肝功能化驗(yàn)異常的分析和解釋課件

肝臟具有那些功能?代謝功能膽汁生成和排泄凝血功能解毒作用1肝臟具有那些功能?代謝功能1肝臟分類檢測Enzymetests–Aminotransferases–Alkalinephosphatase–Gammaglutamyltranspeptidase?Testsofsyntheticfunction–Albumin–Prothrombintime?Testsofhepatictransportcapability–Serumbilirubin2肝臟分類檢測Enzymetests2丙氨酸氨基轉(zhuǎn)移酶

AlanineAminotransferase(ALT)SerumGlutamic-pyruvicTransaminase(SGPT)組織來源:肝細(xì)胞胞漿丙氨酸α酮戊二酸丙酮酸谷氨酸3丙氨酸氨基轉(zhuǎn)移酶

AlanineAminotransfer天冬氨酸氨基轉(zhuǎn)移酶

AspartateAminotransferase(AST)SerumGlutamic-oxaloaceticTransaminase(SGOT)組織來源:心臟,肌肉,腎臟,腦,胰腺,紅細(xì)胞肝細(xì)胞胞漿(20%)及線粒體(80%)天門冬氨酸α酮戊二酸草酰乙酸谷氨酸AST4天冬氨酸氨基轉(zhuǎn)移酶

AspartateAminotransALT與ASTSevere(>20times,1000U/L)急性病毒性肝炎,藥物或毒物損傷,休克肝Moderate(3-20times)慢性肝炎,藥物性肝炎,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5ALT與ASTSevere(>20times,10ALT:ASTratioAST：ALT≥2酒精性肝病AST：ALT>1肝硬化6ALT:ASTratioAST：ALT≥26堿性磷酸酶

AlkalinePhosphatase(ALP)組織來源:肝臟,骨骼,腸道,胎盤機(jī)制:膽汁酸增加ALP脂溶性,刺激ALP合成7堿性磷酸酶

AlkalinePhosphatase(AL堿性磷酸酶

AlkalinePhosphatase(ALP)意義:肝臟相關(guān)的:肝內(nèi)膽汁淤積部分或完全膽道梗阻肝臟腫瘤肉芽腫性病變非肝臟因素:骨腫瘤妊娠8堿性磷酸酶

AlkalinePhosphatase(AL谷酰轉(zhuǎn)肽酶

Gamma-glutamyltransferase(GGT)組織來源:membraneofcells(liver,kidney,pancreas,intestine,prostate)意義:膽汁淤積原發(fā)性或轉(zhuǎn)移性肝癌酒精性肝病胰腺癌,壺腹周圍癌9谷酰轉(zhuǎn)肽酶

Gamma-glutamyltransfer肝功能異常類型化驗(yàn)肝細(xì)胞損傷膽汁淤積轉(zhuǎn)氨酶>8倍正常值<3倍正常值A(chǔ)LP<3倍正常值>8倍正常值BIL增高增高PT延長，對維生素K治療反應(yīng)差延長，對維生素K治療反應(yīng)好腹痛不常見常見（肝外梗阻時(shí)）發(fā)熱，WBC增高不常見常見（肝外梗阻時(shí)）10肝功能異常類型化驗(yàn)肝細(xì)胞損傷膽汁淤積轉(zhuǎn)氨酶>8倍正常值<3膽紅素代謝示意圖11膽紅素代謝示意圖11膽紅素

