肝癌肝昏迷医学知识讲座培训课件.ppt

1、肝癌肝昏迷医学知识肝癌肝昏迷医学知识讲座讲座 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 Incidence rate 14.5846/100,000.HCC is up to 25times more common in men than women and usually arises in a cirrhotic liver.Overview3肝癌肝昏迷医学知识讲座 Chronic li

2、ver disease Aflatoxin Drinking Water Pollution Other factorsEtiology and pathogenesis4肝癌肝昏迷医学知识讲座 Chronic liver disease viral hepatitis 1.HBV:HBV-DNA may be integrated into the host DNA of liver cells,and changes gene expression in liver cells.2.HCV Etiology and pathogenesis5肝癌肝昏迷医学知识讲座 CirrhosisAbo

3、ut 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 Aflatoxin B1 Drinking Water Pollution:Algae toxin could contaminate water sources Chemical carcinogens:nitrite,organic chlorine pesticides Parasite:liver flukeEtiology and pathogenesi

4、s7肝癌肝昏迷医学知识讲座 Pathology Morphological typing Block type(5cm)Nodular type(5cm)Diffuse type Small hepatocarcinoma(3cm)Cell classification Hepatocellular Bile duct cell type8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）

5、implantation metastasisPathology9肝癌肝昏迷医学知识讲座 Subclinical hepatocellular carcinoma:Without any signs and symptoms AFP clinical manifestation10肝癌肝昏迷医学知识讲座 hepatic region pain:Persistent pain or dull pain Progressive enlarge liver:Quality hard,uneven surface,nodule or giant blocks,ragged edge,tendernes

6、s,vascular murmurclinical manifestation11肝癌肝昏迷医学知识讲座 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 Systemic manifestations of malignant tumors:Fatigue,weight loss,cachexia,fever,a

7、norexia 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SYMPTOMS PREVALENCE(%)PHYSICAL SIGNS PREVALENCE(%)Abdominal pain 59-95Hepatomegaly 54-98Weight loss 34-71Hepatic bruit 6-25Weakness 22-53Ascites 35-

8、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讲座Complications Hepatic encephalopathy Upper gastrointestinal

9、bleeding Rupture of liver carcer nodules Secondary infection15肝癌肝昏迷医学知识讲座（一）（一）Detection of liver cancer markers 1.Alpha-fetoprotein(AFP)Clinical Significance:liver cancer census(high-risk groups),diagnosis,Judging treatment and relapseLaboratories and equipment inspection16肝癌肝昏迷医学知识讲座 AFP diagnosti

10、c 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-negative:Detection of AFP heterogeneityLaboratories and equipment inspection17肝癌肝昏迷医学知识讲座 2.Other liver cancer marker r-glutamyl transferase isoenzy

11、me peptide （r-GT）abnormal prothrombin（APT）serum a-l-fucosidase(AFU)ALP isoenzyme（ALP-I）Laboratories and equipment inspection18肝癌肝昏迷医学知识讲座 （二）（二）Imaging examination Ultrasound:2cm or more substantial mass X ray computer tomography（CT）X-hepatic angiography Magnetic resonance imaging(MRI)（三）（三）Liver pu

12、ncture biopsyLaboratories and equipment inspection19肝癌肝昏迷医学知识讲座 Clinical manifestations,coupled with AFP,liver B-Ultrasound,CT etc.Diagnosis20肝癌肝昏迷医学知识讲座Clinical diagnostic criteria for hepatocellular carcinoma(一）一）Non-invasive diagnostic criteria 1.Imaging：Two kinds of imaging studies have shown mo

13、re than 2cm liver mass.2.Imaging with AFP: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（二）（二）Histological diagnostic criteria Less than 2cm of intrahepatic nodules that maging can not determine shoud be punctured to confirm histological ch

