肝疾病肝疾病 Liver DiseaseLiver Disease学习要求学习要求1.1. 掌握掌握肝脓肿、肝癌的诊断和外肝脓肿、肝癌的诊断和外 科治疗 2.2. 熟悉肝脏的解剖特点，细菌性熟悉肝脏的解剖特点，细菌性 和阿米巴性肝脓肿的鉴别诊和阿米巴性肝脓肿的鉴别诊 断 3.3. 了解肝了解肝囊肿、肝海绵状血管瘤囊肿、肝海绵状血管瘤 的诊断和治疗的诊断和治疗原则Surgical Anatomy标志标志 血管血管 肝门肝门 分分叶叶 分段分段Liver functions1.1. 分泌胆汁分泌胆汁 2.2. 代谢功能代谢功能 3.3. 凝血功能凝血功能 4.4. 解毒作用解毒作用 5.5. 吞噬和免疫作用吞噬和免疫作用再生能力再生能力强强缺氧耐受力差缺氧耐受力差肝脓肿肝脓肿 Liver abscessLiver abscessPathogenesis1.1. Biliary Biliary tree tree 2.2. Hepatic artery Hepatic artery 3.3. Portal Portal vein vein 4.4. Nearby infection Nearby infection 5.5. Trauma Trauma Clinical Features1.1. Fever and chillsFever and chills 2.2. RUQ RUQ pain and pain and tenderness tenderness 3.3. Hepatomegaly Hepatomegaly 4.4. JaundiceJaundice 5.5. Nonspecific Nonspecific symptoms symptoms Lab. and imaging 1.1. WBCWBC, ,HGB HGB 2.2. Ultrasound, X-Ray, CTUltrasound, X-Ray, CT 3.3. FNAFNADifferential diagnosis1.1. Amebic live abscessAmebic live abscess 2.2. Intrahepatic biliary infectionsIntrahepatic biliary infections 3.3. Cancer of the liverCancer of the liver 4.4. Subphrenic abscessSubphrenic abscessTreatment1.1. Supportive therapySupportive therapy • • Energy and nutritionEnergy and nutrition • • Electrodes and fluidElectrodes and fluid • • Blood transfusionBlood transfusionTreatment2.2. AntibioticsAntibiotics • • A ASAP, if suspectedSAP, if suspected • • Broad spectrum, covering GBroad spectrum, covering G+ +,G,G- -and and anaerobesanaerobes • • Duration Duration ≥≥2w, recommended2w, recommendedTreatment3.3. DrainageDrainage • • PercutaneousPercutaneous • • LaparotomyLaparotomy • • L LaparoscopicaparoscopicTreatment4.4. HepatectomyHepatectomy 5.5. Traditional medicineTraditional medicine肝囊肿(Cyst of the liver)肝囊肿非寄生虫性先天性单发性多发性 创伤性炎症性肿瘤性寄生虫性肝棘球坳病 Echinococcosis of the liver肝包虫病肝包虫病 （（HydatidHydatid …… ……）） 1.1.牧区生活史牧区生活史 2.2.血清学血清学+ +影像学影像学 3.3.手手术治疗为首术治疗为首选选先天性肝囊肿 congenital cyst of liverp 囊壁内层附有内皮细胞 p 液体清亮，多不含胆汁 p 大而有症状者需适当治疗 p 腹腔镜下开窗术首选，也可选穿 刺。
p 注意：与胆道相通囊肿、病变广泛 的多囊肝肝肿瘤 （tumor of liver)肝肿瘤良性恶性原发性继发性肝海绵状血管瘤 Cavernous hemangioma of liverp 生长缓慢 p 较小时多无症状 p CT、MRI不难诊断 p 小而无症状者随访 p 手术切除适应证小 结pp 肝脏解剖肝脏解剖 pp 肝脓肿肝脓肿 ––临床表现临床表现 ––与阿米巴性肝脓肿的鉴别与阿米巴性肝脓肿的鉴别 ––治疗方法治疗方法原发性肝癌原发性肝癌 Primary Primary l liver canceriver cancerEpidemiologypp CommonCommon pp 600000 new cases found annually600000 new cases found annually pp 55% occurs in China55% occurs in China pp M M＞＞F F pp High incidence in the age of High incidence in the age of 40s, and a tendency to develop 40s, and a tendency to develop earlierearlierEtiologypp Liver cirrhosisLiver cirrhosis pp HBVHBV pp AflatoxinAflatoxin (AFT) (AFT) pp Chronic alcohol abuse Chronic alcohol abuse pp HCVHCV pp Chemicals: Chemicals: nitrites, hydrocarbonsnitrites, hydrocarbons, , solvents, pesticides, solvents, pesticides, vinyl vinyl chloridechloridePathologypp CategoriesCategories ––Cancer cellsCancer cells ––MorphologyMorphology ––SizeSize pp MetastasisMetastasis ––intrahepaticintrahepatic ––extrahepaticextrahepaticClinical Presentationpp RUQ abdominal painRUQ abdominal pain pp Nonspecific symptomsNonspecific symptoms pp HepatomegalyHepatomegalyDiagnosispp HCC markersHCC markers • •Alpha fetoprotein (AFP)Alpha fetoprotein (AFP) • •Serum Serum enzymologyenzymology pp ImagingImaging • •UltrasoundUltrasound • •CT and MRICT and MRI • •DSADSA • •X-raysX-rays pp FNA and BiopsyFNA and BiopsyDiagnosisTreatmentpp 治疗原则治疗原则早期诊断，早期治疗，根据不同病早期诊断，早期治疗，根据不同病 进行综合治疗进行综合治疗 pp 首选方法首选方法早期施行手术治疗早期施行手术治疗Treatment1.1. Surgical treatmentSurgical treatment ––ResectableResectableHepatectomy (Radical, Palliative)Hepatectomy (Radical, Palliative) ––UnresectableUnresectable (op. in procedure) (op. in procedure)HALHAL, EI, RFA, MWA, , EI, RFA, MWA, CryotherapyCryotherapy ––RecurrentRecurrent ––PerforatedPerforated ––Liver transplantationLiver transplantation肝切除术Treatment2.2. Percutaneous ablationPercutaneous ablation ––RFARFA ––MWAMWA ––PEIPEITreatment3.3. ChemotherapyChemotherapy ––TACE: TACE: recoreco- - ––General chemotherapy: not General chemotherapy: not recoreco- - ––Sustained Sustained release release agentagent 4.4. RadiotherapyRadiotherapy 5.5. Biological treatment Biological treatment 6.6. Traditional medicineTraditional medicine继发性肝癌pp 血行转移最常见器官血行转移最常见器官 pp 多来自消化道肿瘤多来自消化道肿瘤 pp 临床表现：原发灶临床表现：原发灶 pp 诊断：影像学诊断：影像学+ +肿瘤标记物，活检肿瘤标记物，活检 pp 治疗：取决于原发肿瘤情况治疗：取决于原发肿瘤情况结直肠癌并肝转移的治疗结直肠癌并肝转移的治疗谢谢 ！。