（精选幻灯片）肝功能化验异常的分析与解释.ppt

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,2020/5/22,3,肝脏分类检测,EnzymetestsAminotransferasesAlkalinephosphataseGammaglutamyltranspeptidaseTestsofsyntheticfunctionAlbuminProthrombintimeTestsofhepatictransportcapabilitySerumbilirubin,2020/5/22,4,丙氨酸氨基转移酶AlanineAminotransferase(ALT),SerumGlutamic-pyruvicTransaminase(SGPT)组织来源:肝细胞胞浆,丙氨酸,酮戊二酸,丙酮酸,谷氨酸,2020/5/22,5,天冬氨酸氨基转移酶AspartateAminotransferase(AST),SerumGlutamic-oxaloaceticTransaminase(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,2020/5/22,6,ALT与AST,Severe(20times,1000U/L)急性病毒性肝炎,药物或毒物损伤,休克肝Moderate(3-20times)慢性肝炎,药物性肝炎,酒精性肝炎,自身免疫性肝炎Mild(1-3times)脂肪肝,非酒精性脂肪性肝炎,肝硬化,2020/5/22,7,ALT:ASTratio,AST：ALT2酒精性肝病AST：ALT1肝硬化,2020/5/22,8,碱性磷酸酶AlkalinePhosphatase(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,2020/5/22,9,碱性磷酸酶AlkalinePhosphatase(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,2020/5/22,10,谷酰转肽酶Gamma-glutamyltransferase(GGT),组织来源:membraneofcells(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,2020/5/22,11,肝功能异常类型,2020/5/22,12,胆红素代谢示意图,2020/5/22,13,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,2020/5/22,14,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%ALT30U/L,AST57U/L,TBIL40.3umol/L,IBIL27.43umol/L,LDH863U/L,2020/5/22,15,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,2020/5/22,16,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ALT16U/L，AST27U/L正常TBIL46.2umol/L，IBIL30.0umol/L。组织病理学最终诊断：Gilbert综合征,2020/5/22,17,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,2020/5/22,18,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ALP302U/L，GGT361U/LTBIL250.60umol/L,DBIL233.60umol/L,2020/5/22,19,肝外胆管梗阻,2020/5/22,20,正常胰胆管系统,2020/5/22,21,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,2020/5/22,22,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,2020/5/22,23,肝内毛细胆管小叶间胆管,ductule,Bilecanaliculus,自ScheuerPJ，LiveBiopsyInterpretation.2006，53,2020/5/22,24,肝内胆汁淤积,ViralhepatitisEtohhepatitisEBV,CMVAnabolic,steroids,Contraceptives,TPNPrimarybiliarysclerosisPrimarysclerosingcholangitis,2020/5/22,25,肝内胆汁淤积,2020/5/22,26,肝内胆汁淤积,2020/5/22,27,肝内胆汁淤积,2020/5/22,28,甘氨酸，牛磺酸,总胆汁酸TBA,2020/5/22,29,2020/5/22,30,肝脏合成功能,白蛋白MalnutritionNephroticsyndromeProteinlosingenteropathy(Sprue,Crohns)凝血酶原活动度60%4060%40%胆碱脂酶,2020/5/22,31,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,2020/5/22,32,肝功能储备Child-Pugh,GradeA1-6;GradeB7-9;GradeC1015,ChildCG,TurcotteJG.Surgeryandportalhypertension.In:Theliverandportalhypertension.EditedbyCGChild.Philadelphia:Saunders1964:50-64.PughRN,Murray-LyonIM,DawsonJL,PietroniMC,WilliamsR(1973).TheBritishjournalofsurgery60(8):6469.,2020/5/22,33,肝功能储备Child-Pugh,2020/5/22,34,肝功能储备MELD,TheModelforEnd-StageLiverDiseaseMELD=3.78Lnserumbilirubin(mg/dL)+11.2LnINR+9.57Lnserumcreatinine(mg/dL)+6.43Interpretation(3month)40ormore-100%mortality30-39-83%mortality20-29-76%mortality10-19-27%mortality10-4%mortality,MalinchocM,KamathPS,GordonFD,etal.(April2000).Hepatology31(4):86471.,2020/5/22,35,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,2020/5/22,36,治疗前后肝功能,2020/5/22,37,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!,2020/5/22,38,Globulinisoneofthetwotypesofserumproteins,theotherbeingalbumin.Proteinelectrophoresis:Alpha1globulinsAlpha2globulinsBetaglobulinsGammaglobulins(onegroupofgammaglobulinsareimmunoglobulins,thatfunctionasantibodies),Globulin,2020/5/22,39,Hyperglobulinemia,Hyperglobulinemia:PolyclonalGammopathyChronicbacterialdiseasesPneumoniaChronicfungaldiseasesChronicprotozoal原虫的/rickettsialdiseases,2020/5/22,40,Hyperglobulinemia,Hyperglobulinemia:PolyclonalGammopathyChronicviraldiseasesNeoplasiaLymphomaMastcelltumorOthertumorsAutoimmunedisordersSystemiclupuserythematosusChronicpolyarthritisOthers,2020/5/22,41,Hyperglobulinemia,Hyperglobulinemia:MonoclonalGammopathyNeoplasiaMultiplemyelomaLymphomaChroniclymphocyticleukemiaInflammation/infectionLeishmaniasisIdiopathicWaldenstrommacroglobulinemiaBenignmonoclonalgammopathy,2020/5/22,42,SerumProteinElectrophoresis-NormalPattern,2020/5/22,43,SerumProteinElectrophoresis-PolyclonalGammopathy,sarcordosis,Thesequentialincreaseoftheglobulinfractionsillustratedsarcoidstepping.,2020/5/22,44,SerumProteinElectrophoresis-NephroticPattern,alpha-2-macroglobulin,Lossoflowermolecularweightproteins(Examples:albumin,IgG)Retentionofhighermolecularweightproteins(examplealpha-2-macroglobulin.),SLE,2020/5/22,45,SerumProteinElectrophoresis-CirrhoticPattern,beta-gammabridgepattern,endstageliverdiseasesecondarytochronicalcoholabuse,2020/5/22,46,SerumProteinElectrophoresis-Acuteinflammatorypattern,pneumoniaandpyelonephritis,albuminandgammaglobulinaredecreasedandalpha-2-globulinbecomesveryprominent,2020/5/22,47,SerumProteinElectrophoresis-Alpha1anti-trypsindeficiency,alpha-1-anti-trypsindeficiency,2020/5/22,48,SerumProteinElectrophoresis-Monoclonal(