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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•viralhepatitis1.HBV:

HBV-DNAmaybeintegratedintothehostDNAoflivercells,andchangesgeneexpressioninlivercells.2.HCVEtiologyandpathogenesis5肝癌肝

昏迷医学知识讲座•CirrhosisAbout50~90%ofHCCaccompaniedcirrhosis.Acuteandchronichepatitis→Cirrhosis→HCCEtiologyandpathogenesis6肝癌肝昏迷医学知识讲座AflatoxinB1DrinkingWa

terPollution:AlgaetoxincouldcontaminatewatersourcesChemicalcarcinogens:nitrite,organicchlorinepesticidesParasit

e:liverflukeEtiologyandpathogenesis7肝癌肝昏迷医学知识讲座PathologyMorphologicaltyping•Blocktype(>5cm)•Nodulartype(＜5cm)•Diffusetype•Smal

lhepatocarcinoma(＜3cm)Cellclassification•Hepatocellular•Bileductcelltype8肝癌肝昏迷医学知识讲座metastasis1.Intrahepatic

metastasis2.Extrahepaticmetastasis（1）Hematogenousmetastasis（2）Lymphaticmetastasis（3）implantationmetastasisPathology9肝癌肝昏迷医学知识讲座Subclinicalh

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

:PersistentpainordullpainProgressiveenlargeliver:Qualityhard,unevensurface,noduleorgiantblocks,ragge

dedge,tenderness,vascularmurmurclinicalmanifestation11肝癌肝昏迷医学知识讲座JaundiceCirrhosissymptomsandsigns:liverdysfunctionandPortalhypertension:SuchasS

plenomegaly,ascites,collateralcirculationclinicalmanifestation12肝癌肝昏迷医学知识讲座Systemicmanifestationsofmalignanttumors:Fatigue,weightloss,cachexia

,fever,anorexiaMetastasisfeatures:thelung,bone,chestParaneoplasticsyndrome:suchashypoglycemia、Erythrocytosisandsoonclinicalm

anifestation13肝癌肝昏迷医学知识讲座SYMPTOMSPREVALENCE(%)PHYSICALSIGNSPREVALENCE(%)Abdominalpain59-95Hepatomegaly54-98Weightloss

34-71Hepaticbruit6-25Weakness22-53Ascites35-61Abdominalswelling28-43Splenomegaly27-42NonspecificJaundice4-35Gastrointestinalsympto

ms25-28Wasting25-41Jaundice5-26Fever11-54Table2.PrevalenceofClinicalFeaturesofHepatocellularCarcinomaclinicalmanifestation14肝癌肝昏迷医学知识讲座C

omplicationsHepaticencephalopathyUppergastrointestinalbleedingRuptureoflivercarcernodulesSecondaryinfection15肝癌肝昏迷医学知识讲

座（一）Detectionoflivercancermarkers1.Alpha-fetoprotein(AFP)•ClinicalSignificance:livercancercensus(high-riskgroups),diagno

sis,JudgingtreatmentandrelapseLaboratoriesandequipmentinspection16肝癌肝昏迷医学知识讲座•AFPdiagnosticcriteriaforlivercancerAFP>500μg/L>4WAFP:Fromlowto

highAFP>200μg/L>8W•Falsepositive:Pregnancy,chronichepatitis,cirrhosis,Gonadalblastoma•False-negative:DetectionofAFPheterogeneityLaborato

riesandequipmentinspection17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）ImagingexaminationUltraso

und: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Clinical

diagnosticcriteriaforhepatocellularcarcinoma(一）Non-invasivediagnosticcriteria1.Imaging：Twokindsofimagings

tudieshaveshownmorethan2cmlivermass.2.ImagingwithAFP:Akindofimagingexaminationshowemorethan2cmlivermassaccompanied

AFP≥400μg/L.Diagnosis21肝癌肝昏迷医学知识讲座（二）HistologicaldiagnosticcriteriaLessthan2cmofintrahepaticnodulesthatmagingcannotdetermineshoudbepuncturedtocon

firmhistologicalcharacteristicsoflivercancer.Diagnosis22肝癌肝昏迷医学知识讲座1.ActivehepatitisandcirrhosisDifferentialDiagnosis（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ActiveliverdiseaseALT,AFPcurveTimedensityAFPchangeALTchangeDifferentialDiagnosis25肝癌肝昏迷医学知识讲座density时间ALTchanceA

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

trointestinaltumors,suchasgastriccancer,pancreaticcancerandmalignantinsulinomaandsoon.DifferentialDiagnosis27肝癌肝昏迷医学知识讲座DifferentialDiagnosis（二

）IdentificationofAFP-negativehepatocellularcarcinoma1.Metastatichepaticcarcinoma.2.Hepatichemangioma.3.Intrahepaticliquidspace-

occupyinglesions:livecyst,liverabscessandliverhydatid.4.Otherbenignspace-occupyingdiseases:inflammatorypseudotumor,liverad

enoma,liverandpartialfattyinfiltration,livernodulesandliversarcomaandsoon.28肝癌肝昏迷医学知识讲座surgicaltreatmentLocaltre

atment1.Hepaticarteryembolizationchemotherapy2.Ethanolinjection3.PhysiotherapyTreatment29肝癌肝昏迷医学知识讲座RadiotherapyBiologicalandimmunotherapySystemicc

hemotherapyComprehensivetreatmentTreatment30肝癌肝昏迷医学知识讲座Surgicalresection:Offersbestchanceforcure,butseldomispossiblewhendisea

seissymptomatic.Maybetechnicallydifficult.Highrecurrencerateafterresection.Livertransplantation:Maybesuccessfulinselectedpatients.

