肝脏病理(新课件).ppt

1、2020-12-08肝脏病理（新课件）1肝脏病理2020-12-08肝脏病理（新课件）2肝脏疾病病理学诊断Outline of Guidelines2020-12-08肝脏病理（新课件）3Classification of liver diseases 2020-12-08肝脏病理（新课件）4LIVER2020-12-08肝脏病理（新课件）5Liver Biopsy2020-12-08肝脏病理（新课件）6Liver Biopsy Confirm the diagnosis Serological blood tests Establish degree of fibrosis Serology

2、 Biopsy not representative Identify cirrhosis Determine optimum therapy2020-12-08肝脏病理（新课件）7Liver biopsy adequacy“Most hepatopathologists 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

3、 size of biopsy that“satisfies”the pathologist.The correct question is:What size of biopsy will provide a reliable assessment for the patients management?2020-12-08肝脏病理（新课件）8Liver biopsy adequacy Guido M and Rugge M.Semin Liv Dis 24,89;2004.In most diffuse liver diseases examination of 12-15 complet

4、e portal tracts is necessary.20mm of a 1.4mm diameter(17 gauge)needle biopsy.Progressively longer samples of thinner biopsies are needed.2020-12-08肝脏病理（新课件）936-1 肝脏活检标本的评价 整体情况-低倍镜 汇管区 中、高倍镜 肝小叶 中、高倍镜 中央静脉 中、高倍镜2020-12-08肝脏病理（新课件）10LOBULE VS ACINUS2020-12-08肝脏病理（新课件）112020-12-08肝脏病理（新课件）12肝小叶2020-12

5、-08肝脏病理（新课件）13肝板、肝窦2020-12-08肝脏病理（新课件）14肝脏,EM2020-12-08肝脏病理（新课件）15肝脏,EM(cont.)2020-12-08肝脏病理（新课件）16汇管区和中央静脉2020-12-08肝脏病理（新课件）1736-2 常用诊断名词的定义 嗜酸性小体 气球样变性 Ductule 叶间胆管 碎宵状坏死n 灶状坏死灶状坏死n 带状坏死带状坏死n 融合性坏死融合性坏死n 大片坏死大片坏死n 桥接坏死桥接坏死 2020-12-08肝脏病理（新课件）18Acidophil body2020-12-08肝脏病理（新课件）19Ballooning Degener

6、ation2020-12-08肝脏病理（新课件）20Fatty Degeneration Alcoholic liver disease2020-12-08肝脏病理（新课件）21Ductule2020-12-08肝脏病理（新课件）22Interlobular bile duct2020-12-08肝脏病理（新课件）23Necrosis,piecemeal2020-12-08肝脏病理（新课件）24Necrosis,focal2020-12-08肝脏病理（新课件）25Necrosis,Zonal2020-12-08肝脏病理（新课件）26Necrosis,Confluent2020-12-08肝脏病

7、理（新课件）27Necrosis,Massive2020-12-08肝脏病理（新课件）28Necrosis,Bridging2020-12-08肝脏病理（新课件）29Drug and Toxin-Induced Liver Disease2020-12-08肝脏病理（新课件）3036-3 肝小叶淋巴细胞浸润伴有或不伴有肝细胞变性或坏死 急性医源性 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 原发性胆管性肝硬化2020-12-08肝脏病理（新课件）3136-4 肝小叶多形核细胞浸润伴有或不伴有肝细胞变性或坏死 酒精性肝炎 细菌/真菌感染

8、 医源性反应 败血症“手术性”肝炎 病毒感染（CMV)2020-12-08肝脏病理（新课件）32Autoimmune Hepatitis 2020-12-08肝脏病理（新课件）3336-5 肝细胞坏死伴轻微炎症反应 急性病毒感染 纤维化性胆汁淤积性肝炎 肝静脉血液外溢 缺血 嗜肝病毒引起的大片坏死 医源或毒素反应 创伤 肿瘤2020-12-08肝脏病理（新课件）3436-6 汇管区淋巴细胞或和浆细胞浸润 急性病毒性肝炎 自身免疫性肝炎 胆管阻塞 移植物抗宿主反应 淋巴瘤/白血病肝小叶炎症或变性或坏死轻微n 肉芽肿或肿瘤肉芽肿或肿瘤n 原发性胆汁性肝硬化原发性胆汁性肝硬化n 原发性硬化性胆管炎原