Bilirubin(BIL)間接膽紅素增高血癥:生成過多肝臟攝取受損葡萄糖醛酸化受損12膽紅素

Bilirubin(BIL)間接膽紅素增高血癥:1間接膽紅素增高血癥(例1)李霞，女，27歲非洲工作（08-4-18至08-10-7）稽留熱5天（08-10-18至08-10-22）血圖片：可見瘧原蟲（外院）服用氯奎3日，青蒿琥酯片及蒿甲醚5日熱退（08-10-20至08-10-27）入院前3日再次高熱伴陣發(fā)中上腹絞痛（08-10-28）血色素9.1g/dl降至3.9g/dl伴醬油色尿，網(wǎng)織紅2.53%ALT30U/L,AST57U/L,TBIL40.3umol/L,IBIL27.43umol/L,LDH863U/L13間接膽紅素增高血癥(例1)李霞，女，27歲13間接膽紅素增高血癥(例2)中年女性。膽結(jié)石擬手術(shù)，發(fā)現(xiàn)間接膽紅素增高請會診。Hb正常網(wǎng)織紅細(xì)胞比例增高。外周血圖片14間接膽紅素增高血癥(例2)中年女性。14間接膽紅素增高血癥(例3)劉壯飛，男性，12歲反復(fù)皮膚黃染伴乏力6年父親自18歲起發(fā)現(xiàn)膽紅素升高，以間接膽紅素為主ALT16U/L，AST27U/L正常TBIL46.2umol/L，IBIL30.0umol/L。組織病理學(xué)最終診斷：Gilbert綜合征

15間接膽紅素增高血癥(例3)劉壯飛，男性，12歲15膽紅素

Bilirubin(BIL)直接膽紅素增高血癥:肝外膽管梗阻肝內(nèi)膽汁淤積16膽紅素

Bilirubin(BIL)直接膽紅素增高血癥:1肝外膽管梗阻李彥紅，女性，77歲突然皮膚鞏膜黃染10天ALT，AST正常ALP302U/L，GGT361U/LTBIL250.60umol/L,DBIL233.60umol/L17肝外膽管梗阻李彥紅，女性，77歲17肝外膽管梗阻18肝外膽管梗阻18正常胰膽管系統(tǒng)

19正常胰膽管系統(tǒng)19

膽汁分泌障礙、流速減慢或停滯，可發(fā)生在從肝細(xì)胞、毛細(xì)膽管直至Vater壺腹各水平。臨床：以瘙癢、黃疸、ALP、GGT增高等為特征。病理：肝細(xì)胞及/或膽道系統(tǒng)膽汁成分蓄積。肝內(nèi)膽汁淤積的概念20膽汁分泌障礙、流速減慢或停滯，可發(fā)生在從肝細(xì)胞、肝內(nèi)各級膽管及其命名Hering管總膽管右肝管左肝管400-800um段膽管300-400um區(qū)膽管>100um隔膽管15-100um葉間小膽管<15um細(xì)膽管毛細(xì)膽管肝細(xì)胞21肝內(nèi)各級膽管及其命名Hering管總膽管右肝管左肝管400-肝內(nèi)毛細(xì)膽管—小葉間膽管ductuleBilecanaliculus自ScheuerPJ，LiveBiopsyInterpretation.2006，5322肝內(nèi)毛細(xì)膽管—小葉間膽管ductuleBilecanali肝內(nèi)膽汁淤積–Viralhepatitis–Etohhepatitis–EBV,CMV–Anabolic,steroids,Contraceptives,TPN–Primarybiliarysclerosis–Primarysclerosingcholangitis23肝內(nèi)膽汁淤積–Viralhepatitis23肝內(nèi)膽汁淤積24肝內(nèi)膽汁淤積24肝內(nèi)膽汁淤積25肝內(nèi)膽汁淤積25肝內(nèi)膽汁淤積26肝內(nèi)膽汁淤積26＋甘氨酸，?；撬峥偰懼酺BA27＋甘氨酸，?；撬峥偰懼酺BA272828肝臟合成功能白蛋白MalnutritionNephroticsyndromeProteinlosingenteropathy(Sprue,Crohn’s)凝血酶原活動(dòng)度60%40~60%<40%膽堿脂酶29肝臟合成功能29膽堿脂酶

Acetylcholinesterase真性膽堿脂酶紅細(xì)胞和腦灰質(zhì)運(yùn)動(dòng)神經(jīng)節(jié)終板有機(jī)磷中毒假性膽堿酶（擬膽堿脂酶）肝臟合成反應(yīng)肝功能儲備孕婦及口服避孕藥可降低30膽堿脂酶