Requirestransfertoatransplantcenterand,postoperatively,lifelongimmunosuppression.Highrecurrencerate.Expensive.Alcoholinjection:Palliat

iveforsmall(usuallymultiple)tumorsthatcannotberesected.Maybedifficulttodecideifallthemalignantcellsh

avebeendestroyed.Proceduremayfacilitatespreadofthetumor.Chemoembolization:Mayshrinkselectedlargetumorstothepointw

heretheymaybecomeresectable.Effectispalliativeforlocalizedbutunresectabletumors.Chemotherapy:Palliativeonly;canbeusedasanadjuncttosurgicalrese

ctionortransplantation.drugtoxicityisfrequent.Table5.TreatmentOptionsforHepatocellularCarcinoma31肝癌肝昏迷医学知识讲座PrognosisThebett

erprognosisasfollowing：1.Tumorlessthan5cm,earlyoperation.2.Cancercapsuleintegrity,andthereisnocancerplugformati

on.3.Normalimmune.32肝癌肝昏迷医学知识讲座Chapter14HepaticEncephalopathyInternalMedicalTeachingandResearchSection,FirstCli

nicalMedicalCollegeofGuangxiMedicalUniversity2005undergraduatcoursewareProfessorXingHuo-Tang33肝癌肝昏迷医学知识讲座DefinitionHepaticencephalopathyisastateo

fdisorderedcentralnervoussystemfunctionresultingfromfailureofthelivertodetoxifynoxiousagentsofgutoriginbecauseofhepatocellulardysfunctionandportosyst

emicshunting.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DrugsInhibitthebrainandrespiratorycenter,resultinginhypoxiaHypovolemiaLeading

toprerenalazotemia,increasedbloodammoniaBenzodiazepinesDiuresis,diarrheaAnestheticVomiting,bleedingAlcoholReleasedascitesIncreasedinammo

niaproductionPortosystemicshuntGut-derivedammoniaintothesystemiccirculationProteinfoodshuntsurgeryDigestivebleedingVascularobstructionInfe

ctionPortalveinthrombosisConstipationHepaticveinthrombosisHypokalemialeadingtometabolicalkalosisPrimarylivercan

cerCommonincentiveingfactorsofhepaticencephalopathy36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,glutamine37肝癌肝昏迷医学知识讲座1.InterferewithbraincellsTCAcycle.2.Increasedbrai

nneutralaminoacidssuchastyrosine,phenylalanine,tryptophan.3.Astrocytesincreasedglutamateandneuronalcellswelling.4.Ammoniaca

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

ologyandpathogenesis（二）ChangesinneurotransmitterNormalneurotransmitter:dopamine,norepinephrine.1.Falseneurotransmitter:TyrosineTyramineβhydroxylt

yramine→→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PathologyAcuteHEpatientsnoobviousanat

omicalabnormalitiesinbrain,mainlysecondarybrainedema41肝癌肝昏迷医学知识讲座ClinicalmanifestationsThemanifestationsoftheprimarydis

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

1phasesmildchangesin±normalprecursorpersonalityandbehaviorphasesNO.2phasesconsciousnessdisorders,sleepdis

orders.+abnormalpre-comaorientationandcomputingabnormalNO.3phasesdrowsiness,mentaldisorder+abnormalsleep

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

ClinicalmanifestationsMinimalhepaticencephalopathy:Noneofthesymptomsandsigns.Psychologicalaptitudetestunresponsive.44肝癌肝昏迷医学知识讲座La

boratoriesandequipmentinspectionAmmoniaElectrolyteacid-baseimbalance,hypokalemia,metabolicalkalosisEvokedPotentialsEEGPsychologicalAptitudeT

estImaging45肝癌肝昏迷医学知识讲座DiagnosisSeriousliverdisease+precipitatingfactors+Neuropsychiatricsymptoms+Excludeotherdiseases46肝癌肝昏迷医学

知识讲座DifferentialdiagnosisCerebrovascularaccident:Age,highbloodpressure,HemiplegiaDiabeticcoma:glucose↑,urineglucose↑,urinek

etone(+)Uremia:Historyofkidneydisease,edema,anemia,highbloodpressure,urinarychanges,renalfunctiondamagedPoisoning47肝癌肝昏迷医学知识讲座Treatment一、T

heeliminationofincentivesandtreatmentofprimarydisease:1.Avoidsedativesanddrugswhichdamagedliverfunction.2.Hemostasis,removalofintestinalhemorrhag

e.3.Correctwaterandelectrolyteacid-basedisturbance.4.Preventionandcontrolinfection.5.Improveliverfunction.48肝癌肝昏迷医学知识讲座Treatment二、Reducingintes

tinalammoniaproductionandabsorption:1.Restrictedproteindiet2.Intestinalcleansing3.Lactulose,lactitol4.Inhibitedbacterialgrow

th5.Probioticpreparations49肝癌肝昏迷医学知识讲座Treatment三、Topromotemetabolismofammoniainvivo:1.L-ornithine-L-aspartat

e(OA)2.Ornithine-α-ketoglutarate3.Sodiumbenzoate4.Glutamate5.Arginine四、GABA/BZreceptorantagonistflumazenilcomposite.五、Antagonisttofalseneurotransm

itter50肝癌肝昏迷医学知识讲座Treatment六、othertreatment1.Artificialliver.2.Livertransplantation.3.Preventionandtre

atmentofcerebraledema,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5

5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