9、发性硬化性胆管炎n 排斥反应排斥反应n 病毒性肝炎病毒性肝炎n Wilson病病2020-12-08肝脏病理（新课件）35Primary biliary cirrhosis 2020-12-08肝脏病理（新课件）36Antimitochondrial antibody2020-12-08肝脏病理（新课件）3736-7 汇管区多形核细胞浸润-肝小叶炎症或变性或坏死轻微肝小叶炎症或变性或坏死轻微 顺行性胆管炎 胆道阻塞 高营养 医源性 病毒性肝炎,“胆管溶解性”2020-12-08肝脏病理（新课件）3836-8 汇管区嗜酸性粒细胞浸润 自身免疫性肝炎 髓外造血 医源反应 寄生虫感染 原发性胆汁性肝

10、硬化 原发性硬化性胆管炎 排斥反应2020-12-08肝脏病理（新课件）39Liver biopsy from a 25 y-o Laotian showing a granulomatous reaction against the ovum(HE).2020-12-08肝脏病理（新课件）4036-9 肉芽肿性炎症 儿童慢性肉芽肿病 克隆氏病 异物反应 原发性肝脏肉芽肿病 免疫性胆管炎 细菌、真菌、立克次氏体、病毒感染 脂肪性肉芽肿 恶性肿瘤 医源性反应 原发性胆汁性肝硬化 肉瘤样病2020-12-08肝脏病理（新课件）4136-10 肝纤维化 淀粉样桥接性纤维化 中央透明变性纤维化 先天性

11、肝纤维化 先天性梅毒 囊性纤维化 灶性结节状增生 肝脏门脉区纤维化 肝脏静脉性血液外溢，慢性阻塞性 代谢性疾病 中央静脉周围纤维化 肿瘤2020-12-08肝脏病理（新课件）42肝纤维化2020-12-08肝脏病理（新课件）43肝硬化=肝细胞再生+纤维化2020-12-08肝脏病理（新课件）4436-11 胆汁淤积 良性家族性胆汁淤积 妊娠性胆汁淤积 医源性 手术后性胆汁淤积 败血症2020-12-08肝脏病理（新课件）45细胞内淤胆2020-12-08肝脏病理（新课件）46Intrahepaptic Cholestasis2020-12-08肝脏病理（新课件）47Extrahepaptic

12、Cholestasis2020-12-08肝脏病理（新课件）4836-12 淤血或出血伴有肝窦扩张 肝静脉血外溢 静脉阻塞性疾病 心力衰竭 医源反应 肿瘤压迫 结节性再生性增生和回管区硬化 门脉阻塞2020-12-08肝脏病理（新课件）49肝淤血2020-12-08肝脏病理（新课件）50肝出血2020-12-08肝脏病理（新课件）5136-13 色素沉积 胆色素 铁 脂褐素 其它外源性色素 福尔马林色素2020-12-08肝脏病理（新课件）52胆色素 bile pigment2020-12-08肝脏病理（新课件）53Hemochromatosis2020-12-08肝脏病理（新课件）54Pru

13、ssian blue iron stain 2020-12-08肝脏病理（新课件）55Lipofuscin2020-12-08肝脏病理（新课件）5636-14 细胞内包含体 腺病毒 抗胰靡蛋白酶缺乏 支链淀粉血症 大泡脂肪变 微泡脂肪变“糖原性”胞核 巨线粒体“毛玻璃”细胞 HSV Mallory hyaline2020-12-08肝脏病理（新课件）57ALPHA-1-ANTITRYPSIN STORAGE MEGAMITOCHONDRIA GROUND GLASS CELLS 2020-12-08肝脏病理（新课件）58Alpha-1-antitrypsin deficiency2020-12

