1、七、消化系统疾七、消化系统疾病病1.1.消化性溃疡消化性溃疡（1)病理变化（病理变化（2)并发症并发症2.2.病毒性肝炎病毒性肝炎（1)基本病理变化（基本病理变化（2)临床病理临床病理类类型型和病变特点和病变特点3.3.门脉性门脉性肝硬化肝硬化（1)病因（病因（2)病理变化（病理变化（3)临床临床病病理理联系联系4.4.胃癌胃癌、食管癌食管癌和和大肠癌大肠癌病理类型和病理变化病理类型和病理变化5.5.原发性原发性肝癌肝癌病理类型和病理变化肉眼和病理类型和病理变化肉眼和组织组织学学类型类型 慢性萎缩性胃炎慢性萎缩性胃炎 消化性溃疡病消化性溃疡病 病毒性肝炎病毒性肝炎 肝硬化肝硬化 消化系统常见肿
2、瘤消化系统常见肿瘤 （胃癌、肝癌）（胃癌、肝癌）This is the normal appearance of the stomach,which has been opened along the greater curvature.The esophagus is at the left.In the fundus can be seen the lesser curvature.Just beyond the antrum is the pylorus emptying into the first portion of duodenum is at the lower right.T
3、he normal appearance of the gastric fundus on upper GI endoscopy is shown below at the left,with the normal duodenal appearance at the right.This is the normal appearance of the gastric antrum extending to the pylorus at the right of center.The first portion of the duodenum(duodenal bulb)is at the f
4、ar right.In the endoscopic views above,the normal appearance of the pylorus is seen at the left,with the first portion of the duodenum at the right.This is the normal appearance of the gastric fundal mucosa,with short pits lined by pale columnar mucus cells leading into long glands which contain bri
5、ght pink parietal cells that secrete hydrochloric acid.The normal gastric wall in fundus.There are mucosa,muscularis propria,submucoma,muscularis and sera.+表面黏液表面黏液细胞细胞+1.胃小凹胃小凹+2.固有层固有层（胃底腺）（胃底腺）The gastric fundal epithelium has long tubular glands that are lined by pink-staining parietal cells as
6、well as mucus cells.+1.主细胞主细胞+2.壁细胞壁细胞+3.颈黏液细颈黏液细胞胞The gastric antral epithelium has long pits with shorter glands than the fundus.部位部位：胃窦部：胃窦部胃其他部位胃其他部位病变：病变：多呈灶性或弥漫状多呈灶性或弥漫状 胃镜观：病变胃粘膜充血、水肿、呈淡红色胃镜观：病变胃粘膜充血、水肿、呈淡红色 有时可见点状出血和糜烂有时可见点状出血和糜烂 表面有灰黄或灰白色粘液性渗出物覆盖表面有灰黄或灰白色粘液性渗出物覆盖 光镜观：浅层粘膜（粘膜层上光镜观：浅层粘膜（粘膜层上1
7、/3）灶性或弥漫分布灶性或弥漫分布 胃粘膜充血、水肿、表浅上皮坏死脱落胃粘膜充血、水肿、表浅上皮坏死脱落 固有层有淋巴细胞、浆细胞浸润固有层有淋巴细胞、浆细胞浸润 结局：结局：大多经治疗或合理饮食而痊愈，少数转为慢大多经治疗或合理饮食而痊愈，少数转为慢 性萎缩性胃炎性萎缩性胃炎Chronic superficial gastritis.Note the inflammatory infiltrateslimit the upper one third of the mucosa.Superficial chronic gastritis with H.pylori infection show
