肝癌肝昏迷医学知识讲座培训课件

1、肝癌肝昏迷医学知识讲座肝癌肝昏迷医学知识讲座 Overview Definition Heaptocellular carcinoma(HCC) originated in the liver cells or intrahepatic bile duct cells.2肝癌肝昏迷医学知识讲座 Overview2肝癌肝昏迷医学知识讲座 Incidence rate 14.5846 / 100,000. HCC is up to 25times more common in men than women and usually arises in a cirrhotic liver.Overvi

2、ew3肝癌肝昏迷医学知识讲座 Incidence rate 14.5846 / Chronic liver disease Aflatoxin Drinking Water Pollution Other factorsEtiology and pathogenesis4肝癌肝昏迷医学知识讲座Etiology and pathogenesis4肝癌肝昏 Chronic liver disease viral hepatitis 1. HBV: HBV-DNA may be integrated into the host DNA of liver cells , and changes gen

3、e expression in liver cells. 2. HCV Etiology and pathogenesis5肝癌肝昏迷医学知识讲座 Chronic liver diseaseEtiolo CirrhosisAbout 50 90% of HCC accompanied cirrhosis. Acute and chronic hepatitis CirrhosisHCC Etiology and pathogenesis6肝癌肝昏迷医学知识讲座 CirrhosisEtiology and pathog Aflatoxin B1 Drinking Water Pollution:

4、 Algae toxin could contaminate water sources Chemical carcinogens : nitrite, organic chlorine pesticides Parasite: liver flukeEtiology and pathogenesis7肝癌肝昏迷医学知识讲座 Aflatoxin B1Etiology and Pathology Morphological typing Block type (5cm) Nodular type ( 5cm) Diffuse type Small hepatocarcinoma (3cm) Ce

5、ll classification Hepatocellular Bile duct cell type8肝癌肝昏迷医学知识讲座 Pathology8肝癌肝昏迷医学知识讲座 metastasis 1. Intrahepatic metastasis 2. Extrahepatic metastasis （1）Hematogenous metastasis （2）Lymphatic metastasis （3）implantation metastasisPathology9肝癌肝昏迷医学知识讲座 metastasisPathology9肝癌肝昏迷医学 Subclinical hepatocel

6、lular carcinoma: Without any signs and symptoms AFP clinical manifestation10肝癌肝昏迷医学知识讲座 clinical manifestation10肝癌肝昏迷 hepatic region pain: Persistent pain or dull pain Progressive enlarge liver: Quality hard, uneven surface, nodule or giant blocks, ragged edge, tenderness, vascular murmurclinical ma

7、nifestation11肝癌肝昏迷医学知识讲座 hepatic region pain:clinica Jaundice Cirrhosis symptoms and signs: liver dysfunction and Portal hypertension: Such as Splenomegaly, ascites, collateral circulationclinical manifestation12肝癌肝昏迷医学知识讲座 Jaundiceclinical manife Systemic manifestations of malignant tumors: Fatigue

8、, weight loss, cachexia, fever, anorexia Metastasis features : the lung, bone, chest Paraneoplastic syndrome: such as hypoglycemia、 Erythrocytosis and so onclinical manifestation13肝癌肝昏迷医学知识讲座 Systemic manifestatSYMPTOMS PREVALENCE(%) PHYSICAL SIGNS PREVALENCE(%) Abdominal pain 59-95Hepatomegaly 54-9

9、8Weight loss 34-71Hepatic bruit 6-25Weakness 22-53Ascites 35-61Abdominal swelling 28-43Splenomegaly 27-42Nonspecific Jaundice 4-35Gastrointestinal symptoms 25-28Wasting 25-41Jaundice 5-26Fever 11-54Table 2. Prevalence of Clinical Features of Hepatocellular Carcinoma clinical manifestation14肝癌肝昏迷医学知识

10、讲座SYMPTOMS PREVALENCEPHYSICAL SIComplications Hepatic encephalopathy Upper gastrointestinal bleeding Rupture of liver carcer nodules Secondary infection15肝癌肝昏迷医学知识讲座Complications Hepat（一）Detection of liver cancer markers 1. Alpha-fetoprotein (AFP) Clinical Significance :liver cancer census (high- ri

11、sk groups), diagnosis, Judging treatment and relapseLaboratories and equipment inspection16肝癌肝昏迷医学知识讲座Laboratories and equipment ins AFP diagnostic criteria for liver cancer AFP 500g/L 4W AFP:From low to high AFP200g/L 8W False positive: Pregnancy, chronic hepatitis, cirrhosis,Gonadal blastoma False

12、-negative: Detection of AFP heterogeneityLaboratories and equipment inspection17肝癌肝昏迷医学知识讲座 AFP diagnostic criteria 2. Other liver cancer marker r-glutamyl transferase isoenzyme peptide （r-GT） abnormal prothrombin（APT） serum a-l-fucosidase (AFU) ALP isoenzyme（ALP-I）Laboratories and equipment inspect

