肝功能化验异常的分析与解释课件

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,*,*,肝功能化验异常的,分析与解释,赵新颜,1,肝脏具有那些功能,?,代谢功能,胆汁生成和排泄,凝血功能,解毒作用,2,肝脏分类检测,Enzyme tests,Aminotransferases,Alkaline,phosphatase,Gamma,glutamyl,transpeptidase,Tests of synthetic function, Albumin,Prothrombin,time,Tests of hepatic transport capability,Serum,bilirubin,3,丙氨酸氨基转移酶,Alanine,Aminotransferase,(ALT),Serum,Glutamic-pyruvic,Transaminase,(SGPT),组织来源,:,肝细胞胞浆,丙氨酸,酮戊二酸,丙酮酸,谷氨酸,4,天冬氨酸氨基转移酶,Aspartate,Aminotransferase,(AST),Serum,Glutamic-oxaloacetic,Transaminase,(SGOT),组织来源,:,心脏,肌肉,肾脏,脑,胰腺,红细胞,肝细胞胞浆,(20%),及线粒体,(80%),天门冬氨酸,酮戊二酸,草酰乙酸,谷氨酸,AST,5,ALT,与,AST,Severe ( 20 times, 1000 U/L),急性病毒性肝炎,药物或毒物损伤,休克肝,Moderate (3-20 times ),慢性肝炎,药物性肝炎,酒精性肝炎,自身免疫性肝炎,Mild (1-3 times),脂肪肝,非酒精性脂肪性肝炎,肝硬化,6,ALT,:,AST ratio,AST,：,ALT,2,酒精性肝病,AST,：,ALT,1,肝硬化,7,碱性磷酸酶,Alkaline,Phosphatase,(ALP),组织来源,:,肝脏,骨骼,肠道,胎盘,机制,:,胆汁酸增加,ALP,脂溶性,刺激,ALP,合成,8,碱性磷酸酶,Alkaline,Phosphatase,(ALP),意义,:,肝脏相关的,:,肝内胆汁淤积,部分或完全胆道梗阻,肝脏肿瘤,肉芽肿性病变,非肝脏因素,:,骨肿瘤,妊娠,9,谷酰转肽酶,Gamma-,glutamyl,transferase,(GGT),组织来源,:,membrane of cells (liver, kidney, pancreas, intestine, prostate),意义,:,胆汁淤积,原发性或转移性肝癌,酒精性肝病,胰腺癌,壶腹周围癌,10,肝功能异常类型,化验,肝细胞损伤,胆汁淤积,转氨酶,8,倍正常值,3,倍正常值,ALP,8,倍正常值,BIL,增高,增高,PT,延长，对维生素,K,治疗反应差,延长，对维生素,K,治疗反应好,腹痛,不常见,常见（肝外梗阻时）,发热，,WBC,增高,不常见,常见（肝外梗阻时）,11,胆红素代谢示意图,12,胆红素,Bilirubin,(BIL),间接胆红素增高血症,:,生成过多,肝脏摄取受损,葡萄糖醛酸化受损,13,间接胆红素增高血症,(,例,1),李霞，女，,27,岁,非洲工作（,08-4-18,至,08-10-7,）,稽留热,5,天（,08-10-18,至,08-10-22,）,血图片：可见疟原虫（外院）,服用氯奎,3,日，青蒿琥酯片及蒿甲醚,5,日热退,（,08-10-20,至,08-10-27,）,入院前,3,日再次高热伴阵发中上腹绞痛（,08-10-28,）,血色素,9.1g/dl,降至,3.9g/dl,伴酱油色尿，网织红,2.53%,ALT 30U/L,AST 57U/L,TBIL 40.3umol/L,IBIL 27.43umol/L,LDH863U/L,14,间接胆红素增高血症,(,例,2),中年女性。,胆结石拟手术，发现间接胆红素增高请会诊。,Hb,正常,网织红细胞比例增高。,外周血图片,15,间接胆红素增高血症,(,例,3),刘壮飞 ，男性，,12,岁,反复皮肤黄染伴乏力,6,年,父亲自,18,岁起发现胆红素升高，以间接胆红素为主,ALT 16U/L,，,AST 27 U/L,正常,TBIL 46.2umol/L,，,IBIL 30.0umol/L,。,组织病理学,最终诊断：,Gilbert,综合征,16,胆红素,Bilirubin,(BIL),直接胆红素增高血症,:,肝外胆管梗阻,肝内胆汁淤积,17,肝外胆管梗阻,李彦红，女性，,77,岁,突然皮肤巩膜黄染,10,天,ALT,，,AST,正常,ALP 302U/L,，,GGT361U/L,TBIL 250.60umol/L, DBIL 233.60umol/L,18,肝外胆管梗阻,19,正常胰胆管系统,20,胆汁分泌障碍、流速减慢或停滞，可发生在从肝细胞、,毛细胆管直至,Vater,壶腹各水平。,临床：以瘙痒、黄疸、,ALP,、,GGT,增高等为特征。,病理：肝细胞及,/,或胆道系统胆汁成分蓄积。,肝内胆汁淤积的概念,21,肝内各级胆管及其命名,Hering,管,总胆管,右肝管,左肝管,400-800um,段胆管,300 -400um,区胆管,100um,隔胆管,15-100um,叶间小胆,管,15um,细胆管,毛细胆管,肝细胞,22,肝内毛细胆管,小叶间胆管,ductule,Bile,canaliculus,自,Scheuer,P J,，,Live Biopsy Interpretation. 2006,，,53,23,肝内胆汁淤积,Viral hepatitis,Etoh,hepatitis,EBV,CMV,Anabolic,steroids,Contraceptives,TPN,Primary,biliary,sclerosis,Primary,sclerosing,cholangitis,24,肝内胆汁淤积,25,肝内胆汁淤积,26,肝内胆汁淤积,27,甘氨酸,，,牛磺酸,总胆汁酸,TBA,28,29,肝脏合成功能,白蛋白,Malnutrition,Nephrotic,syndrome,Protein losing,enteropathy,(,Sprue,Crohns,),凝血酶原活动度,60%,4060%,3.5,2.8-3.5,6,胆红素,mg/dl,2,2-3,3,腹水,无,少量,中量,肝性脑病,无,12,34,Grade A 1-6; Grade B 7-9;Grade C 1015,Child CG,Turcotte,JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64.,Pugh RN, Murray-Lyon IM, Dawson JL,Pietroni,MC, Williams R (1973). The British journal of surgery 60 (8): 6469.,32,肝功能储备,Child-Pugh,Points,Class,One year survival (%),Two year