8、s the inflammation limited in the portion of mucosa occupied by the foveolae.A A型和型和B B型慢性萎缩性胃炎比较表型慢性萎缩性胃炎比较表A型B型病因与发病机制自身免疫HP感染（60%70%)病变部位胃体或胃底部弥漫性分布胃窦部多灶性分布抗内因子抗体抗壁细胞抗体（胃液和血清）阳性阴性血清胃泌素水平高低胃内分泌细胞G细胞的增生有无血清中自身抗体阳性（90%）无胃酸分泌明显降低中度降低或正常血清VitB12水平降低正常恶性贫血常有无伴发消化性溃疡无高病变病变 两型病变基本类似两型病变基本类似 胃镜观：胃粘膜由正常的橘红
9、色变为灰色或灰绿色胃镜观：胃粘膜由正常的橘红色变为灰色或灰绿色 粘膜层变薄、皱襞变浅、甚至消失粘膜层变薄、皱襞变浅、甚至消失 粘膜下血管清晰可见粘膜下血管清晰可见 表面呈细颗粒状，偶有出血及糜烂表面呈细颗粒状，偶有出血及糜烂 光镜观光镜观 胃粘膜固有腺体萎缩胃粘膜固有腺体萎缩 粘膜有粘膜有肠上皮化生肠上皮化生或假幽门腺化生或假幽门腺化生 完全化生（杯状细胞和吸收细胞）完全化生（杯状细胞和吸收细胞）不完全化生不完全化生 大肠型大肠型 肠型胃癌肠型胃癌 小肠型小肠型 固有膜内淋巴细胞、浆细胞浸润固有膜内淋巴细胞、浆细胞浸润（只有杯状细胞）（只有杯状细胞）Endoscopic view of chr
10、onic atrophic gastritis.The mucosa of the antrum is pale,thinner.The undermucosal blood vessels can be seen.A normal picture of antrum as control in the right.Advanced chronic atrophic gastritis with H.Pylori infection showsa whole thickness mucosa inflammation and decrease of glands.Advanced type A
11、 of chronic atrophic gastritis with burned-out inflammation from a patient with pernicious anemia.Focal intestinal metaplasia in a chronic atrophic gastritis.Note theadjacent mucosa with superficial gastritis.Severe intestinal metaplasia in later stage of chronic gastritis.Chronic gastritis with H.P
12、ylori infection is always with lymph follicles.H.Pylori organisms are readily identified by a silver stain.临床病理联系临床病理联系 胃酸分泌减少，患者出现消化不良、食欲不胃酸分泌减少，患者出现消化不良、食欲不 佳，上腹部不适等症状佳，上腹部不适等症状 恶性贫血恶性贫血 癌变癌变3.3.慢性肥厚性胃炎（慢性肥厚性胃炎（chronic hypertrophic chronic hypertrophic gastritisgastritis）（自学）（自学）4.4.疣状胃炎疣状胃炎(gastr
13、itis verrucosa)(gastritis verrucosa)（自学）（自学）+胃炎是胃粘膜的炎症胃炎是胃粘膜的炎症+慢性萎缩性胃炎慢性萎缩性胃炎A型和型和B型具有相同的形态学特型具有相同的形态学特征征+慢性胃炎的并发症有消化性溃疡病和肠上皮化慢性胃炎的并发症有消化性溃疡病和肠上皮化生生Diagram of aggravating causes of and defence mechanisms against peptic ulceration.损伤性因素损伤性因素胃酸、胃蛋白酶胃酸、胃蛋白酶正常黏膜正常黏膜防御性因素防御性因素表面黏液分泌表面黏液分泌碳酸氢盐分泌到黏液碳酸氢盐分泌