13、ion18肝癌肝昏迷医学知识讲座 2. Other liver cancer marker （二）Imaging examination Ultrasound: 2cm or more substantial mass X ray computer tomography（CT） X-hepatic angiography Magnetic resonance imaging(MRI)（三）Liver puncture biopsyLaboratories and equipment inspection19肝癌肝昏迷医学知识讲座 （二）Imaging examination Lab Clini

14、cal manifestations, coupled with AFP, liver B- Ultrasound, CT etc.Diagnosis20肝癌肝昏迷医学知识讲座 Diagnosis20肝癌肝昏迷医学知识讲座Clinical diagnostic criteria for hepatocellular carcinoma(一）Non-invasive diagnostic criteria 1. Imaging：Two kinds of imaging studies have shown more than 2cm liver mass. 2. Imaging with AFP

15、 : A kind of imaging examination showe more than 2cm liver mass accompanied AFP 400g / L.Diagnosis21肝癌肝昏迷医学知识讲座Clinical diagnostic criteria f（二）Histological diagnostic criteria Less than 2cm of intrahepatic nodules that maging can not determine shoud be punctured to confirm histological characterist

16、ics of liver cancer.Diagnosis22肝癌肝昏迷医学知识讲座（二）Histological diagnostic Di 1. Active hepatitis and cirrhosisDifferential Diagnosis（一）Differential diagnosis in AFP-positive liver cancer 23肝癌肝昏迷医学知识讲座 1. Active hepatitis and cirActive liver disease Liver Cancer Differential Diagnosis24肝癌肝昏迷医学知识讲座Active l

17、iver diseaseDifferentiActive liver disease ALT, AFP curveTimedensityAFPchangeALTchangeDifferential Diagnosis25肝癌肝昏迷医学知识讲座Active liver disease ALT, AFP density时间ALTchanceAFPchanceHCC ALT, AFP curveDifferential Diagnosis26肝癌肝昏迷医学知识讲座density时间ALTchanceAFPchanceHCC2. Pregnancy3. Embryonic gonad tumors4.

18、 Other gastrointestinal tumors, such as gastric cancer , pancreatic cancer and malignant insulinoma and so on.Differential Diagnosis27肝癌肝昏迷医学知识讲座2. PregnancyDifferential DiagDifferential Diagnosis （二）Identification of AFP-negative hepatocellular carcinomaMetastatic hepatic carcinoma.Hepatic hemangio

19、ma.Intrahepatic liquid space-occupying lesions :live cyst, liver abscess and liver hydatid.4. Other benign space-occupying diseases:inflammatory pseudotumor, liver adenoma, liver and partial fatty infiltration, liver nodules and liver sarcoma and so on.28肝癌肝昏迷医学知识讲座Differential Diagnosis （二）Ide surg

20、ical treatment Local treatment 1. Hepatic artery embolization chemotherapy 2. Ethanol injection 3. Physiotherapy Treatment29肝癌肝昏迷医学知识讲座Treatment29肝癌肝昏迷医学知识讲座 Radiotherapy Biological and immunotherapy Systemic chemotherapy Comprehensive treatmentTreatment30肝癌肝昏迷医学知识讲座 RadiotherapyTreatment30肝癌Surgica

21、l resection: Offers best chance for cure, but seldom is possible when disease is symptomatic. May be technically difficult. High recurrence rate after resection.Liver transplantation: May be successful in selected patients. Requires transfer to a transplant center and, postoperatively, lifelong immu

22、nosuppression. High recurrence rate. Expensive.Alcohol injection: Palliative for small (usually multiple) tumors that cannot be resected. May be difficult to decide if all the malignant cells have been destroyed. Procedure may facilitate spread of the tumor.Chemoembolization: May shrink selected lar

23、ge tumors to the point where they may become resectable. Effect is palliative for localized but unresectable tumors.Chemotherapy: Palliative only; can be used as an adjunct to surgical resection or transplantation. drug toxicity is frequent. Table 5. Treatment Options for Hepatocellular Carcinoma 31

24、肝癌肝昏迷医学知识讲座Surgical resection: Offers besPrognosisThe better prognosis as following ：1. Tumor less than 5cm, early operation.2. Cancer capsule integrity, and there is no cancer plug formation.3. Normal immune.32肝癌肝昏迷医学知识讲座PrognosisThe better prognosis Chapter 14 Hepatic EncephalopathyInternal Medica

25、l Teaching and Research Section ,First Clinical Medical College of Guangxi Medical University2005undergraduat courseware Professor XingHuo-Tang33肝癌肝昏迷医学知识讲座Chapter 14 Hepatic EncephaDefinitionHepatic encephalopathy is a state of disordered central nervous system function resulting from failure of th

