外科学 第14讲肝脏疾病(英文)

LIVERDISEASES

1Anatomy22Liverdiseaseligamenttereshepatis3ThefirstportahepatisThethirdportahepatisThesecondportahepatisCouinaudmethodligamenttereshepatis4Frenchsegmentalsystem:Couinaud5262AnteriorsurfacePosteriorsurfaceligamenttereshepatisfundusofgallbladder7AnatomicfeaturesAdualbloodsupply:PVandHAAspecificarchitecturalarrangementofsinglecellsandcellmassesthatfacilitatesexchangebetweenbloodandhapatocytes.Aspecificorientationofthehapatocytesthatcompartmentalizesbiliaryversusbloodpathways.Anorganizedbiliaryexcretorysystemthatregulatestheenterohepaticcirculation.8292LiverFunctions

Metabolism–Carbohydrate,Fat&ProteinSecretory–bile,Bileacids,salts&pigmentsExcretory–Bilirubin,drugs,toxinsSynthesis–Albumin,coagulationfactorsStorage–Vitamins,carbohydratesetc.Detoxification–toxins,ammonia,etc.102112PRIMARYLIVERCANCERPrimaryhepaticcancer12EpidemiologyisuncommonintheUSAishighandisincreasinginpartsofAsiaandAfrica.Insomeregions,hepatomaisthesinglemostfrequentabdominaltumor.ChronichepatitisBandCvirus(HBVandHCV)infectionistheprincipaletiologicfactorworldwide.Cirrhosisfromalmostanycause(eg,alcoholism,hemochromatosis,1-antitrypsindeficiency,orprimarybiliarycirrhosis)isassociatedwithanincreasedriskofhepatocellularcarcinoma.13MaleFemaleLungGastricLiverColon/rectumEsophagealBladderPancreaticLeukemiaLymphomaBrainBreastLungLiverColon/rectumEsophagealOvaryPancreaticUterusGastricBrainChina2006142LiverdiseaseEtiologyHBVandHCVinfectionistheprincipleetiologicfactorworldwide.Cirrhosisfromalmostanycauseisassociatedwithanincreasedriskofhepatocellularcarcinoma.

Certainfungusmetabolitescalledaflatoxinshavebeenshownexperimentallytobecapableofproducinglivertumors.

Widespreadinfectionwithliverflukes(Clonorchissinensis)isatleastpartlyresponsibleforthehigherincidenceofthesetumorsinAsia.15162Liverdisease172TrilogyHepatitisBLiverCirrhosisLiverCancer182PathologicclassificationHepatocellularcarcinoma----hepatoma:constituteabout80%ofprimaryhepaticcancers.Cholangiocellularcarcinoma----cholangiocarcinoma.15%Amixedform----hepatocholangioma19GrossmorphologyclassificationAmassiveform:asinglepredominantmassclearlydemarcatedfromthesurroundingliver,occasionallywithsmallsatellitenodulesAnodularform:multiplenodulars,oftendistributedthroughouttheliver.(prognosisisbad)Adiffusevariety:infiltrationoftumorthroughouttheremainingparenchyma.(prognosisisbad)20Massivelivercancer21Liverdisease2222Nodularlivercancer23Liverdisease2242Diffuselivercancer25Liverdisease2262Encapsulatedtumors(favorablesign)

▲

About50%ofrespectabletumorsaresurroundedbyafibrouscapsule,astructurethatdevelopsasaresultofcompressionandcollagenizationofadjacentliverstroma.▲

