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肝癌肝昏迷医学知识讲座OverviewDefinitionHeaptocellularcarcinoma(HCC)originatedinthelivercellsorintrahepaticbileductcells.2肝癌肝昏迷医

学知识讲座Incidencerate14.58~46/100,000.HCCisupto2~5timesmorecommoninmenthanwomenandusuallyarisesinacirrhoticliver.Overview3肝癌肝昏迷医学知识讲座Chronicliverd

iseaseAflatoxinDrinkingWaterPollutionOtherfactorsEtiologyandpathogenesis4肝癌肝昏迷医学知识讲座Chronicliverdisease•vir

alhepatitis1.HBV:HBV-DNAmaybeintegratedintothehostDNAoflivercells,andchangesgeneexpressioninlivercells.2.HCVEtiolog

yandpathogenesis5肝癌肝昏迷医学知识讲座•CirrhosisAbout50~90%ofHCCaccompaniedcirrhosis.Acuteandchronichepatitis→Cirrhos

is→HCCEtiologyandpathogenesis6肝癌肝昏迷医学知识讲座AflatoxinB1DrinkingWaterPollution:AlgaetoxincouldcontaminatewatersourcesChemicalcarcinog

ens:nitrite,organicchlorinepesticidesParasite:liverflukeEtiologyandpathogenesis7肝癌肝昏迷医学知识讲座PathologyMorphologicaltyping•B

locktype(>5cm)•Nodulartype(＜5cm)•Diffusetype•Smallhepatocarcinoma(＜3cm)Cellclassification•Hepatocellular•Bileductcelltype8肝癌肝昏迷医学知识讲座m

etastasis1.Intrahepaticmetastasis2.Extrahepaticmetastasis（1）Hematogenousmetastasis（2）Lymphaticmetastasis（

3）implantationmetastasisPathology9肝癌肝昏迷医学知识讲座Subclinicalhepatocellularcarcinoma:Withoutanysignsandsy

mptomsAFPclinicalmanifestation10肝癌肝昏迷医学知识讲座hepaticregionpain:PersistentpainordullpainProgressiveenlargeliver:Quali

tyhard,unevensurface,noduleorgiantblocks,raggededge,tenderness,vascularmurmurclinicalmanifestation11肝癌肝昏迷医学知识讲座JaundiceCirrhosi

ssymptomsandsigns:liverdysfunctionandPortalhypertension:SuchasSplenomegaly,ascites,collateralcirculationclinicalmanifestation12肝癌肝昏迷

医学知识讲座Systemicmanifestationsofmalignanttumors:Fatigue,weightloss,cachexia,fever,anorexiaMetastasisfeatures:thelung,bone,chestParaneoplasticsyndrome

:suchashypoglycemia、Erythrocytosisandsoonclinicalmanifestation13肝癌肝昏迷医学知识讲座SYMPTOMSPREVALENCE(%)PHYSICA

LSIGNSPREVALENCE(%)Abdominalpain59-95Hepatomegaly54-98Weightloss34-71Hepaticbruit6-25Weakness22-53Ascites35-

61Abdominalswelling28-43Splenomegaly27-42NonspecificJaundice4-35Gastrointestinalsymptoms25-28Wasting2

5-41Jaundice5-26Fever11-54Table2.PrevalenceofClinicalFeaturesofHepatocellularCarcinomaclinicalmanifestation14肝癌肝昏迷医学知识讲座Complic

ationsHepaticencephalopathyUppergastrointestinalbleedingRuptureoflivercarcernodulesSecondaryinfection15肝癌肝昏迷医学知识讲座（一）Detectionoflivercancermarker

s1.Alpha-fetoprotein(AFP)•ClinicalSignificance:livercancercensus(high-riskgroups),diagnosis,JudgingtreatmentandrelapseLaboratoriesandequipmentinsp

ection16肝癌肝昏迷医学知识讲座•AFPdiagnosticcriteriaforlivercancerAFP>500μg/L>4WAFP:FromlowtohighAFP>200μg/L>8W•Falsepositive:Pregnancy,chronichepatitis,cirr

hosis,Gonadalblastoma•False-negative:DetectionofAFPheterogeneityLaboratoriesandequipmentinspection17肝癌肝昏迷医学知识讲座2.Otherlivercancermarker•r-gluta

myltransferaseisoenzymepeptide（r-GT）•abnormalprothrombin（APT）•seruma-l-fucosidase(AFU)•ALPisoenzyme（ALP-I）Laboratoriesandequipmentinspectio

n18肝癌肝昏迷医学知识讲座（二）ImagingexaminationUltrasound:2cmormoresubstantialmassXraycomputertomography（CT）X-hepaticangiographyMagneticresonanceimaging(MRI)（三

）LiverpuncturebiopsyLaboratoriesandequipmentinspection19肝癌肝昏迷医学知识讲座Clinicalmanifestations,coupledwithAFP,liverB-Ultrasound,CTetc.D

iagnosis20肝癌肝昏迷医学知识讲座Clinicaldiagnosticcriteriaforhepatocellularcarcinoma(一）Non-invasivediagnosticcriteria1.Imaging：Twokindsofimagi

ngstudieshaveshownmorethan2cmlivermass.2.ImagingwithAFP:Akindofimagingexaminationshowemorethan2cmlivermassaccompaniedAFP≥400μg/L.Diagnosis2

