【文档说明】肝癌肝昏迷医学知识讲座培训课件.ppt，共(75)页，3.384 MB，由小橙橙上传

转载请保留链接：https://www.ichengzhen.cn/view-241470.html

以下为本文档部分文字说明：

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Chronicliverdisease

AflatoxinDrinkingWaterPollutionOtherfactorsEtiologyandpathogenesis4肝癌肝昏迷医学知识讲座Chronicliverdisease•viralhepatitis1.HBV:HBV-D

NAmaybeintegratedintothehostDNAoflivercells,andchangesgeneexpressioninlivercells.2.HCVEtiologyandpathogenesis5肝癌肝昏迷医学知识讲座•Cirrh

osisAbout50~90%ofHCCaccompaniedcirrhosis.Acuteandchronichepatitis→Cirrhosis→HCCEtiologyandpathogenesis6肝癌肝昏迷医学知识讲座AflatoxinB1DrinkingWate

rPollution:AlgaetoxincouldcontaminatewatersourcesChemicalcarcinogens:nitrite,organicchlorinepesticidesParasite:li

verflukeEtiologyandpathogenesis7肝癌肝昏迷医学知识讲座PathologyMorphologicaltyping•Blocktype(>5cm)•Nodulartype(＜5cm)•Diffusetype•Smallhepatocarcinoma(＜3cm

)Cellclassification•Hepatocellular•Bileductcelltype8肝癌肝昏迷医学知识讲座metastasis1.Intrahepaticmetastasis2.Ext

rahepaticmetastasis（1）Hematogenousmetastasis（2）Lymphaticmetastasis（3）implantationmetastasisPathology9肝癌肝昏迷医学知识讲座Subc

linicalhepatocellularcarcinoma:WithoutanysignsandsymptomsAFPclinicalmanifestation10肝癌肝昏迷医学知识讲座hepaticregionpain:Persistentpainor

dullpainProgressiveenlargeliver:Qualityhard,unevensurface,noduleorgiantblocks,raggededge,tenderness,vascularmurmurclin

icalmanifestation11肝癌肝昏迷医学知识讲座JaundiceCirrhosissymptomsandsigns:liverdysfunctionandPortalhypertension:SuchasSplenomegaly,ascites,collateralci

rculationclinicalmanifestation12肝癌肝昏迷医学知识讲座Systemicmanifestationsofmalignanttumors:Fatigue,weightloss,

cachexia,fever,anorexiaMetastasisfeatures:thelung,bone,chestParaneoplasticsyndrome:suchashypoglycemia、Erythrocytosisandsoonclinicalmanifestation

13肝癌肝昏迷医学知识讲座SYMPTOMSPREVALENCE(%)PHYSICALSIGNSPREVALENCE(%)Abdominalpain59-95Hepatomegaly54-98Weightloss34-71Hepaticbruit6-25Weakness22-53

Ascites35-61Abdominalswelling28-43Splenomegaly27-42NonspecificJaundice4-35Gastrointestinalsymptoms25-28Wasting25-41Jaundic

e5-26Fever11-54Table2.PrevalenceofClinicalFeaturesofHepatocellularCarcinomaclinicalmanifestation14肝癌肝昏迷医学知识讲座Compl

icationsHepaticencephalopathyUppergastrointestinalbleedingRuptureoflivercarcernodulesSecondaryinfection15肝癌肝昏迷医学知识讲座（一）Detectionoflivercancermar

kers1.Alpha-fetoprotein(AFP)•ClinicalSignificance:livercancercensus(high-riskgroups),diagnosis,JudgingtreatmentandrelapseLaboratoriesandequipme

ntinspection16肝癌肝昏迷医学知识讲座•AFPdiagnosticcriteriaforlivercancerAFP>500μg/L>4WAFP:FromlowtohighAFP>200μg/L>8W•Falsepositive:Pregnancy,chroniche

patitis,cirrhosis,Gonadalblastoma•False-negative:DetectionofAFPheterogeneityLaboratoriesandequipmentinspection17肝癌

肝昏迷医学知识讲座2.Otherlivercancermarker•r-glutamyltransferaseisoenzymepeptide（r-GT）•abnormalprothrombin（APT）•seruma-

l-fucosidase(AFU)•ALPisoenzyme（ALP-I）Laboratoriesandequipmentinspection18肝癌肝昏迷医学知识讲座（二）ImagingexaminationUlt

rasound:2cmormoresubstantialmassXraycomputertomography（CT）X-hepaticangiographyMagneticresonanceimaging(MRI)（三）LiverpuncturebiopsyLaborator

iesandequipmentinspection19肝癌肝昏迷医学知识讲座Clinicalmanifestations,coupledwithAFP,liverB-Ultrasound,CTetc.Diagnosis20肝癌