14、到黏液黏膜血流黏膜血流上皮再生能力上皮再生能力前列腺素产生前列腺素产生完整的上皮屏障完整的上皮屏障损伤增加损伤增加HP感染感染NSAIDs吸烟吸烟酒酒高胃酸分泌高胃酸分泌十二指肠胃返流十二指肠胃返流防御机制受损防御机制受损缺血缺血休克休克胃排空延迟胃排空延迟出血出血幽门狭窄幽门狭窄穿孔穿孔癌变癌变愈合愈合溃疡形成溃疡形成龛影胃消化性溃疡（大体）Here is a much larger 3 x 4 cm gastric ulcer that led to the resection of the stomach shown here.This ulcer is much deeper with
15、 more irregular margins.Complications of gastric ulcers(either benign or malignant)include pain,bleeding,perforation,and obstruction.（三）病理与临床联系（三）病理与临床联系 周期性上腹部疼痛周期性上腹部疼痛 原因有二：胃酸刺激神经末梢、平滑肌痉挛原因有二：胃酸刺激神经末梢、平滑肌痉挛 夜间痛夜间痛 十二指肠溃疡多见十二指肠溃疡多见 原因：迷走神经兴奋性增高，刺激胃酸分泌增多原因：迷走神经兴奋性增高，刺激胃酸分泌增多 反酸、嗳气和上腹部饱胀反酸、嗳气和上腹部饱胀
16、原因：胃幽门括约肌痉挛、胃逆蠕动、早期幽门原因：胃幽门括约肌痉挛、胃逆蠕动、早期幽门狭窄狭窄 胃内容物排空受阻，食物滞留发酵有关胃内容物排空受阻，食物滞留发酵有关 幽门狭窄（幽门狭窄（3%）：反复呕吐）：反复呕吐 代谢性碱中毒代谢性碱中毒 癌变（癌变（1%）：主要见于胃溃疡）：主要见于胃溃疡 损伤、再生损伤、再生+致癌因素致癌因素+掌握溃疡病的大体特点及镜下特点掌握溃疡病的大体特点及镜下特点+掌握溃疡病的并发症掌握溃疡病的并发症-AnonymousNormal adult livers weigh 1400-1600 g.Liver weight is widely variable at a
17、utopsy.An end-stage cirrhotic is with a 700 g liver,and an alcoholic with a 7000 g liver.Liver lobular architecture,showing blood and bile flow.The sinusoids receive blood from branches of portal vein and hepatic artery and drain into the central vein.+PS.门管区门管区 +CV.中央静脉中央静脉+CV.中央静脉中央静脉+左左.人肝人肝 右右.猪
18、肝猪肝The normal structure of the liver.Limiting plate:The row of hepatocytes immediately adjacent to the portal tract.It should be smooth and uniform.+1.小叶小叶间静脉间静脉 +2.小叶小叶间胆管间胆管 +3.小叶小叶间动脉间动脉（三）基本病变（三）基本病变 各型病毒性肝炎基本病变相同，都是以肝细胞的各型病毒性肝炎基本病变相同，都是以肝细胞的变变性性、坏死坏死为主，同时伴有不同程度的炎细胞浸润、为主，同时伴有不同程度的炎细胞浸润、肝细胞再生和纤维组
19、织增生肝细胞再生和纤维组织增生 属于属于变质变质为主炎症为主炎症1、变质（肝细胞变性坏死）、变质（肝细胞变性坏死）肝细胞水肿肝细胞水肿 肝细胞溶解性（液化性）坏死肝细胞溶解性（液化性）坏死 细胞水肿细胞水肿(cellular swelling)：为最常见的病变：为最常见的病变 光镜光镜 胞质疏松化、气球样变胞质疏松化、气球样变 电镜电镜 溶解性坏死：溶解性坏死：点状坏死（灶状坏死）：常见于急性普通型肝炎点状坏死（灶状坏死）：常见于急性普通型肝炎 碎片状坏死：常见于慢性肝炎碎片状坏死：常见于慢性肝炎 桥接坏死：常见于中度和重度慢性肝炎桥接坏死：常见于中度和重度慢性肝炎 大片坏死：常见于重型肝炎大
20、片坏死：常见于重型肝炎肝细胞凋亡（嗜酸性变肝细胞凋亡（嗜酸性变 嗜酸性坏死）嗜酸性坏死）Histology in acute hepatitis.This is a liver biopsy from a patient with acute viral hepatitis.Many liver cells are swollen and vacuolated,a phenomenon known as“ballooning degeneration”.Focal necrosis of hepatocytes occurs,affecting the centrilobular areas.
