肝癌肝昏迷医学知识讲座培训ppt课件

肝癌肝昏迷医学知肝癌肝昏迷医学知识识讲讲座座肝癌肝昏迷医学知识讲座1 Overview Definition Heaptocellular carcinoma(HCC)originated in the liver cells or intrahepatic bile duct cells.2肝癌肝昏迷医学知识讲座 Overview2肝癌肝昏迷医学知识讲座2 Incidence rate 14.5846/100,000.HCC is up to 25times more common in men than women and usually arises in a cirrhotic liver.Overview3肝癌肝昏迷医学知识讲座 Incidence rate 14.5846/3 Chronic liver disease Aflatoxin Drinking Water Pollution Other factorsEtiology and pathogenesis4肝癌肝昏迷医学知识讲座Etiology and pathogenesis4肝癌肝昏4 Chronic liver disease viral hepatitis 1.HBV:HBV-DNA may be integrated into the host DNA of liver cells,and changes gene expression in liver cells.2.HCV Etiology and pathogenesis5肝癌肝昏迷医学知识讲座 Chronic liver diseaseEtiolo5 CirrhosisAbout 50 90%of HCC accompanied cirrhosis.Acute and chronic hepatitis CirrhosisHCC Etiology and pathogenesis6肝癌肝昏迷医学知识讲座 CirrhosisEtiology and pathog6 Aflatoxin B1 Drinking Water Pollution:Algae toxin could contaminate water sources Chemical carcinogens:nitrite,organic chlorine pesticides Parasite:liver flukeEtiology and pathogenesis7肝癌肝昏迷医学知识讲座 Aflatoxin B1Etiology and 7 Pathology Morphological typing Block type(5cm)Nodular type(5cm)Diffuse type Small hepatocarcinoma(3cm)Cell classification Hepatocellular Bile duct cell type8肝癌肝昏迷医学知识讲座 Pathology8肝癌肝昏迷医学知识讲座8 metastasis 1.Intrahepatic metastasis 2.Extrahepatic metastasis （1）Hematogenous metastasis （2）Lymphatic metastasis （3）implantation metastasisPathology9肝癌肝昏迷医学知识讲座 metastasisPathology9肝癌肝昏迷医学9 Subclinical hepatocellular carcinoma:Without any signs and symptoms AFP clinical manifestation10肝癌肝昏迷医学知识讲座 clinical manifestation10肝癌肝昏迷10 hepatic region pain:Persistent pain or dull pain Progressive enlarge liver:Quality hard,uneven surface,nodule or giant blocks,ragged edge,tenderness,vascular murmurclinical manifestation11肝癌肝昏迷医学知识讲座 hepatic region pain:clinica11 Jaundice Cirrhosis symptoms and signs:liver dysfunction and Portal hypertension:Such as Splenomegaly,ascites,collateral circulationclinical manifestation12肝癌肝昏迷医学知识讲座 Jaundiceclinical manife12 Systemic manifestations of malignant tumors:Fatigue,weight loss,cachexia,fever,anorexia Metastasis features:the lung,bone,chest Paraneoplastic syndrome:such as hypoglycemia、Erythrocytosis and so onclinical manifestation13肝癌肝昏迷医学知识讲座 Systemic manifestat13SYMPTOMS PREVALENCE(%)PHYSICAL SIGNS PREVALENCE(%)Abdominal pain 59-95Hepatomegaly 54-98Weight loss 34-71Hepatic bruit 6-25Weakness 22-53Ascites 35-61Abdominal swelling 28-43Splenomegaly 27-42Nonspecific Jaundice 4-35Gastrointestinal symptoms 25-28Wasting 25-41Jaundice 5-26Fever 11-54Table 2.Prevalence of Clinical Features of Hepatocellular Carcinoma clinical manifestation14肝癌肝昏迷医学知识讲座SYMPTOMS PREVALENCEPHYSICAL SI14Complications Hepatic encephalopathy Upper gastrointestinal bleeding Rupture of liver carcer nodules Secondary infection15肝癌肝昏迷医学知识讲座Complications Hepat15（一）（一）Detection of liver cancer markers 1.Alpha-fetoprotein(AFP)Clinical Significance:liver cancer census(high-risk groups),diagnosis,Judging treatment and relapseLaboratories and equipment inspection16肝癌肝昏迷医学知识讲座Laboratories and equipment ins16 AFP diagnostic criteria for liver cancer AFP 500g/L 4W AFP:From low to high AFP200g/L 8W