1肝癌肝昏迷医学知识讲座（二）HistologicaldiagnosticcriteriaLessthan2cmofintrahepaticnodulesthatmagingcannotdetermineshoudbepuncturedtoconfirmhistologicalcharac

teristicsoflivercancer.Diagnosis22肝癌肝昏迷医学知识讲座1.ActivehepatitisandcirrhosisDifferentialDiagnosis（一）Differentialdiagnosisi

nAFP-positivelivercancer23肝癌肝昏迷医学知识讲座•Activeliverdisease•LiverCancerDifferentialDiagnosis24肝癌肝昏迷医学知识讲座Activel

iverdiseaseALT,AFPcurveTimedensityAFPchangeALTchangeDifferentialDiagnosis25肝癌肝昏迷医学知识讲座density时间ALTchanceAFPchanceHCCALT,AFPc

urveDifferentialDiagnosis26肝癌肝昏迷医学知识讲座2.Pregnancy3.Embryonicgonadtumors4.Othergastrointestinaltumors,suchasgastriccancer,pancre

aticcancerandmalignantinsulinomaandsoon.DifferentialDiagnosis27肝癌肝昏迷医学知识讲座DifferentialDiagnosis（二）IdentificationofAFP-negativ

ehepatocellularcarcinoma1.Metastatichepaticcarcinoma.2.Hepatichemangioma.3.Intrahepaticliquidspace-occupyinglesions:livecyst,liverabscessa

ndliverhydatid.4.Otherbenignspace-occupyingdiseases:inflammatorypseudotumor,liveradenoma,liverandpartialfattyinfiltration,liverno

dulesandliversarcomaandsoon.28肝癌肝昏迷医学知识讲座surgicaltreatmentLocaltreatment1.Hepaticarteryembolizationchemotherapy2.Ethanolinjection3.Physi

otherapyTreatment29肝癌肝昏迷医学知识讲座RadiotherapyBiologicalandimmunotherapySystemicchemotherapyComprehensivetreatmentTreatment30肝癌肝昏迷医学知识讲座Surgicalresecti

on:Offersbestchanceforcure,butseldomispossiblewhendiseaseissymptomatic.Maybetechnicallydifficult.Highrecurrencerateafterresection.Livertransplanta

tion:Maybesuccessfulinselectedpatients.Requirestransfertoatransplantcenterand,postoperatively,lifelong

immunosuppression.Highrecurrencerate.Expensive.Alcoholinjection:Palliativeforsmall(usuallymultiple)tumorsthatcannotberesected.Maybed

ifficulttodecideifallthemalignantcellshavebeendestroyed.Proceduremayfacilitatespreadofthetumor.Chemoemboliz

ation:Mayshrinkselectedlargetumorstothepointwheretheymaybecomeresectable.Effectispalliativeforlocalizedbutunresectable

tumors.Chemotherapy:Palliativeonly;canbeusedasanadjuncttosurgicalresectionortransplantation.drugtoxi

cityisfrequent.Table5.TreatmentOptionsforHepatocellularCarcinoma31肝癌肝昏迷医学知识讲座PrognosisThebetterprognosisasfollowing：1.Tumorles

sthan5cm,earlyoperation.2.Cancercapsuleintegrity,andthereisnocancerplugformation.3.Normalimmune.32肝癌肝昏迷医学知识讲

座Chapter14HepaticEncephalopathyInternalMedicalTeachingandResearchSection,FirstClinicalMedicalCollegeofGuangxiMedicalUniversity2

005undergraduatcoursewareProfessorXingHuo-Tang33肝癌肝昏迷医学知识讲座DefinitionHepaticencephalopathyisastateofdisorderedcentralnervoussyste

mfunctionresultingfromfailureofthelivertodetoxifynoxiousagentsofgutoriginbecauseofhepatocellulardysfunctionandportosystemicshunting.34肝癌肝昏迷医学知识讲座

EtiologyandpathogenesisEtiology:cirrhosis,severehepatitis,hepatocellularcarcinoma,fattyliverofpregnancyetal.35肝癌肝昏迷医学知识讲座Dru

gsInhibitthebrainandrespiratorycenter,resultinginhypoxiaHypovolemiaLeadingtoprerenalazotemia,increasedbloodammoniaBenzodiazepi

nesDiuresis,diarrheaAnestheticVomiting,bleedingAlcoholReleasedascitesIncreasedinammoniaproductionPorto

systemicshuntGut-derivedammoniaintothesystemiccirculationProteinfoodshuntsurgeryDigestivebleedingVascularobstructionInfect

ionPortalveinthrombosisConstipationHepaticveinthrombosisHypokalemialeadingtometabolicalkalosisPrimaryl

ivercancerCommonincentiveingfactorsofhepaticencephalopathy36肝癌肝昏迷医学知识讲座Glutamine→NH3+GlutamateUrea,protein→NH3+CO2Intestinalamm