14、-08肝脏病理（新课件）59CMV hepatitis 2020-12-08肝脏病理（新课件）60Glycogen Nuclei2020-12-08肝脏病理（新课件）61A 30-year-old woman in the 30th week of pregnancy with Fulminant hepatic failure 2020-12-08肝脏病理（新课件）62herpes simplex virus2020-12-08肝脏病理（新课件）63Mallory hyaline2020-12-08肝脏病理（新课件）6436-15 脂肪变显著不伴有或轻微坏死 酒精性脂肪性肝炎 妊娠脂肪肝 灶

15、性脂肪变 肝细胞腺瘤、癌 医源、毒素反应 代谢性疾病 非酒精性脂肪性肝炎 非特异性脂肪变 Wilson病2020-12-08肝脏病理（新课件）6536-16 组织中出现不常见细胞 髓外造血 巨核细胞 转移瘤 储备细胞（肝、Kupffer或Ito)2020-12-08肝脏病理（新课件）66髓外造血2020-12-08肝脏病理（新课件）6736-17“几乎正常”的肝活检 肝汇管区纤维化 医源性反应 Missed lesion 结节状再生或增生 蓄积或代谢性疾病2020-12-08肝脏病理（新课件）6836-18 缺少(观察不到)正常结构 胆管 中央静脉 肝细胞 汇管区 汇管静脉 肝窦2020-12

16、-08肝脏病理（新课件）6936-19 肝脏代谢性疾病的光镜诊断类型类型诊断性诊断性LM诊断性诊断性EMa-抗胰糜蛋白酶缺乏抗胰糜蛋白酶缺乏汇管区周肝细胞内汇管区周肝细胞内PAS阳性球滴阳性球滴扩张内质网内出现颗粒状物扩张内质网内出现颗粒状物囊性纤维化囊性纤维化灶性胆管性纤维化灶性胆管性纤维化胆管纤维状物胆管纤维状物Gaucher病病Kupffer增大，汇管区巨噬细胞，增大，汇管区巨噬细胞，“Crinkled paper”胞浆胞浆溶酶体内管状包含体溶酶体内管状包含体糖原沉积症糖原沉积症 IV嗜碱性细胞内包含物嗜碱性细胞内包含物,PSA+丝状物丝状物粘多糖贮积症粘多糖贮积症肝细胞肝细胞,Kupp

17、fer 胶体铁染色胶体铁染色溶酶体内溶酶体内“羊毛羊毛”状物状物迟发性皮肤卟啉症迟发性皮肤卟啉症肝细胞内针状包含物肝细胞内针状包含物肝细胞内针状包含物肝细胞内针状包含物红细胞生成性原卟啉症红细胞生成性原卟啉症胆素色胆素色(毛细核小胆管毛细核小胆管)“Starburst”状排列的结晶状排列的结晶2020-12-08肝脏病理（新课件）7036-20 肝脏代谢性疾病的电镜和非特异性光镜诊断类型类型LMEM糖原沉积糖原沉积,II细胞内糖原增加细胞内糖原增加结合溶酶体结合溶酶体,糖原糖原GM2神经节苷脂沉积症神经节苷脂沉积症正常正常膜性层状包含体膜性层状包含体Niemann-Pick 病病泡沫状肝、泡沫

18、状肝、Kupffer细胞细胞溶酶体内溶酶体内“myelin”样包含体样包含体Wolman病病泡沫状肝、泡沫状肝、Kupffer细胞细胞肝、肝、Kupffer细胞内脂滴细胞内脂滴Zellweger综合症综合症非特异性肝细胞改变非特异性肝细胞改变缺乏过氧化小体缺乏过氧化小体(peroxisomes)2020-12-08肝脏病理（新课件）7136-21 肝脏代谢性疾病非诊断的光镜和电镜特点类型类型LMEM半乳糖血症Galactosemia同高酪氨酸血症同高酪氨酸血症糖原沉积(I,III)Glycogenstorage肝细胞大,窦受压,铺转排列,脂肪变,高糖原核仁糖原分隔细胞器,脂滴,高糖原核仁遗传性

