肝臟病理_ppt

1、Welcome,肝臟疾病病理學(xué)診斷,Outline of Guidelines,Classification of liver diseases,LIVER,Liver Biopsy,Liver Biopsy,Confirm the diagnosis Serological blood tests Establish degree of fibrosis Serology Biopsy not representative Identify cirrhosis Determine optimum therapy,Liver biopsy adequacy,“Most hepatopathol

2、ogists are satisfied with a biopsy specimen containing at least six to eight portal tracts”. Bravo AA et al NEJM 344, 495; 2001. We should not be primarily concerned with the size of biopsy that “satisfies” the pathologist. The correct question is: What size of biopsy will provide a reliable assessm

3、ent for the patients management?,Liver biopsy adequacy,Guido M and Rugge M. Semin Liv Dis 24, 89; 2004. In most diffuse liver diseases examination of 12-15 complete portal tracts is necessary. 20mm of a 1.4mm diameter (17 gauge) needle biopsy. Progressively longer samples of thinner biopsies are nee

4、ded.,36-1 肝臟活檢標(biāo)本的評(píng)價(jià),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,LOBULE VS ACINUS,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,Acidophil body,Ballooning Degeneration,Fatty Degeneration Alcoholic liver disease,Ductule,Interlobular bile duc

5、t,Necrosis, piecemeal,Necrosis, focal,Necrosis, Zonal,Necrosis, Confluent,Necrosis, Massive,Necrosis, Bridging,Drug and Toxin- Induced Liver Disease,36-3 肝小葉淋巴細(xì)胞浸潤伴有或不伴有肝細(xì)胞變性或壞死,急性醫(yī)源性 急性病毒性 (HAV, HBVB,HCV, CMV, EBV etc) 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(xì)胞浸潤伴有或不伴有肝細(xì)胞變性或壞死,酒精性肝炎 細(xì)菌/真菌感染 醫(yī)源性反應(yīng)

6、 敗血癥 “手術(shù)性”肝炎 病毒感染（CMV),Autoimmune Hepatitis,36-5 肝細(xì)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(xì)胞或和漿細(xì)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,Primary biliary cirrhosis,Antimitochondrial antibody,36-7 匯管區(qū)多形核

7、細(xì)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(xì)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),Liver biopsy from a 25 y-o Laotian showing a granulomatous reaction against the ovum (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(xì)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

8、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(xì)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(xì)胞內(nèi)淤膽,Intrahepaptic Cholestasis,Extrahepaptic Cholestasis,36-12 淤血或出血伴有肝竇擴(kuò)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)

9、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 bile pigment,Hemochromatosis,Prussian blue iron stain,Lipofuscin,36-14 細(xì)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(xì)胞 HSV Mallory hyaline,ALPHA-1-ANTITRYPSIN STORAGE,MEGAMITOCHONDRIA,GROUND GLASS CELLS,Alpha-1-antitrypsin deficienc

10、y,CMV hepatitis,Glycogen Nuclei,A 30-year-old woman in the 30th week of pregnancy with Fulminant hepatic failure,herpes simplex virus,Mallory hyaline,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(xì)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(xì)胞,髓外造血 巨核細(xì)胞 轉(zhuǎn)移瘤 儲(chǔ)備細(xì)胞（肝、Kupffer或Ito),髓外造血,36-17

11、 “幾乎正?！钡母位顧z,肝匯管區(qū)纖維化 醫(yī)源性反應(yīng) Missed lesion 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(xì)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(diǎn),高酪氨酸血癥肝臟,Glycogen storage, Liver, LM,Glycogen storage, 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),Alcoholic Fatty Liv

12、er,Alcoholic Fatty Liver,Cirrhosis,Fibrosis Regenerating Nodule,Micronodular cirrhosis,Micronodular cirrhosis:,Hepatic Adenoma,Hepatocellular Carcinoma,Hepatic metastasis:,Hepatic metastasis:,Amoebic Liver Abscess:,Hepar Lobatum (cong. Syphilis):,HCC- The Global Perspective The Big Five Cancers,The

13、Major Etiological Factors,Chronic hepatitis - types B or C Cirrhosis/chronic liver disease of any type Aflatoxin exposure Males, increasing age,8% - High,2-7% - Intermediate,2% - Low,Data from CDC,Chronic HBV Infection - Geographic Distribution,Prospective Study of HCC Development in HBsAg Seroposit

14、ive Male Chinese,HCC DEVELOPMENT 19,223 (HBsAg -ve) 9 22,707 Mean follow-up = 8.9 years Male Chinese 3,454 (HBsAg +ve) 152 Relative risk = 98.4 (50.2-193),Beasley, 1982,Beasley 1986,“The lifetime risk of developing Hepatocellular carcinoma In a Chinese male carrier Of the hepatitis B virus Is between 40 and 50%”,Chronic Viral Hepatitis & HCC,Okuda , 1999,Anti-HCV Prevalence,5% - High,1.1-5% - Intermediate,0.2-1% - Low,0.2-1% - Low,Chronic HCV Infection -