onia:→Ammonia→liver→Etiologyandpathogenesis（一）NeurotoxinNH3+H+NH4+pH＜6pH＞6urea,glutamine37肝癌肝昏迷医学知识讲座1.Inter

ferewithbraincellsTCAcycle.2.Increasedbrainneutralaminoacidssuchastyrosine,phenylalanine,tryptophan.3.Astrocytesincreasedgl

utamateandneuronalcellswelling.4.Ammoniacanalsodirectlyinterferewiththeelectricalactivityofneurons.EtiologyandpathogenesisAmmoniainhibited

thecentralnervoussystem:38肝癌肝昏迷医学知识讲座Etiologyandpathogenesis（二）ChangesinneurotransmitterNormalneurotransmitt

er:dopamine,norepinephrine.1.Falseneurotransmitter:TyrosineTyramineβhydroxyltyramine→→PhenylalaninePhenylethylamine

Phenylethanolamine39肝癌肝昏迷医学知识讲座Etiologyandpathogenesis2.GABA/BZ3.TryptophanTryptophan→Brain→5-hydroxytryptamine,5-HIAA→Inhibi

tedbrainfunction40肝癌肝昏迷医学知识讲座PathologyAcuteHEpatientsnoobviousanatomicalabnormalitiesinbrain,mainlysecondarybrainedema41肝癌肝昏迷医学知识讲座Clinical

manifestationsThemanifestationsoftheprimarydisease.Themanifestationsofthecentralnervoussystem.42肝癌肝昏迷医学知识讲座PhasesThelevelofconsc

iousnessPounce-liketremorEEGNO.1phasesmildchangesin±normalprecursorpersonalityandbehaviorphasesNO.2phasesconsciousnessdisorder

s,sleepdisorders.+abnormalpre-comaorientationandcomputingabnormalNO.3phasesdrowsiness,mentaldisorder+abnormalsleepingp

eriodneurologicalsignspostiveNO.4phasescompletelossofconsciousness_abnormalcomadeepcoma43肝癌肝昏迷医学知识讲座Cli

nicalmanifestationsMinimalhepaticencephalopathy:Noneofthesymptomsandsigns.Psychologicalaptitudetestunresponsive.44肝癌肝昏

迷医学知识讲座LaboratoriesandequipmentinspectionAmmoniaElectrolyteacid-baseimbalance,hypokalemia,metabolicalkalosisEvokedPotentialsE

EGPsychologicalAptitudeTestImaging45肝癌肝昏迷医学知识讲座DiagnosisSeriousliverdisease+precipitatingfactors+Neuropsychiatricsymptoms+Excludeotherdi

seases46肝癌肝昏迷医学知识讲座DifferentialdiagnosisCerebrovascularaccident:Age,highbloodpressure,HemiplegiaDiabeticcoma:glucose

↑,urineglucose↑,urineketone(+)Uremia:Historyofkidneydisease,edema,anemia,highbloodpressure,urinarychanges,renalfunctiondamaged

Poisoning47肝癌肝昏迷医学知识讲座Treatment一、Theeliminationofincentivesandtreatmentofprimarydisease:1.Avoidsedativesanddrugswhichdamagedliverfunction.2.H

emostasis,removalofintestinalhemorrhage.3.Correctwaterandelectrolyteacid-basedisturbance.4.Preventionandcontrol

infection.5.Improveliverfunction.48肝癌肝昏迷医学知识讲座Treatment二、Reducingintestinalammoniaproductionandabsorption:1.Restricted

proteindiet2.Intestinalcleansing3.Lactulose,lactitol4.Inhibitedbacterialgrowth5.Probioticpreparations49肝癌肝昏迷医学知识讲座Treatment三、Topromotemeta

bolismofammoniainvivo:1.L-ornithine-L-aspartate(OA)2.Ornithine-α-ketoglutarate3.Sodiumbenzoate4.Glutamate5.Arginine四、G

ABA/BZreceptorantagonistflumazenilcomposite.五、Antagonisttofalseneurotransmitter50肝癌肝昏迷医学知识讲座Treatment六、othertreatment1.Artificialli

ver.2.Livertransplantation.3.Preventionandtreatmentofcerebraledema,andprotectingbraincellsfunction.4.Tomaintainairwa

y.51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大肝癌53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大肝癌55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57肝癌肝昏迷医学知识讲座58肝癌肝昏迷医学知

识讲座59肝癌肝昏迷医学知识讲座61肝癌肝昏迷医学知识讲座62肝癌肝昏迷医学知识讲座63肝癌肝昏迷医学知识讲座64肝癌肝昏迷医学知识讲座65肝癌肝昏迷医学知识讲座66肝癌肝昏迷医学知识讲座67肝癌肝昏迷

医学知识讲座68肝癌肝昏迷医学知识讲座69肝癌肝昏迷医学知识讲座70肝癌肝昏迷医学知识讲座71肝癌肝昏迷医学知识讲座结节型肝癌72肝癌肝昏迷医学知识讲座73肝癌肝昏迷医学知识讲座74肝癌肝昏迷医学知识讲座75肝癌肝昏迷医学知识讲座