19、果糖不耐症Hereditary fructose intolerance同高酪氨酸血症“fructoseholes”同心排列内质网,糖原颗粒高酪氨酸血症Tyrosinemia肝细胞变性伴脂肪变(灶性),淤胆,纤维化,肝硬化淤胆,脂滴,内质网增加,异常线粒体2020-12-08肝脏病理（新课件）72高酪氨酸血症肝脏2020-12-08肝脏病理（新课件）73Glycogen storage,Liver,LM2020-12-08肝脏病理（新课件）74Glycogen storage,Liver,EM2020-12-08肝脏病理（新课件）75肝脏疾病诊断 病因学 形态（LM&EM)组化和免疫组化 血清

20、学、酶学检查 临床表现2020-12-08肝脏病理（新课件）76Alcoholic Fatty Liver2020-12-08肝脏病理（新课件）77Alcoholic Fatty Liver2020-12-08肝脏病理（新课件）78CirrhosisFibrosisRegenerating Nodule2020-12-08肝脏病理（新课件）79Micronodular cirrhosis2020-12-08肝脏病理（新课件）80Micronodular cirrhosis:2020-12-08肝脏病理（新课件）81Hepatic Adenoma2020-12-08肝脏病理（新课件）82Hepa

21、tocellular Carcinoma2020-12-08肝脏病理（新课件）83Hepatic metastasis:2020-12-08肝脏病理（新课件）84Hepatic metastasis:2020-12-08肝脏病理（新课件）85Amoebic Liver Abscess:2020-12-08肝脏病理（新课件）86Hepar Lobatum(cong.Syphilis):2020-12-08肝脏病理（新课件）87Stomach20%Breast20%Colorectal20%Liver13%Lung27%2020-12-08肝脏病理（新课件）88The Major Etiologi

22、cal Factors Chronic hepatitis -types B or C Cirrhosis/chronic liver disease of any type Aflatoxin exposureMales,increasing age2020-12-08肝脏病理（新课件）898%-High 2-7%-Intermediate 2%-LowData from CDC Chronic HBV Infection-Geographic Distribution2020-12-08肝脏病理（新课件）90Prospective Study of HCC Development in H

23、BsAg Seropositive 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)2020-12-08肝脏病理（新课件）91Beasley 1986“The lifetime risk of developing Hepatocellular carcinomaIn a Chinese male carrier Of the hepatitis B virusIs

24、between 40 and 50%”2020-12-08肝脏病理（新课件）92Chronic Viral Hepatitis&HCCHBsAg positivity(%)Anti-HCV positivity(%)HCCControlHCCControlFinlandFranceSpainUSAItalyGreeceSouth AfricaJapanHong KongChinaTaiwan491718214661128286910.22.2-0-7.311.31.818.022.015-22-5875297639297572533-0.680.500.700.870.600.701.150.

25、64-0.95Okuda,19992020-12-08肝脏病理（新课件）93Anti-HCV Prevalence5%-High 1.1-5%-Intermediate 0.2-1%-Low 0.2-1%-LowChronic HCV Infection-Geographic Distribution 2020-12-08肝脏病理（新课件）94Thank Your Attendance!2020-12-08肝脏病理（新课件）95肝脏肿瘤-Neoplasms of the Liver Hepatocellular Carcinoma and Cholangiocarcinoma2020-12-08肝脏病理（新课件）96Pathology of Vascular Diseases of the Liver 2020-12-08肝脏病理（新课件）97References 2020-12-08肝脏病理（新课件）982020-12-08肝脏病理（新课件）99谢谢感谢您的聆听您的关注使我们更努力