1、Welcome,肝脏疾病病理学诊断,Outline of Guidelines,Classification of liver diseases,LIVER,Liver Biopsy,Liver Biopsy,Confirm the diagnosisSerological blood testsEstablish degree of fibrosisSerologyBiopsy not representativeIdentify cirrhosisDetermine optimum therapy,Liver biopsy adequacy,“Most hepatopathologists
2、 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 assessment fo
3、r 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 needed.,3
4、6-1 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,LOBULE VS ACINUS,肝小叶,肝板、肝窦,肝脏,EM,肝脏,EM (cont.),汇管区和中央静脉,36-2 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,灶状坏死 带状坏死 融合性坏死 大片坏死 桥接坏死,Acidophil body,Ballooning Degeneration,Fatty Degeneration Alcoholic liver disease,Ductule,Interlobular bile duct,Necr
5、osis, piecemeal,Necrosis, focal,Necrosis, Zonal,Necrosis, Confluent,Necrosis, Massive,Necrosis, Bridging,Drug and Toxin- Induced Liver Disease,36-3 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,36-4 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 医源性反应 败血症 “
6、手术性”肝炎 病毒感染(CMV),Autoimmune Hepatitis,36-5 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,36-6 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,肉芽肿或肿瘤 原发性胆汁性肝硬化 原发性硬化性胆管炎 排斥反应 病毒性肝炎 Wilson病,Primary biliary cirrhosis,Antimitochondrial antibody,36-7 汇管区多形核细胞浸润 -
7、,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”,36-8 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 原发性胆汁性肝硬化 原发性硬化性胆管炎 排斥反应,Liver biopsy from a 25 y-o Laotian showing a granulomatous reaction against the ovum (HE).,36-9 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
8、瘤样病,36-10 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,肝纤维化,肝硬化 = 肝细胞再生 + 纤维化,36-11 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,细胞内淤胆,Intrahepaptic Cholestasis,Extrahepaptic Cholestasis,36-12 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
9、塞,肝淤血,肝出血,36-13 色素沉积,胆色素 铁 脂褐素 其它外源性色素 福尔马林色素,胆色素 bile pigment,Hemochromatosis,Prussian blue iron stain,Lipofuscin,36-14 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 hyaline,ALPHA-1-ANTITRYPSIN STORAGE,MEGAMITOCHONDRIA,GROUND GLASS CELLS,Alpha-1-antitrypsin deficiency,CMV
10、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,36-16 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),髓外造血,36-17 “几乎正常
11、”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,36-18 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,36-19 肝脏代谢性疾病的光镜诊断,36-20 肝脏代谢性疾病的电镜和非特异性光镜诊断,36-21 肝脏代谢性疾病非诊断的光镜和电镜特点,高酪氨酸血症肝脏,Glycogen storage, Liver, LM,Glycogen storage, Liver, EM,肝脏疾病诊断,病因学 形态(LM & EM) 组化和免疫组化 血清学、酶学检查 临床表现,Alcoholic Fatty Liver,Alc
12、oholic Fatty Liver,Cirrhosis,FibrosisRegenerating 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 Major E
13、tiological Factors,Chronic hepatitis - types B or C Cirrhosis/chronic liver disease of any type Aflatoxin exposureMales, increasing age,8% - High,2-7% - Intermediate,2% - Low,Data from CDC,Chronic HBV Infection - Geographic Distribution,Prospective Study of HCC Development in HBsAg Seropositive Male
14、 Chinese,HCC DEVELOPMENT 19,223 (HBsAg -ve) 922,707 Mean follow-up = 8.9 years Male Chinese3,454 (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 5
15、0%”,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 - Geographic Distribution,Thank Your Attendance !,肝脏肿瘤 - Neoplasms of the Liver,Hepatocellular Carcinoma and Cholangiocarcinoma,Pathology of Vascular Diseases of the Liver,References,http:/ http:/medlib.med.utah.edu/WebPath/,Questions?,