False positive:Pregnancy,chronic hepatitis,cirrhosis,Gonadal blastoma False-negative:Detection of AFP heterogeneityLaboratories and equipment inspection17肝癌肝昏迷医学知识讲座 AFP diagnostic criteria 17 2.Other liver cancer marker r-glutamyl transferase isoenzyme peptide （r-GT）abnormal prothrombin（APT）serum a-l-fucosidase(AFU)ALP isoenzyme（ALP-I）Laboratories and equipment inspection18肝癌肝昏迷医学知识讲座 2.Other liver cancer marker 18 （二）（二）Imaging examination Ultrasound:2cm or more substantial mass X ray computer tomography（CT）X-hepatic angiography Magnetic resonance imaging(MRI)（三）（三）Liver puncture biopsyLaboratories and equipment inspection19肝癌肝昏迷医学知识讲座 （二）Imaging examination Lab19 Clinical manifestations,coupled with AFP,liver B-Ultrasound,CT etc.Diagnosis20肝癌肝昏迷医学知识讲座 Diagnosis20肝癌肝昏迷医学知识讲座20Clinical diagnostic criteria for hepatocellular carcinoma(一）一）Non-invasive diagnostic criteria 1.Imaging：Two kinds of imaging studies have shown more than 2cm liver mass.2.Imaging with AFP:A kind of imaging examination showe more than 2cm liver mass accompanied AFP 400g/L.Diagnosis21肝癌肝昏迷医学知识讲座Clinical diagnostic criteria f21（二）（二）Histological diagnostic criteria Less than 2cm of intrahepatic nodules that maging can not determine shoud be punctured to confirm histological characteristics of liver cancer.Diagnosis22肝癌肝昏迷医学知识讲座（二）Histological diagnostic Di22 1.Active hepatitis and cirrhosisDifferential Diagnosis（一）（一）Differential diagnosis in AFP-positive liver cancer 23肝癌肝昏迷医学知识讲座 1.Active hepatitis and cir23Active liver disease Liver Cancer Differential Diagnosis24肝癌肝昏迷医学知识讲座Active liver diseaseDifferenti24Active liver disease ALT,AFP curveTimedensityAFPchangeALTchangeDifferential Diagnosis25肝癌肝昏迷医学知识讲座Active liver disease ALT,AFP 25density时间ALTchanceAFPchanceHCC ALT,AFP curveDifferential Diagnosis26肝癌肝昏迷医学知识讲座density时间ALTchanceAFPchanceHCC262.Pregnancy3.Embryonic gonad tumors4.Other gastrointestinal tumors,such as gastric cancer,pancreatic cancer and malignant insulinoma and so on.Differential Diagnosis27肝癌肝昏迷医学知识讲座2.PregnancyDifferential Diag27Differential Diagnosis（二）二）Identification of AFP-negative hepatocellular carcinoma1.1.Metastatic hepatic carcinoma.Metastatic hepatic carcinoma.2.Hepatic hemangioma.3.Intrahepatic liquid space-occupying lesions:live cyst,liver abscess and liver hydatid.4.Other benign space-occupying diseases:inflammatory pseudotumor,liver adenoma,liver and partial fatty infiltration,liver nodules and liver sarcoma and so on.28肝癌肝昏迷医学知识讲座Differential Diagnosis（二）Ide28 surgical treatment Local treatment 1.Hepatic artery embolization chemotherapy 2.Ethanol injection 3.Physiotherapy Treatment29肝癌肝昏迷医学知识讲座Treatment29肝癌肝昏迷医学知识讲座29 Radiotherapy Biological and immunotherapy Systemic chemotherapy Comprehensive treatmentTreatment30肝癌肝昏迷医学知识讲座 RadiotherapyTreatment30肝癌30Surgical resection:Offers best chance for cure,but seldom is possible when disease is symptomatic.May be technically difficult.High recurrence rate after resection.Liver transplantation:May be successful in selected patients.Requires transfer to a transplant center and,postoperatively,lifelong immunosuppression.High recurrence rate.Expensive.Alcohol injection:Palliative for small(usually multiple)tumors that