26、e liver to detoxify noxious agents of gut origin because of hepatocellular dysfunction and portosystemic shunting. 34肝癌肝昏迷医学知识讲座Definition34肝癌肝昏迷医学知识讲座Etiology and pathogenesisEtiology : cirrhosis, severe hepatitis,hepatocellular carcinoma, fatty liver of pregnancy et al.35肝癌肝昏迷医学知识讲座Etiology and pa

27、thogenesis35肝癌肝 Drugs Inhibit the brain and respiratory center, resulting in hypoxia Hypovolemia Leading to prerenal azotemia, increased blood ammonia Benzodiazepines Diuresis, diarrhea Anesthetic Vomiting, bleeding Alcohol Released ascites Increased in ammonia production Portosystemic shuntGut-deri

28、ved ammonia into the systemic circulation Protein food shunt surgery Digestive bleeding Vascular obstruction Infection Portal vein thrombosis Constipation Hepatic vein thrombosis Hypokalemia leading to metabolic alkalosis Primary liver cancer Common incentiveing factors of hepatic encephalopathy36肝癌

29、肝昏迷医学知识讲座 Drugs Hypovolemia Glutamine NH3+Glutamate Urea, protein NH3+CO2Intestinal ammonia: Ammonialiver Etiology and pathogenesis（一）Neurotoxin NH3+H+NH4+pH6pH6urea, glutamine37肝癌肝昏迷医学知识讲座Glutamine NH3+Glutamate IntesInterfere with brain cells TCA cycle.2. Increased brain neutral amino acids such a

30、s tyrosine, phenylalanine, tryptophan.3. Astrocytes increased glutamate and neuronal cell swelling.Ammonia can also directly interfere with the electrical activity of neurons.Etiology and pathogenesisAmmonia inhibited the central nervous system :38肝癌肝昏迷医学知识讲座Interfere with brain cells TCA Etiology a

31、nd pathogenesis（二） Changes in neurotransmitterNormal neurotransmitter: dopamine, norepinephrine. 1.False neurotransmitter: Tyrosine Tyramine hydroxyl tyramine Phenylalanine Phenylethylamine Phenylethanolamine 39肝癌肝昏迷医学知识讲座 Etiology and pathogenesis39肝癌Etiology and pathogenesis2. GABA / BZ3. Tryptoph

32、an Tryptophan Brain5 - hydroxytryptamine, 5 - HIAA Inhibited brain function 40肝癌肝昏迷医学知识讲座Etiology and pathogenesis40肝癌肝Pathology Acute HE patients no obvious anatomical abnormalities in brain, mainly secondary brain edema 41肝癌肝昏迷医学知识讲座Pathology Acute HE patients no Clinical manifestations The manife

33、stations of the primary disease.The manifestations of the central nervous system. 42肝癌肝昏迷医学知识讲座 Clinical manifestations 42肝癌肝Phases The level of consciousness Pounce-like tremor EEG NO.1 phases mild changes in normal precursor personality and behavior phases NO.2 phases consciousness disorders, slee

34、p disorders. + abnormalpre-coma orientation and computing abnormalNO.3 phases drowsiness, mental disorder + abnormalsleeping period neurological signs postiveNO.4 phases complete loss of consciousness _ abnormalcoma deep coma 43肝癌肝昏迷医学知识讲座Phases The level of co Clinical manifestations Minimal hepati

35、c encephalopathy: None of the symptoms and signs. Psychological aptitude test unresponsive.44肝癌肝昏迷医学知识讲座 Clinical manifestations44肝癌肝昏 Laboratories and equipment inspection Ammonia Electrolyte acid-base imbalance, hypokalemia, metabolic alkalosis Evoked Potentials EEG Psychological Aptitude Test Ima

36、ging 45肝癌肝昏迷医学知识讲座 Laboratories and equipment iDiagnosis Serious liver disease + precipitating factors + Neuropsychiatric symptoms + Exclude other diseases 46肝癌肝昏迷医学知识讲座Diagnosis 46肝Differential diagnosis Cerebrovascular accident: Age, high blood pressure, Hemiplegia Diabetic coma: glucose ,urine gl

37、ucose,urine ketone (+) Uremia: History of kidney disease, edema, anemia, high blood pressure, urinary changes, renal function damaged Poisoning 47肝癌肝昏迷医学知识讲座Differential diagnosis 47肝癌肝昏迷Treatment 一、The elimination of incentives and treatment of primary disease: 1. Avoid sedatives and drugs which da

38、maged liver function.2. Hemostasis, removal of intestinal hemorrhage.3. Correct water and electrolyte acid-base disturbance. 4. Prevention and control infection.5. Improve liver function. 48肝癌肝昏迷医学知识讲座Treatment 48肝癌肝昏迷医学知识讲座Treatment二、Reducing intestinal ammonia production and absorption: 1. Restricted protein diet 2. Intestinal cleansing 3. Lactulose, lactitol 4. I