Acetylcholinesterase真性膽堿肝功能儲備Child-Pugh1分2分3分白蛋白g/dL>3.52.8-3.5<2.8PT延長秒1-34-6>6膽紅素mg/dl≤22-3>3腹水無少量中量肝性腦病無1~23~4GradeA1-6;GradeB7-9;GradeC10~15ChildCG,TurcotteJG.Surgeryandportalhypertension.In:Theliverandportalhypertension.EditedbyCGChild.Philadelphia:Saunders1964:50-64.PughRN,Murray-LyonIM,DawsonJL,PietroniMC,WilliamsR(1973).TheBritishjournalofsurgery60(8):646–9.31肝功能儲備Child-Pugh1分2分3分白蛋白g/dL>肝功能儲備Child-PughPointsClassOneyearsurvival(%)Twoyearsurvival(%)5-6A100857-9B815710-15C453532肝功能儲備Child-PughPointsClassOne肝功能儲備MELD

TheModelforEnd-StageLiverDisease

MELD=3.78[Lnserumbilirubin(mg/dL)]+11.2[LnINR]+9.57[Lnserumcreatinine(mg/dL)]+6.43

Interpretation(3month)40ormore-100%mortality30-39-83%mortality20-29-76%mortality10-19-27%mortality<10-4%mortalityMalinchocM,KamathPS,GordonFD,etal.(April2000)."Hepatology31(4):864–71.33肝功能儲備MELDTheModelforEnd-S女性，54歲主訴：上腹不適、惡心2天入院日期：2008－08－21高球蛋白血癥34女性，54歲高球蛋白血癥34治療前后肝功能ALTASTALPGGTALBGLOCHETBILDBIL08-2080470531.872.481.1161.0108-2251545013329126.3743.2680.3862.0908-28155931433432362.73.2231.3524.0809-03907916135222.564.33.1737.4727.0609-10(↑)9711219336322.462.42.9547.9434.2609-16706519238924.164.53.3326.5117.9209-2412811418344432.867.84.5144.3625.7710-21458913640230.164.84.926.6915.0910-15584210725231.854.65.1516.7935治療前后肝功能ALTASTALPGGTALBGLOCHETB高球蛋白血癥中年女性,急性起病.轉(zhuǎn)氨酶顯著增高,輕度黃疸.明顯高球蛋白血癥.ANA陽性.肝組織病理學(xué)符合自身免疫性肝炎的表現(xiàn).激素治療基本有效!36高球蛋白血癥中年女性,急性起病.36Globulinisoneofthetwotypesofserum

proteins,theotherbeingalbumin.Proteinelectrophoresis:Alpha1globulins

Alpha2globulins

Betaglobulins

Gammaglobulins(onegroupofgammaglobulinsareimmunoglobulins,thatfunctionasantibodies)Globulin37GlobulinisoneofthetwotypHyperglobulinemiaHyperglobulinemia:PolyclonalGammopathy

Chronicbacterialdiseases

?Pneumonia

ChronicfungaldiseasesChronicprotozoal原蟲的/rickettsialdiseases

38HyperglobulinemiaHyperglobuliHyperglobulinemiaHyperglobulinemia:PolyclonalGammopathyChronicviraldiseasesNeoplasia

?Lymphoma

?Mastcelltumor

?OthertumorsAutoimmunedisorders

?Systemiclupuserythematosus

?Chronicpolyarthritis

?Others

39HyperglobulinemiaHyperglobulinHyperglobulinemiaHyperglobulinemia:MonoclonalGammopathy

Neoplasia

?Multiplemyeloma

?Lymphoma

?ChroniclymphocyticleukemiaInflammation/infection

?LeishmaniasisIdiopathic

?Waldenstrommacroglobulinemia

?Benignmonoclonalgammopathy40HyperglobulinemiaHyperglobulinSerumProteinElectrophoresis--NormalPattern41SerumProteinElectrophoresis-SerumProteinElectrophoresis--PolyclonalGammopathy

sarcordosisThesequentialincreaseoftheglobulinfractionsillustrated"sarcoidstepping."42SerumProteinElectrophoresis-SerumProteinElectrophoresis--NephroticPatternalpha-2-macroglobulinLossoflowermolecularweightproteins(Examples:albumin,IgG)Retentionofhighermolecularweightproteins(examplealpha-2-macroglobulin.)SLE43SerumProteinElectrophoresis-SerumProteinElectrophoresis--CirrhoticPattern"beta-gammabridge"patternendstageliverdiseasesecondarytochronicalcoholabuse44Serum