cannot be resected.May be difficult to decide if all the malignant cells have been destroyed.Procedure may facilitate spread of the tumor.Chemoembolization:May shrink selected large tumors to the point where they may become resectable.Effect is palliative for localized but unresectable tumors.Chemotherapy:Palliative only;can be used as an adjunct to surgical resection or transplantation.drug toxicity is frequent.Table 5.Treatment Options for Hepatocellular Carcinoma 31肝癌肝昏迷医学知识讲座Surgical resection:Offers bes31PrognosisThe better prognosis as following ：1.1.Tumor less than 5cm,early operation.2.2.Cancer capsule integrity,and there is no cancer plug formation.3.3.Normal immune.32肝癌肝昏迷医学知识讲座PrognosisThe better prognosis 32Chapter 14 Hepatic EncephalopathyInternal Medical Teaching and Research SectionInternal Medical Teaching and Research Section,First First Clinical Medical College of Guangxi Medical UniversityClinical Medical College of Guangxi Medical University2005undergraduat courseware Professor XingHuo-Tang Professor XingHuo-Tang33肝癌肝昏迷医学知识讲座Chapter 14 Hepatic Encepha33DefinitionHepatic encephalopathy is a state of disordered central nervous system function resulting from failure of the liver to detoxify noxious agents of gut origin because of hepatocellular dysfunction and portosystemic shunting.34肝癌肝昏迷医学知识讲座Definition34肝癌肝昏迷医学知识讲座34Etiology and pathogenesisEtiology:cirrhosis,severe hepatitis,hepatocellular carcinoma,fatty liver of pregnancy et al.35肝癌肝昏迷医学知识讲座Etiology and pathogenesis35肝癌肝35 Drugs Inhibit the brain and respiratory center,resulting in hypoxia Hypovolemia Leading to prerenal azotemia,increased blood ammonia Benzodiazepines Diuresis,diarrhea Anesthetic Vomiting,bleeding Alcohol Released ascites Increased in ammonia production Portosystemic shuntGut-derived ammonia into the systemic circulation Protein food shunt surgery Digestive bleeding Vascular obstruction Infection Portal vein thrombosis Constipation Hepatic vein thrombosis Hypokalemia leading to metabolic alkalosis Primary liver cancer Common incentiveing factors of hepatic encephalopathy36肝癌肝昏迷医学知识讲座 Drugs Hypovolemia 36Glutamine NH3+Glutamate Urea,protein NH3+CO2Intestinal ammonia:Ammonialiver Etiology and pathogenesis（一）（一）Neurotoxin NH3+H+NH4+pH6pH6urea,glutamine37肝癌肝昏迷医学知识讲座Glutamine NH3+Glutamate Intes371.Interfere with brain cells TCA cycle.2.Increased brain neutral amino acids such as tyrosine,phenylalanine,tryptophan.3.Astrocytes increased glutamate and neuronal cell swelling.4.Ammonia can also directly interfere with the electrical activity of neurons.Etiology and pathogenesisAmmonia inhibited the central nervous system:38肝癌肝昏迷医学知识讲座Interfere with brain cells TCA38 Etiology and pathogenesis（二）（二）Changes in neurotransmitterNormal neurotransmitter:dopamine,norepinephrine.1.False neurotransmitter:Tyrosine Tyramine hydroxyl tyramine Phenylalanine Phenylethylamine Phenylethanolamine 39肝癌肝昏迷医学知识讲座 Etiology and pathogenesis39肝癌39Etiology and pathogenesis2.GABA/BZ3.Tryptophan Tryptophan Brain5-hydroxytryptamine,5-HIAA Inhibited brain function 40肝癌肝昏迷医学知识讲座Etiology and pathogenesis40肝癌肝40Pathology Acute HE patients no obvious anatomical abnormalities in brain,mainly secondary brain edema 41肝癌肝昏迷医学知识讲座Pathology Acute HE patients no41 Clinical manifestations The manifestations of the primary disease.The manifestations of the central nervous system.42肝癌肝昏迷医学知识讲座 Clinical manifestations 42肝癌肝42Phases The level of consciousness Pounce-like tremor EEG NO.1 phases mild changes in normal precursor personality and behavior phases NO.2 phases consciousness disorders,sleep disorders.