21、There is also Councilman body.Ballooning change in liver cells.Note the enlarged hepatocyteswith pale cytoplasm(H)andcentral nuclei.Cell swelling of liver cells(Ballooning degeneration)胞质疏松化、气球样变胞质疏松化、气球样变毛玻璃样肝细胞“Ground glass”of liver cellsIn chronic hepatitis due to hepatitis B infection,liver cell
22、s accumulateHBsAg in the cytoplasm,which appears hemogeneous,pale and glassy.These so-called“ground glass”hepatocytes may be immunostained byantibodies to HBsAg,as shown in this picture.The core antigen of hepatitis B virus shows by in situ hybridizationSpotty necrosis(arrow)and ballooning degenerat
23、ion点状坏死或灶性坏死点状坏死或灶性坏死碎片状坏死碎片状坏死(piecemeal necrosis)Piecemeal necrosis and cloud swelling of liver cells.Note the“moth eating”of limiting plate.Focal necrosis of hepatocytes桥接坏死桥接坏死(bridging necrosis)bridging necrosisCentral-portal bridging necrosis in a case of chronic severe hepatitismassive/submas
24、sive necrosis大片坏死（大片坏死（Massive necrosis）肝细胞凋亡（嗜酸性变、嗜酸性坏死）肝细胞凋亡（嗜酸性变、嗜酸性坏死）病病 变变Spotty necrosis(arrow)and ballooning degenerationin a case of acute hepatitisAcute hepatitis:The necrosis and lobular collapse is seen here as areas of hemorrhage and irregular furrows and granularity on the cut surface o
25、f the liver.临床表现：临床表现：肝大、肝区痛肝大、肝区痛 血清转氨酶升高血清转氨酶升高 黄疸黄疸结局：多在结局：多在6个月内治愈个月内治愈 少数转为慢性少数转为慢性临床表现、结局临床表现、结局肝细胞合成胆汁肝细胞合成胆汁 胆小管胆小管 小叶间胆管小叶间胆管十二指肠十二指肠 胆总管胆总管 肝总管肝总管左右肝管左右肝管胆囊：暂时存储胆汁胆囊：暂时存储胆汁（1）轻度慢性肝炎）轻度慢性肝炎 肝细胞变性，轻度碎片状坏死肝细胞变性，轻度碎片状坏死 门管区慢性炎细胞浸润，周围有少量纤维组织增生门管区慢性炎细胞浸润，周围有少量纤维组织增生 肝小叶界板无破坏，小叶结构清楚肝小叶界板无破坏，小叶结构清
26、楚（2）中度慢性肝炎）中度慢性肝炎 肝细胞变性、坏死明显肝细胞变性、坏死明显 中度碎片状坏死，特征性的桥接坏死中度碎片状坏死，特征性的桥接坏死 小叶内有纤维间隔形成小叶内有纤维间隔形成 小叶结构大部分保存小叶结构大部分保存重度慢性肝炎（活动型肝炎）重度慢性肝炎（活动型肝炎）临临 床床 表表 现现光镜观：光镜观：肝细胞弥漫大片坏死，从肝小叶中央区向四周扩展肝细胞弥漫大片坏死，从肝小叶中央区向四周扩展 肝窦明显扩张、充血甚至出血，肝窦明显扩张、充血甚至出血，Kupffers细胞增生细胞增生肥大、吞噬活跃肥大、吞噬活跃 坏死区和门管区有大量炎细胞浸润坏死区和门管区有大量炎细胞浸润数日后网状支架塌陷，
27、残留的肝细胞无再生现象数日后网状支架塌陷，残留的肝细胞无再生现象临床表现：肝细胞性黄疸、出血倾向、肝性脑病（肝昏临床表现：肝细胞性黄疸、出血倾向、肝性脑病（肝昏 迷）、肝肾综合征（迷）、肝肾综合征（hepatorenal syndrome）结局：多数在短期内死亡结局：多数在短期内死亡 少数转为亚急性重型肝炎少数转为亚急性重型肝炎临临 床床 表表 现现四、酒精性肝病（四、酒精性肝病（alcoholic liver disease）（自学）（自学）脂肪肝脂肪肝(fatty liver)酒精性肝炎酒精性肝炎(alcoholic hepatitis)酒精性肝硬化酒精性肝硬化(alcoholic cirrhosis)