Encapsulatedtumorsexhibitalowerincidenceofdirectliverinvision,tumormicrosatellites,andvenouspermeationcomparedwithnonencapsulatedones.Liverdisease272Metastases▲In70%ofpatients,tumorhasspreadoutsidetheliverwhenhepatomaisfirstdiagnosed.(prognosisisbad)▲Metastasesarealmostinvariablepresentwiththenodularordifuseforms.▲About40%ofthemassivetypeareconfinedtotheliver.Liverdisease282Metastases▲Thehilarandceliaclymphnodesaremostcommonlyinvolved.▲Metastasestolungandtheperitonealsurfacealsooccurfrequently.▲Theportalorhepaticveinsareofteninvadedbytumor,andvenousocclusionmayoccurineithercase.29Liverdisease2Microscopically,▲thereisusuallylittlestromabetweenthemalignantcells,andthetumorhasasoftconsistency.▲thetumormaybehighlyvascularized,afeaturethatsometimesproducesmassiveintraperitonealhemorrhagefollowingspontaneousrupture.30Liverdisease2LiverdiseaseClinicalfindingsA.SymptomsandsignsB.LaboratoryfindsC.LiverscanD.AngiographyE.LiverbiopsyF.ScreeningG.Tumormarkers312SymptomsandsignsRightupperquadrantpain,whichmaybeassociatedwithreferredpainintherightshoulder.Weightlossisusuallypresent.Jaundiceisevidentinaboutonethirdofcased.Hepatomegaly

oramassispalpableinmanypatients.Intermittentfevermaybeapresentingfeature.Ascitesorgastrointestinalbleedingindicatesadvanceddisease.Noclinicalfindings.32Thepatternsofpresentationpainwithorwithouthepatomegalysuddendeteriorationoftheconditionofacirrhoticpatientowingtotheappearanceofhepaticfailure,bleedingvarices,orascitessudden,massiveintraperitonealhemorrhageacuteillnesswithfeverandabdominalpaindistantmetastasesnoclinicalfindings33LaboratoryfindingsTheserumbilirubiniselevatedinonethirdofpatientsInanother25%,serumalkalinephosphataseisincreasedbuttheserumbilirubinisnormalAbout75%ofpatientsarepositiveforHBsAgorhepatitisC34LiverScanCTscans,ultrasoundscans,andMRIscansdemonstratetheprincipallesionin80%ofpatients.MRIscansarethebestwaytoshowextensionintothehepaticveins.CTportographyissuperiortoordinarycontrast-enhancedCTscans.35Ultrasound362372382MRI392MRI402412AngiographyHepatomasareusuallysuppliedbythehepaticartery,and80%aremorevascularthanadjacentparenchyma.Cholangiocarcinomasusuallyappearlessvascularthanadjacenttissue.Hemangiomascanberecognizedbyacharacteristicpictureofpatchyvascularpooling.Angiographymaybeequivocalinsmalltumors42Angiography43LiverBiopsyThediagnosiscanbeestablishedbypercutaneouscorebiopsyoraspirationbiopsyinmostpatientsifthebiopsysiteisselectedaccordingtothescan.Percutaneousbiopsyisrisk,becausethesetumorsaresovascular(rateoffatalhemorrhageis0.4%).44452462LiverdiseaseTumormarkers

Alpha-fetoprotein(AFP)

AFPisaglycoproteinnormallypresentonlyinthefetalcirculation,。ispresentinhighconcentrationsintheserumofabout80%ofpatientswithprimaryhepatomasandtesticulartumors.Valuesabove200ng/mLaresuggestiveofhepatoma.Levelsintheintermediaterangemayoccurwithotherkindsofliverdisease,suchascirrhosisandchronichepatitis.