+abnormalpre-coma orientation and computing abnormalNO.3 phases drowsiness,mental disorder +abnormalsleeping period neurological signs postiveNO.4 phases complete loss of consciousness _ abnormalcoma deep coma 43肝癌肝昏迷医学知识讲座Phases The level of co43 Clinical manifestations Minimal hepatic encephalopathy:None of the symptoms and signs.Psychological aptitude test unresponsive.44肝癌肝昏迷医学知识讲座 Clinical manifestations44肝癌肝昏44 Laboratories and equipment inspection Ammonia Electrolyte acid-base imbalance,hypokalemia,metabolic alkalosis Evoked Potentials EEG Psychological Aptitude Test Imaging 45肝癌肝昏迷医学知识讲座 Laboratories and equipment i45Diagnosis Serious liver disease +precipitating factors +Neuropsychiatric symptoms +Exclude other diseases 46肝癌肝昏迷医学知识讲座Diagnosis 46肝46Differential diagnosis Cerebrovascular accident:Age,high blood pressure,Hemiplegia Diabetic coma:glucose ,urine glucose,urine ketone(+)Uremia:History of kidney disease,edema,anemia,high blood pressure,urinary changes,renal function damaged Poisoning 47肝癌肝昏迷医学知识讲座Differential diagnosis 47肝癌肝昏迷47Treatment 一、一、The elimination of incentives and treatment of primary disease:1.Avoid sedatives and drugs which damaged liver function.2.Hemostasis,removal of intestinal hemorrhage.3.Correct water and electrolyte acid-base disturbance.4.Prevention and control infection.5.Improve liver function.48肝癌肝昏迷医学知识讲座Treatment 48肝癌肝昏迷医学知识讲座48Treatment二、二、Reducing intestinal ammonia production and absorption:1.Restricted protein diet 2.Intestinal cleansing 3.Lactulose,lactitol 4.Inhibited bacterial growth 5.Probiotic preparations 49肝癌肝昏迷医学知识讲座Treatment49肝癌肝昏迷医学知识讲座49 Treatment 三、三、To promote metabolism of ammonia in vivo:1.L-ornithine-L-aspartate(OA)2.Ornithine-ketoglutarate 3.Sodium benzoate 4.Glutamate 5.Arginine 四、四、GABA/BZ receptor antagonist flumazenil composite.五、五、Antagonist to false neurotransmitter 50肝癌肝昏迷医学知识讲座 Treatment 50肝癌肝昏迷医学知识讲座50Treatment六、六、other treatment 1.Artificial liver.2.Liver transplantation.3.Prevention and treatment of cerebral edema,and protecting brain cells function.4.To maintain airway.51肝癌肝昏迷医学知识讲座Treatment51肝癌肝昏迷医学知识讲座51小小 肝肝 癌癌52肝癌肝昏迷医学知识讲座小 肝 癌52肝癌肝昏迷医学知识讲座52大大 肝肝 癌癌53肝癌肝昏迷医学知识讲座大 肝 癌53肝癌肝昏迷医学知识讲座53大大 肝肝 癌癌54肝癌肝昏迷医学知识讲座大 肝 癌54肝癌肝昏迷医学知识讲座54大大 肝肝 癌癌55肝癌肝昏迷医学知识讲座大 肝 癌55肝癌肝昏迷医学知识讲座55大大 肝肝 癌癌56肝癌肝昏迷医学知识讲座大 肝 癌56肝癌肝昏迷医学知识讲座5657肝癌肝昏迷医学知识讲座57肝癌肝昏迷医学知识讲座5758肝癌肝昏迷医学知识讲座58肝癌肝昏迷医学知识讲座5859肝癌肝昏迷医学知识讲座59肝癌肝昏迷医学知识讲座59肝癌肝昏迷医学知识讲座培训ppt课件6061肝癌肝昏迷医学知识讲座61肝癌肝昏迷医学知识讲座6162肝癌肝昏迷医学知识讲座62肝癌肝昏迷医学知识讲座6263肝癌肝昏迷医学知识讲座63肝癌肝昏迷医学知识讲座6364肝癌肝昏迷医学知识讲座64肝癌肝昏迷医学知识讲座6465肝癌肝昏迷医学知识讲座65肝癌肝昏迷医学知识讲座6566肝癌肝昏迷医学知识讲座66肝癌肝昏迷医学知识讲座6667肝癌肝昏迷医学知识讲座67肝癌肝昏迷医学知识讲座6768肝癌肝昏迷医学知识讲座68肝癌肝昏迷医学知识讲座6869肝癌肝昏迷医学知识讲座69肝癌肝昏迷医学知识讲座6970肝癌肝昏迷医学知识讲座70肝癌肝昏迷医学知识讲座7071肝癌肝昏迷医学知识讲座71肝癌肝昏迷医学知识讲座71结结 节节 型型 肝肝 癌癌72肝癌肝昏迷医学知识讲座结 节 型 肝 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