotDubin-Johnson42Gilbert52

cuallySUV,CTandMR(magneticresonance)cannotdetectthecalculusinbillarysystemforonetime,sowemustrepeatthesedetection.Jaundiceisaverycommonandsophisticatedsymptom.Bytakingand yzingthesein-patients′datum,wehavegotsomeconclusions.Aboveall,bylistingoutofthereasonsthatcausedjaundice,autoim-muneliverdiseasewasthewinnerwhoseratiowas51/214,whichincludes:AIH,PBC,PSC,SS-syndromeandsoon;therunneruptoautoimmuneliverdiseasewasNo.2-viralhepatitis,anditsratiowas42/214;No.3-thedrug-inducedliverdiseasewhoseratiowas34/214;No.4-obstrustivejaundice,whichcomprisedbenignobstructionandcarcinoma,itsratiowas33/229;No.5-alcoholicliverdisease,congentaldisease[6,7]andtheunknownreasondiseases, allofthemoccu-Hepatolenticulardegen-

Not

pied12/214;nexttothemwasacutehepaticCholestatic Pancreatic Not

whoseratiowas8/214.Besidesthem,therewereex-ceptionalkindsofdiseases,suchasmalformationmbloodAcuteadiposishepaticaongestationalperiod

Not

hepaticbloodvesselandacuteadiposishepaticaongestationalperiod.Wecanexplainitinfullasfollow:Theworldoftenseesviralhepatitis,whileviralmarkNote:theliverbiopsyofsomediseaseswith*havenodirectrelationwiththeirsignificantvariant,P<0.05).ThemeanvaluesofAFPofthepatientssufferedfromhepatomawerehigherthanotherpatients(AccordingtothemeanvalueofAFP,mostdiseaseshadnosignificantvariantexceptforhepatoma,P<0.05).phFromtable4(omitted),havingcompared214cas-esphysicalsigns,wecouldlearnthat:thepatientssufferedfromthesediseasesincludingPBC,alcoholicliverdisease,unknownreasondiseases,acu failureandacuteadiposishepaticaongestationalpe-riodwhohadmorephysicalsignsthanotherdiseases(≥6/9)(Morethan6kindsofphysicalsignscouldbefoundoutinabove-mentioneddiseases).Correlationbetweendiagnosisandpercuta-neousneedlebiopsyofliverDiagnosisFromtable3,wecanlearnthat:ingeneral,liverbiopsycanhelpustogettherightofsomediseases[2,4],exceptforsomediseaseincludingPSCandmalformationofhepaticbloodvessel[5].Oc-

couldnotbefoundoutduringtheearlyperiod.Some-timesweneedrepeattheviraltestsinorderthatwearesuretoexcludethem.Formostpatientssufferedfromautoimmuneliverdiseasearefemale,wemustperformtheautologousantibodytests,ESRandotherimmunodetection,whichcanhelpusgetdefinitediag-nosissometimes[1,8].Ifwemeetsomepregnantwomenorjustafterpregnancy,withseveresymptoms,thepossibilityofacuteadiposishepaticaongestationalperiodshouldoccurtous.Fromtheliverfunctiontestresults,thepatientssufferedfromviralhepatitis,thedrug-inducedliverdisease,theunknownreasondis-easesandacuteliverfailure,whosemeanvaluewashigherthanotherdiseases,especiallythefiveclinicalindications,namelyALT,AST,TBIL,ALPandGGT.Percutaneousneedlebiopsyoftheliverplaysaveryessentialrole gnosis,itcanhelpusgettherightreasonsandconditionsofmostliverdiseases.Butitisnotalmighty,wemustcollectdiversityclinicaldatumbeforewegetthefinaldiagnosis.Let`slookatafewcases,thepatientssufferedfromthedrug-induced(Continuedonpage不盡相同,結(jié)果也缺乏可比性。本研究的的結(jié)果是第一個(gè)基于本方法的,小鼠肝臟硫酸乙酰肝素的生參考文獻(xiàn)KINOSHITAA,SUGAHARA sofJapaneseCarbohydrateSymposium,August5-7,1997,Nishi-nomiya,Japan,p.106.SUGAHARAK,YAMADAS,YOSHIDAK,etal.Anovelfatedstructureinthecarbohydrate-proteinlinkageregionisolatedfromporcineintestinalheparin[J].J.Biol.Chem,1992,267,1528-1533.SALMIVIRTAM,LIDHOLTK,LINDAHLU.Heparansulfate:pieceofinformation[J].FASEBJ,1996,10:1270-BERNFIELDM,GOTTEM,PARKP,etal.Functionsofsurfaceheparansulfateproteoglycans[J].Annu.Rev.Biochem,1999,68:729-777.

OOHIRAA.,MATSUIF.,TOKITAY.,etal.Molecularinterac-tionsofneuralchondroitinsulfateproteoglycansinthebrainde-velopment[J].ArchBiochem.Biophys,2000,374:24-34.XIAOY,KLEEFFJ,SHIX,etal.Heparanaseexpressioninhepatocellularcarcinomaandthecirrhoticliver[J].HepatolRes,2003,26(3):192-198.SATOT,YAMAGUCHIA,GOIT,etal.Heparanaseexpressioninhumancolorectalcanceranditsrelationshiptotumorangio-genesis,hematogenousmetastasis,andprognosis[J].JSurgOncol,2004,87(4):174-181.GOLDSHMIDTO,ZCHARIAE,ABRAMOVITCHR,etal.surfaceexpressionandsecretionofheparanasemarkedlypromotetumorangiogenesisandmetastasis[J].ProcNatlAcadSciUSA,2002,99(15):10031-10036.SMITHTA,IDAMAKANTIN,MARSHALL-NEFFJ,etal.ceptorinteractionsinvolvedinadenoviral-mediatedgenedeliveryaftersystemicadministrationinnon-humanprimates[J].HumGeneTher,2003,14(17):1595-1604.(張蕾編輯liverdiseasemusthavethehistoriesoftakingsomemedicineswhichcanhurttheliver,atthesametimeeosinophilsmightincreasesignificantlyinblood[9,10].Althoughmostdiseaseshavetheirownpathologicalspeciality,whenwethinkitpossiblethatsomepa-tientsaresufferedfromPSC[3],weshouldprefertheERCPinsteadofpercutaneousliverbiopsy.InordertofindoutBuddy-Chiarisyndrome,bothSUVandCTplaymoreimportantrolesthanpathologicalbiopsy.Thosepeoplesufferedfrommalformationofhepaticbloodvessel,SUV,CT,andhepaticangiographycanhelpuscometotherightconclusion[11].Wearesorrytosaythatwecouldnotfindthedefinitereasonsofsomecasesafterhavingdoneasmuchaspossible.Occasionallysomepathologicalreportssuggestthatthereischronichepatitisintheliver,butnoharmfulfactorscouldbefoundincludingviral,alcoholicfac-torsandtoxicdrugandsoon. ing]Wehavenotstudiedthosepatientswith