TheprognosisisworsewhenAFPlevelsarehigh.472DifferentialdiagnosisTheclinicalpictureisusuallynonspecific.▲Livercancerismostoftenconfusedwithotherabdominalcarcinomas.▲Oncehepatomegalyandafillingdefectintheliverarefound,itmustbedeterminedwhethertheliverharborsaprimaryneoplasmorametastasis.Arteriography,biopsy,andserumAFPlevelsestablishthediagnosisinmostcases.482Livercystmetastasis492Liverdiseaseliverabscess502ComplicationsSpontaneousbleeding:rupture,intra-abdominalhemorrhagePortalhypertension:obstructionoftheportalveinBudd-Chiarisyndrome:obstructionofthehepaticveinLiverfailure51TreatmentPartialhepatectomyLivertransplantationEthanolinjectionRadiofrequencyablationArterialchemoembolization52532HepatectomyResectionofthetumorofferstheonlypossibilityofcure.Thecriteriaofrespectablityare:----thetumormustbeconfinedtotheliver.----thelesionmustbeentirelyencompassedbylocalexcision,lobectomy,orextendedlobectomy.Therateofrecurrenceisabout50%54552562572Theoutlookisworsewithageover50yearscoexistenthepatocellulardisease(ie,cirrhosis)vascularinvasionportalveinthrombosistumorlocateddeepintheliverintracapsularinfiltrationoftumorcellsbilobarinvolvementmorethanonedepositoftumor58Liverdisease▲Ifvisibletumorisleftbehindorifthemarginsofresectionarelessthan0.5cm,progressivediseaseistherule.▲Overall,therateoftumorrecurrenceisabout50%.The5-yearsurvivalrateforpatientswithcirrhosisisclosetozero,butforthosepatientswithoutcirrhosis,itisabout40%.▲Aftersurgery,thepatientshouldbefollowedbyimagingstudiesandAFPmeasurement,andalocalizedrecurrenceshouldbeconsideredforrepeatresectionorpalliativetherapy.592LivertransplantationTheoreticadvantage:----lesionsthatareunresectablebecauseofsizeormultifocaldistribution----theinabilityofacirrhoticlivertotolerateanybutthemostlimitedresection----thelikelihoodinmanycasesthatanundectablesecondtumorislocatedremotefromtheindexlesion60Livertransplantation5-yearsurvivalisabout35%Forsmallhepatoma,5-yearsurvivalismorethan75%NeedimmunosuppressivetherapySafe,good,butexpensiveandlongwaitingtime61Liverdisease622632EthanolinjectionUsingultrasoundguidanceLessthan3cm95%ethanol(5-20ml)isinjectedintotheneoplasmCausecompletenecrosisofthelesionin75%ofpatientsandpartial(90%)necrosisin20%Thepatientisfollowedandre-treatmentgivenforresidualornewprimarytumors1,2,3yearsaftertreatmentwas90%,80%,and63%,respectively642RadiofrenquencyablationUsingultrasoundguidance,aradiofrenquencyablationprobeisintroducedintothelivertumorpercuteaneously,atlaparotomyorlaparoscopy.Electricalenergyisusedtodestroythelesionbyproducingheat.Resultinginnecrosis.Thegeneratorisactivatedtoachievehightemperatureswithinthetumor.Itcauselocaltissuedestructionbyheat.Itisagoodpalliativetreatment.65Liverdisease662672ArterialchemoembolizationSystemicchemotherapy:Poorsensitivity(5-Fu,cisplatin,EPI,Dox).Drugsgivenbyhepaticarteryinfusion:Highconcentrationinliver,continuousinfusioncausechemicalhepatitis.Drugsgivenbychemoembolization.

TACE:TransArteryChemotherapyEmbolization.68TACEPatientswithChildclassCcirrhosisorthrombosisoftheportalveinarenotsuitablecandidates.EmbolizationisusuallyperformedwithGelfoam,whichdissolvesafterafewweeks,allowingrepeatedtreatment.Lipiodol,whichlodgesinthetumor,canbeusedasacarrierforthedrugsandembolization.Doxorubicin,mitomycin,andcisplatininvariouscombinationsarethedrugsmostoftengiven.69Liverdisease702712SIDEEFFECTSNauseaand/orvomitingAbdominalpainFeverTemporarylossofhairSoresinmouthorvaginaIncreasedriskofinfectionLiverfailureAnemiaDeath72PrognosisMostpatientswithunresectablelesionssuccumbwithinayearafterdiagnosis.Patientsgenerallydiefromtheeffectsoftheexpandinghepaticneoplasmratherthanfrommetastases.73Case