肝昏迷医学知识讲座Clinicaldiagnosticcriteriaforhepatocellularcarcinoma(一）Non-invasivediagnosticcriteria1.Imaging：Twokindsofima

gingstudieshaveshownmorethan2cmlivermass.2.ImagingwithAFP:Akindofimagingexaminationshowemorethan2cmlivermassaccompaniedAFP≥400μg/L.Diagnosis21肝癌肝昏

迷医学知识讲座（二）HistologicaldiagnosticcriteriaLessthan2cmofintrahepaticnodulesthatmagingcannotdeterminesho

udbepuncturedtoconfirmhistologicalcharacteristicsoflivercancer.Diagnosis22肝癌肝昏迷医学知识讲座1.ActivehepatitisandcirrhosisDifferentialDiagnos

is（一）DifferentialdiagnosisinAFP-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Ac

tiveliverdiseaseALT,AFPcurveTimedensityAFPchangeALTchangeDifferentialDiagnosis25肝癌肝昏迷医学知识讲座density时间A

LTchanceAFPchanceHCCALT,AFPcurveDifferentialDiagnosis26肝癌肝昏迷医学知识讲座2.Pregnancy3.Embryonicgonadtumors4.Othergastrointestinaltum

ors,suchasgastriccancer,pancreaticcancerandmalignantinsulinomaandsoon.DifferentialDiagnosis27肝癌肝昏迷医学知识讲

座DifferentialDiagnosis（二）IdentificationofAFP-negativehepatocellularcarcinoma1.Metastatichepaticcarcinoma.2.Hepaticheman

gioma.3.Intrahepaticliquidspace-occupyinglesions:livecyst,liverabscessandliverhydatid.4.Otherbenignspace-

occupyingdiseases:inflammatorypseudotumor,liveradenoma,liverandpartialfattyinfiltration,livernodulesandliversarcomaandsoon.28肝癌肝昏迷医学知识讲座su

rgicaltreatmentLocaltreatment1.Hepaticarteryembolizationchemotherapy2.Ethanolinjection3.PhysiotherapyTreatment29肝癌肝昏迷医学知识讲座Radiot

herapyBiologicalandimmunotherapySystemicchemotherapyComprehensivetreatmentTreatment30肝癌肝昏迷医学知识讲座Surgicalresection:Offersbestchanceforc

ure,butseldomispossiblewhendiseaseissymptomatic.Maybetechnicallydifficult.Highrecurrencerateafterresection.Livertransplant

ation:Maybesuccessfulinselectedpatients.Requirestransfertoatransplantcenterand,postoperatively,lifelongimm

unosuppression.Highrecurrencerate.Expensive.Alcoholinjection:Palliativeforsmall(usuallymultiple)tumorsthatcannotberesecte

d.Maybedifficulttodecideifallthemalignantcellshavebeendestroyed.Proceduremayfacilitatespreadofthetumor.

Chemoembolization:Mayshrinkselectedlargetumorstothepointwheretheymaybecomeresectable.Effectispalliativeforlocalizedbutunre

sectabletumors.Chemotherapy:Palliativeonly;canbeusedasanadjuncttosurgicalresectionortransplantation.drugtoxicityisf

requent.Table5.TreatmentOptionsforHepatocellularCarcinoma31肝癌肝昏迷医学知识讲座PrognosisThebetterprognosisasfollowing：1.Tumorlessthan5cm,earlyoperation.2.

Cancercapsuleintegrity,andthereisnocancerplugformation.3.Normalimmune.32肝癌肝昏迷医学知识讲座Chapter14HepaticEncephalopathyInternalMedicalTeachingandResearchSe

ction,FirstClinicalMedicalCollegeofGuangxiMedicalUniversity2005undergraduatcoursewareProfessorXingHuo-Tang33肝

癌肝昏迷医学知识讲座DefinitionHepaticencephalopathyisastateofdisorderedcentralnervoussystemfunctionresultingfromfailur

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

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

inandrespiratorycenter,resultinginhypoxiaHypovolemiaLeadingtoprerenalazotemia,increasedbloodammoniaBenzodiazepinesDiuresis,diarrheaAnestheticVom

iting,bleedingAlcoholReleasedascitesIncreasedinammoniaproductionPortosystemicshuntGut-derivedammoniaintothesystemiccirculationProt

einfoodshuntsurgeryDigestivebleedingVascularobstructionInfectionPortalveinthrombosisConstipationHepa

ticveinthrombosisHypokalemialeadingtometabolicalkalosisPrimarylivercancerCommonincentiveingfactorsofhepaticencephalopathy36肝癌肝昏迷医学知识讲座Glutamine→NH3