survival(%),5-6,A,100,85,7-9,B,81,57,10-15,C,45,35,33,肝功能储备,MELD,The Model for End-Stage Liver Disease,MELD = 3.78Ln serum,bilirubin,(mg/,dL,) + 11.2Ln INR + 9.57Ln serum,creatinine,(mg/,dL,) + 6.43,Interpretation (3 month),40 or more - 100% mortality,30-39 - 83% mortality,20-29 - 76% mortality,10-19 - 27% mortality,10 - 4% mortality,Malinchoc,M,Kamath,PS, Gordon FD, et al. (April 2000). ,Hepatology,31 (4): 86471.,34,女性,，,54,岁,主诉：上腹不适、恶心,2,天,入院日期：,2008,08,21,高球蛋白血症,35,治疗前后肝功能,ALT,AST,ALP,GGT,ALB,GLO,CHE,TBIL,DBIL,08-20,804,705,31.8,72.4,81.11,61.01,08-22,515,450,133,291,26.3,74,3.26,80.38,62.09,08-28,155,93,143,343,23,62.7,3.22,31.35,24.08,09-03,90,79,161,352,22.5,64.3,3.17,37.47,27.06,09-10(,),97,112,193,363,22.4,62.4,2.95,47.94,34.26,09-16,70,65,192,389,24.1,64.5,3.33,26.51,17.92,09-24,128,114,183,444,32.8,67.8,4.51,44.36,25.77,10-2,145,89,136,402,30.1,64.8,4.9,26.69,15.09,10-15,58,42,107,252,31.8,54.6,5.15,16.7,9,36,高球蛋白血症,中年女性,急性起病,.,转氨酶显著增高,轻度黄疸,.,明显高球蛋白血症,.,ANA,阳性,.,肝组织病理学符合自身免疫性肝炎的表现,.,激素治疗基本有效,!,37,Globulin,is one of the two types of,serum,proteins, the other being,albumin,.,Protein electrophoresis,:,Alpha 1 globulins,Alpha 2 globulins,Beta globulins,Gamma globulins,(one group of gamma globulins are,immunoglobulins, that function as,antibodies,),Globulin,38,Hyperglobulinemia,Hyperglobulinemia,: Polyclonal,Gammopathy,Chronic bacterial diseases Pneumonia Chronic fungal diseases,Chronic,protozoal,原虫的,/,rickettsial,diseases,39,Hyperglobulinemia,Hyperglobulinemia,: Polyclonal,Gammopathy,Chronic viral diseases,Neoplasia, Lymphoma Mast cell tumor Other tumors,Autoimmune disorders Systemic lupus,erythematosus, Chronic,polyarthritis, Others,40,Hyperglobulinemia,Hyperglobulinemia,: Monoclonal,Gammopathy,Neoplasia, Multiple,myeloma, Lymphoma Chronic,lymphocytic,leukemia,Inflammation/infection,Leishmaniasis,Idiopathic,Waldenstrom,macroglobulinemia, Benign monoclonal,gammopathy,41,Serum Protein Electrophoresis-Normal Pattern,42,Serum Protein Electrophoresis-Polyclonal,Gammopathy,sarcordosis,The sequential increase of the globulin fractions illustrated ,sarcoid,stepping.,43,Serum Protein Electrophoresis-,Nephrotic,Pattern,alpha-2-macroglobulin,Loss of lower molecular weight proteins (Examples: albumin,IgG,),Retention of higher molecular weight proteins (example alpha-2-macroglobulin.),SLE,44,Serum Protein Electrophoresis-Cirrhotic Pattern,beta-gamma bridge pattern,end stage liver disease secondary to chronic alcohol abuse,45,Serum Protein Electrophoresis-Acute inflammatory pattern,pneumonia and,pyelonephritis,albumin and gamma globulin are decreased and alpha-2-globulin becomes very prominent,46,Serum Protein Electrophoresis-Alpha 1 anti-,trypsin,deficiency,alpha-1-anti-trypsin deficiency,47,Serum Protein Electrophoresis-Monoclonal (M) Protein Present,IgG,kappa,multiple,myeloma,48,Serum Protein Electrophoresis-,Biclonal,Gammopathy,IgG-k,and,IgA,-lambda,multiple,myeloma,49,总结,转氨酶增高敏感性高,特异性差。,肝脏合成功能可反应肝脏功能储备。,胆红素增高首先明确肝前、肝性、肝后。,如为肝前性首先除外溶血。,如为肝后性明确是肝外还是肝内胆汁淤积。,球蛋白高首先区分是单克隆性还是多克隆性。,50,