50y/oChinesemale,lossofappetiteandweightforthreeMonths.Wenttoseedoctorsinalocalhospital.PhysicalexaminationrevealedanabdominalmassjustunderthexiphoidProcess,sized6cmX8cm.Themassprojectedtothelefthypochondriaarea.Theupperboundaryofthemasscouldn'tbeidentifiedonpalpation.Therewasn’ttendernesswhenthemasswaspalpated.Itwashardandmovedupanddownwhenpatientbreathed.74QuestionsAreyougoingtoaskmorequestionsofthepatient’shistory?Whattestsandfurtherexaminationrequired?Differentialdiagnosisoflivermass?Yourdiagnosis?Therapystrategy?75secondarylivercancerMETASTATICNEOPLASMSOFTHELIVER76InductionMetastaticcanceris20timesmorecommonthanprimarytumorsintheliver.Cancersofthebreast,lung,pancreas,stomach,largeintestine,kidney,ovary,anduterusaccountforabout75%ofcases.Spreadtothelivermaybeviathesystemiccirculation,portalvein,or,thelymphatics.77InductionThecirrhoticliverislesssusceptiblethannormallivertoimplantationofmetastases.Over90%ofpatientswithhepaticmetastaseshavetumorimplantsinotherorgans.Thelungismostcommonlyinvolvedandcontainstumorin30%ofcases.78SymptomsandSignsWeightloss,fatigue,andanorexiaRightupperabdominalpain,ascites,andjaundice.Feverwithoutdemonstrableinfectionispresentin15%ofcasesandbearsonlyalooserelationshiptoleukocytosis.In60%ofcases,hepatomegalyorapalpablemetastatictumorintheupperabdomen.Portalhypertensionmaybemanifestedbyabdominalvenouscollateralsorsplenomegaly.79LaboratoryFindingsahematocritbetween30%and36%.Theserumbilirubiniselevatedinalmosthalfofpatients.Thealkalinephosphataseisalsousuallyincreased.ThediagnosiscanbeestablishedinmostcasesbyPercutaneousliverbiopsyorfine-needleaspirationformalignantcells.80ImagingStudiesMRIprovidesusefuladditionalinformation,anditmaybesuperiortoCTscans.CTportographyissuperiortoordinarycontrast-enhancedCT.Whereavailable,MRIandCTportographyshouldbothbeperformedifthepatientisbeingconsideredforresectionofhepaticmetastasesorinsertionofahepaticarteryinfusionpump.Duringsurgerythelivershouldbefurtherexaminedbyultrasoundtocheckforlesionsthatmighthavebeenmissedbypreoperativestudies.81TreatmentHepaticResectionRadiofrequencyAblationChemotherapyMiscellaneous82HepaticResectionforcolorectalcancersPartial

hepatectomy--eitherwedgeresectionorlobectomy--isindicatedforthe5%ofpatientswithlivermetastasesfromcolorectalcancerwhosediseaseisresectable.Ifallgrosstumorcanberemoved,about25%ofpatientsarecured.Theonlyabsoluterequirementsarethatnoextrahepaticdiseasebe

presentandthatresectionbetechnicallyfeasible.83IndicationaworseprognosisoriginaltumorstageDukesCcomparedwithDukesBfourormoreliverlesionsover25%ofthemassoftheliverreplacedbytumorlessthan1yearsinceresectionofthecolonprimary1cmorlessmarginofresection84Variablesthatdonotinfluencetheoutcomelobectomyversuswedgeresectionhistologicpatternofthetumorbilateralratherthanunilateraldiseasesiteoftheprimarytumorwithinthelargeintestinethegenderofthepatient85Prognosis

