肝脏疾病病理学诊断课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Welcome,肝脏疾病病理学诊断,Outline of Guidelines,Classification of liver diseases,LIVER,Liver Biopsy,Liver Biopsy,Confirm the diagnosis,Serological blood tests,Establish degree of fibrosis,Serology,Biopsy not representative,Identify cirrhosis,Determine optimum therapy,Liver 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 size of biopsy that,“,satisfies,”,the pathologist.,The correct question is:,What size of biopsy will provide a reliable assessment for the patient,s 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.,36-1 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,Necrosis, 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,“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 -,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 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”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,类型,诊断性,LM,诊断性,EM,a-,抗胰糜蛋白酶缺乏,汇管区周肝细胞内,PAS,阳性球滴,扩张内质网内出现颗粒状物,囊性纤维化,灶性胆管性纤维化,胆管纤维状物,Gaucher,病,Kupffer,增大，汇管区巨噬细胞， “,Crinkled paper”,胞浆,溶酶体内管状包含体,糖原沉积症,IV,嗜碱性细胞内包含物,PSA +,丝状物,粘多糖贮积症,肝细胞,Kuppfer,胶体铁染色,溶酶体内“羊毛”状物,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,红细胞生成性原卟啉症,胆素色(毛细核小胆管),“Starburst”,状排列的结晶,36-20 肝脏代谢性疾病的电镜和非特异性光镜诊断,类型,LM,EM,糖原沉积,II,细胞内糖原增加,结合溶酶体, 糖原,GM2,神经节苷脂沉积症,正常,膜性层状包含体,Niemann-Pick,病,泡沫状肝、,Kupffer,细胞,溶酶体内“,myelin”,样包含体,Wolman,病,泡沫状肝、,Kupffer,细胞,肝、,Kupffer,细胞内脂滴,Zellweger,综合症,非特异性肝细胞改变,缺乏过氧化小体(,peroxisomes),36-21 肝脏代谢性疾病非诊断的光镜和电镜特点,类型,LM,EM,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),Glycogen storage,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,果糖不耐症,Hereditary fructose intolerance,同,高酪氨酸血症,“,fructose holes”,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,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,Alcoholic Fatty Liver,Cirrhosis,Fibrosis,Regenerating 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 Etiological Factors,Chronic hepatitis - types B or C,Cirrhosis/chronic liver disease of any type,Aflatoxin exposure,Males, 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 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),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 50%”,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,