+GlutamateUrea,protein→NH3+CO2Intestinalammonia:→Ammonia→liver→Etiologyandpathogenesis（一）NeurotoxinNH3+H+NH4+pH＜6pH＞6urea,glutamine

37肝癌肝昏迷医学知识讲座1.InterferewithbraincellsTCAcycle.2.Increasedbrainneutralaminoacidssuchastyrosine,phenylalanine,trypt

ophan.3.Astrocytesincreasedglutamateandneuronalcellswelling.4.Ammoniacanalsodirectlyinterferewiththeel

ectricalactivityofneurons.EtiologyandpathogenesisAmmoniainhibitedthecentralnervoussystem:38肝癌肝昏迷医学知识讲座

Etiologyandpathogenesis（二）ChangesinneurotransmitterNormalneurotransmitter:dopamine,norepinephrine.1.Falseneurotransmitter:TyrosineTyr

amineβhydroxyltyramine→→PhenylalaninePhenylethylaminePhenylethanolamine39肝癌肝昏迷医学知识讲座Etiologyandpathogenesis2

.GABA/BZ3.TryptophanTryptophan→Brain→5-hydroxytryptamine,5-HIAA→Inhibitedbrainfunction40肝癌肝昏迷医学知识讲座PathologyAcuteHEpatients

noobviousanatomicalabnormalitiesinbrain,mainlysecondarybrainedema41肝癌肝昏迷医学知识讲座ClinicalmanifestationsThemanifes

tationsoftheprimarydisease.Themanifestationsofthecentralnervoussystem.42肝癌肝昏迷医学知识讲座PhasesThelevelofconsciousnessPounce-liketremorEEGNO.1p

hasesmildchangesin±normalprecursorpersonalityandbehaviorphasesNO.2phasesconsciousnessdisorders,sleepdisorders.+abnormal

pre-comaorientationandcomputingabnormalNO.3phasesdrowsiness,mentaldisorder+abnormalsleepingperiodneurologicalsignspostiveNO.4phasescomp

letelossofconsciousness_abnormalcomadeepcoma43肝癌肝昏迷医学知识讲座ClinicalmanifestationsMinimalhepaticencephal

opathy:Noneofthesymptomsandsigns.Psychologicalaptitudetestunresponsive.44肝癌肝昏迷医学知识讲座Laboratoriesandequipmentinsp

ectionAmmoniaElectrolyteacid-baseimbalance,hypokalemia,metabolicalkalosisEvokedPotentialsEEGPsychologicalAp

titudeTestImaging45肝癌肝昏迷医学知识讲座DiagnosisSeriousliverdisease+precipitatingfactors+Neuropsychiatricsymptoms+Excludeot

herdiseases46肝癌肝昏迷医学知识讲座DifferentialdiagnosisCerebrovascularaccident:Age,highbloodpressure,HemiplegiaDiabeticcoma:glucose↑,urine

glucose↑,urineketone(+)Uremia:Historyofkidneydisease,edema,anemia,highbloodpressure,urinarychanges,renalfunctiondamagedPoisoning47肝癌肝昏迷医学

知识讲座Treatment一、Theeliminationofincentivesandtreatmentofprimarydisease:1.Avoidsedativesanddrugswhichdamagedliverfuncti

on.2.Hemostasis,removalofintestinalhemorrhage.3.Correctwaterandelectrolyteacid-basedisturbance.4.Preventionandcon

trolinfection.5.Improveliverfunction.48肝癌肝昏迷医学知识讲座Treatment二、Reducingintestinalammoniaproductionandabsorption:1.Restrictedproteindiet2.Intestinal

cleansing3.Lactulose,lactitol4.Inhibitedbacterialgrowth5.Probioticpreparations49肝癌肝昏迷医学知识讲座Treatment三、Topromotemetabolismofammoniainvivo

:1.L-ornithine-L-aspartate(OA)2.Ornithine-α-ketoglutarate3.Sodiumbenzoate4.Glutamate5.Arginine四、GABA/BZreceptorantagonistfl

umazenilcomposite.五、Antagonisttofalseneurotransmitter50肝癌肝昏迷医学知识讲座Treatment六、othertreatment1.Artificialliver.2.Live

rtransplantation.3.Preventionandtreatmentofcerebraledema,andprotectingbraincellsfunction.4.Tomaintainairway.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