forcolorectalcancerThemortalityrateforresectionofhepaticmetastasesisabout2%inhospitalswherethisoperationisperformedfrequently.followingaresectionthatremovedalldetectabletumor,themediantimetorecurrenceis9ms.Theinitialrecurrenceinabouthalfofthesepatientsisconfinedtotheliver.Anotherresectionmaybeperformed.Thechancesofpermanentlyeradicatingthediseasebyasecondresectionisabout15%.86HepaticResection

forothercancersOthertumorsthatoccasionallyproducediseaselocalizedtoonelobeoftheliverandamenabletocurativeresection.Partialhepatectomyisalsosometimesworthwhiletoextirpateatumorinvadingdirectlyfromacontiguousorgan.Hepaticresectionofapparentlysolitarymetastasesfromcancersofthebreast,pancreas,stomach,femalepelvicorgans,andlunghasbeenfruitless.87RadiofrequencyAblationRadiofrequeneyenergyhasbeenusedtodestroymetastasestotheliverfromavarietyoftumortypes.Trialsarecurrentlyongoingtodefinetheroleofthistherapy.88ChemotherapyInasmanyas30%ofcases,theliveristheonlyevidentsiteofmetastasesfromcolorectalcancer.Placingacatheterinthehepaticarteryconnectedtoanimplantableinfusionpump(Infusaidpump),whichallowsthedeliveryofmuchhigherconcentrationsofdrugtothetumorthanispossiblewithsystemicadministration.Druds:floxuridineToxicity:gastroduodenalerosions,chemicalhepatitis,orchemicalsclerosingcholangitis.89ChemotherapyExtrahepaticlesionsthatappearduringtherapyaretreatedbyconcomitantsystemicchemotherapy.Hepaticarteryinfusionchemotherapymaybeausefuladjunctivetherapy.Systemicchemotherapy(eg,withfluorouracil)doesnotimprovesurvival,thoughitisoftenprescribed.90MiscellaneousHepaticarteryligationorangiograpbicemboIizationofthetumorhasbeenofbenefitinafewpatientswithhepaticmetastasesfromspecifictumortypes,suchascarcinoidandisletcelltumors.PVE91HEPATICABSCESSLiverabscess92Epidemiology

Maybebacterial,parasitic,orfungalinorigin.IntheUSA,pyogenicabscessesarethemostcommonandtheamebicabscessesthenextmostcommon.InChina,pyogenicabscessesarethemostcommon.Pyogenicabscessesarethemostcommonandamebicabscessesthenextmostcommon.Casesareaboutevenlydividedbetweenthosewithasingleabscessandthosewithmanyabscesses.About90%ofrightlobeabscessesaresolitary,whileonly10%ofleftlobeabscessaresolitary.93942PathogenesisInvolvestwobasicelement:----thepresenceoftheorganism----thevulnerabilityoftheliverInmostcases,theorganismisofentericorgin.Mostcommon:Escherichiacoli,Klebsiellapneumoniae,bacteroides,enterococci,anaerobicstreptococci,andmicroaerophilicstreptococci.95EtiologyInmostcases,thedevelopmentofahepaticabscessfollowsasuppurativeprocesselsewhereinthebody.Manyabscessesareduetodirectspreadfrombiliaryinfectionsuchasempyemaofthegallbladderorprotractedcholangitis.Abdominalinfectionssuchasappendicitisordiverticulitismayspreadthroughtheportalveintoinvolvetheliverwithabscessformation.

