肝功能化验异常的分析与解释

1,肝功能化验异常的分析与解释,赵新颜,2,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,3,肝脏分类检测,Enzyme testsAminotransferasesAlkaline phosphataseGamma glutamyl transpeptidase Tests of synthetic function Albumin Prothrombin time Tests of hepatic transport capabilitySerum bilirubin,4,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,5,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,6,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,7,ALT: AST ratio,AST：ALT2酒精性肝病AST：ALT1肝硬化,8,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,9,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,10,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,11,肝功能异常类型,12,胆红素代谢示意图,13,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,14,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,15,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,16,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,17,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,18,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/LTBIL 250.60umol/L, DBIL 233.60umol/L,19,肝外胆管梗阻,20,正常胰胆管系统,21,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,22,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,23,肝内毛细胆管小叶间胆管,ductule,Bile canaliculus,自Scheuer P J ， Live Biopsy Interpretation. 2006 ，53,24,肝内胆汁淤积,Viral hepatitisEtoh hepatitisEBV,CMVAnabolic, steroids,Contraceptives,TPNPrimary biliary sclerosisPrimary sclerosing cholangitis,25,肝内胆汁淤积,26,肝内胆汁淤积,27,肝内胆汁淤积,28,甘氨酸，牛磺酸,总胆汁酸 TBA,29,30,肝脏合成功能,白蛋白MalnutritionNephrotic syndromeProtein losing enteropathy (Sprue,Crohns)凝血酶原活动度60%4060%40%胆碱脂酶,31,胆碱脂酶Acetylcholinesterase,真性胆碱脂酶红细胞和脑灰质运动神经节终板 有机磷中毒假性胆碱酶（拟胆碱脂酶）肝脏合成反应肝功能储备孕妇及口服避孕药可降低,32,肝功能储备 Child-Pugh,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.,33,肝功能储备 Child-Pugh,34,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.,35,女性，54岁主诉：上腹不适、恶心2天入院日期：20080821,高球蛋白血症,36,治疗前后肝功能,37,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!,38,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,39,Hyperglobulinemia,Hyperglobulinemia: Polyclonal Gammopathy Chronic bacterial diseases Pneumonia Chronic fungal diseases Chronic protozoal 原虫的 / rickettsial diseases,40,Hyperglobulinemia,Hyperglobulinemia: Polyclonal GammopathyChronic viral diseases Neoplasia Lymphoma Mast cell tumor Other tumors Autoimmune disorders Systemic lupus erythematosus Chronic polyarthritis Others,41,Hyperglobulinemia,Hyperglobulinemia: Monoclonal Gammopathy Neoplasia Multiple myeloma Lymphoma Chronic lymphocytic leukemiaInflammation/infection Leishmaniasis Idiopathic Waldenstrom macroglobulinemia Benign monoclonal gammopathy,42,Serum Protein Electrophoresis-Normal Pattern,43,Serum Protein Electrophoresis-Polyclonal Gammopathy,sarcordosis,The sequential increase of the globulin fractions illustrated sarcoid stepping.,44,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,45,Serum Protein Electrophoresis-Cirrhotic Pattern,beta-gamma bridge pattern,end stage liver disease secondary to chronic alcohol abuse,46,Serum Protein Electrophoresis-Acute inflammatory pattern,pneumonia and pyelonephritis,albumin and gamma globulin are decreased and alpha-2-globulin becomes very prominent,47,Serum Protein Electrophoresis-Alpha 1 anti-trypsin deficiency,alpha-1-anti-trypsin deficiency,48,Serum Protein Electrophores