96Spreadoforganismtothehepaticparenchymamayoccurthrough:ThepotalsystemAscensionfromthebiliarytreeThehepaticarteryduringgeneralizedsepticemiaDirectextensionfromsubhepaticorsubdiaphragmaticinfectionAdirectroutefollowingtrauma97982992ClassificationSingerabscess90%:rightlobe10%:leftlobeMutipleabscess100SymptomsandsignsFever(90%)39-41℃RUQ,epigastricpainJaundicehepatomegalyChillsAnorexiaWeightlossNausea,vomitingWeakness,malais1011022⑴Whenliverabscessdevelopsinthecourseofanotherintra-abdominalinfectionsuchasdiverticulitis,itisaccompaniedbyincreasingtoxicity,higherfever,jaundiceandagenerallydeterioratingclinicalpicture.Rightupperquadrantpainandchillsmayappear.103Hepaticabscess2⑵Inothercases,thediagnosisismuchlessobvious,sincetheillnessdevelopsinsidiouslyinapreviouslyhealthyperson.Inthese,thefirstsymptomsareusuallymalaiseandfatigue,followedaftersevereweeksbyfever.Epigastricorrightupperquadrantpainispresentinabouthalfofcases.Thepainmaybeaggravatedbymotionormaybereferredtotherightshoulder.Hepaticabscess1042⑶Thecourseoffeverisoftenerratic,andspikesto40-41℃arecommon.Chillsarepresentinabout25%ofcases.Theliverisusuallyenlargedandmaybetendertopalpation.Iftendernessissevere,theconditionmaybeconfusedwithcholecystitis.⑷Jaundiceisusuallyinsolitaryabscessesunlessthepatient’sconditionisseriouslyworsening.Itisoftenpresentinpatientswithmultipleabscessesandprimarydiseaseinthebiliarytreeandingeneralisabadprognosticsign.1052Laboratoryfindings⑴

Leukocytosisispresentinmostcasesandisusuallyover15×109/L.Asmallgroupofpatients-includingsomeofthemostseriouslyill-failtodevelopleukocytosis.⑵Anemiaispresentinmost.Theaveragehematocritis33%.106Hepaticabscess2⑶Serumbilirubinisusuallynormalexceptinpatientswithmultipleabscessorbiliaryobstructionorwhenhepaticfailurehassupervened.⑷Alkalinephosphataseisoftenelevatedeveninthepresentofanormalbilirubin.107Hepaticabscess2ImagingStudiesUltrasoundandCTscanarethemostdiagnostictests,providingaccurateinformationregardingthepresence,size,number,andlocationofabscesseswithintheliver.CTscanshavetheaddedadvantageofbeingabletodemonstrateabscessorneoplasmselsewhereintheabdomen.Plainfilmsoftheabdomenareusuallynormalorshowonlyhepatomegaly.Inafewpatients,anairfluidlevelintheregionoftheliverrevealsthepresenceandlocationoftheabscess.108Hepaticabscess2Ultrasound:85%-95%1092CTscanCTisthemostsensitiveoftheimagingprocedures:95%-100%.CTallowsdiagnosticandtherapeuticintervention.Theappearanceisvariable,andlesionsmayappearcysticorisodense,withsolidmetastaticlesions.Aminorityofhepaticlesionscontaingas.11011121122DiagnosisImagingUltrasoundCTMicrobialcultures(aerobic,anaerobic)AspirationSerologyR/OAmebicIdentifyunderlyingsource1131142DifferentialDiagnosisSimplecyst–noelements/strandinginwallsMalignancy–solidAmebicabscess–cannotbedistinguishedbyimagingRightsubphrenicabscessBiliaryinfection,cholangitis115Ameba1162pyogenicandamebicliverabscessespyogenicliverabscessesareseenmoreofteninpatientsolderthan50yearsandareassociatedwithjaundice,pruritus,sepsis,apalpablemass.elevatedbilirubinandalkalinephosphataselevels.Amebiasisshouldbeconsideredineveryeaseofsolitaryabscess.amebicabscessesmoreoftenhavebeentoanendemicareaandhaveabdominalpainandtenderness,diarrhea,hepatomegaly.positiveserologictestsforamebiasis.1172AmebicliverabscessHavebeentoanendemicareaAbdominalpainandtendernessDiarrheaHepatomegalyPositiveserologictestsforamebiasisTreatment:anti-amebadrugssuchasmetronidazole,chloroquineandemetine.

1182ComplicationsIntrahepaticspreadofinfectionmaycreatemultiple