14、aracteristics of liver cancer.Diagnosis22肝癌肝昏迷医学知识讲座 1.Active hepatitis and cirrhosisDifferential Diagnosis（一）（一）Differential diagnosis in AFP-positive liver cancer 23肝癌肝昏迷医学知识讲座 Active liver disease Liver Cancer Differential Diagnosis24肝癌肝昏迷医学知识讲座Active liver disease ALT,AFP curveTimedensityAFPchan

15、geALTchangeDifferential Diagnosis25肝癌肝昏迷医学知识讲座density时间ALTchanceAFPchanceHCC ALT,AFP curveDifferential Diagnosis26肝癌肝昏迷医学知识讲座2.Pregnancy3.Embryonic gonad tumors4.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

16、识讲座Differential Diagnosis（二）二）Identification of AFP-negative hepatocellular carcinoma1.1.MetastaticMetastatic hepatic hepatic carcinoma.carcinoma.2.Hepatic hemangioma.3.Intrahepatic liquid space-occupying lesions:live cyst,liver abscess and liver hydatid.4.Other benign space-occupying diseases:infla

17、mmatory 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 surgical 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 Radiotherapy Biological and immunoth

18、erapy Systemic chemotherapy Comprehensive treatmentTreatment30肝癌肝昏迷医学知识讲座Surgical 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.Re

19、quires transfer to a transplant center and,postoperatively,lifelong immunosuppression.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 facilita

20、te spread of the tumor.Chemoembolization:May shrink selected large 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

21、.Table 5.Treatment Options for Hepatocellular Carcinoma 31肝癌肝昏迷医学知识讲座PrognosisThe better prognosis as following ：1.1.Tumor less than 5cm,early operation.2.2.Cancer capsule integrity,and there is no cancer plug formation.3.3.Normal immune.32肝癌肝昏迷医学知识讲座Hepatic Encephalopathy2005undergraduat courseware

22、33肝癌肝昏迷医学知识讲座Hepatic encephalopathy is a state of disordered central nervous system function resulting from failure of the 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Etiology:cirrhosis,severe hepatitis,hepatocellular c

23、arcinoma,fatty liver of pregnancy et al.35肝癌肝昏迷医学知识讲座 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 prod

24、uction Portosystemic shuntGut-derived 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 fac

25、tors of hepatic encephalopathy36肝癌肝昏迷医学知识讲座Glutamine NH3+Glutamate Urea,protein NH3+CO2Intestinal ammonia:Ammonialiver（一）（一）Neurotoxin NH3+H+NH4+pH6pH6urea,glutamine37肝癌肝昏迷医学知识讲座1.Interfere with brain cells TCA cycle.2.Increased brain neutral amino acids such as tyrosine,phenylalanine,tryptophan.3.A

26、strocytes increased glutamate and neuronal cell swelling.4.Ammonia can also directly interfere with the electrical activity of neurons.Ammonia inhibited the central nervous system:38肝癌肝昏迷医学知识讲座（二）（二）Changes in neurotransmitterNormal neurotransmitter:dopamine,norepinephrine.1.False neurotransmitter:T

27、yrosine Tyramine hydroxyl tyramine Phenylalanine Phenylethylamine Phenylethanolamine 39肝癌肝昏迷医学知识讲座2.GABA/BZ3.Tryptophan Tryptophan Brain5-hydroxytryptamine,5-HIAA Inhibited brain function 40肝癌肝昏迷医学知识讲座Pathology Acute HE patients no obvious anatomical abnormalities in brain,mainly secondary brain ede

28、ma 41肝癌肝昏迷医学知识讲座 Clinical manifestations The manifestations of the primary disease.The manifestations of the central nervous system.42肝癌肝昏迷医学知识讲座Phases The level of consciousness Pounce-like tremor EEG NO.1 phases mild changes in normal precursor personality and behavior phases NO.2 phases conscious

29、ness disorders,sleep 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 Clinical manifestations Minimal hepatic encep

30、halopathy:None of the symptoms and signs.Psychological aptitude test unresponsive.44肝癌肝昏迷医学知识讲座 Laboratories and equipment inspection Ammonia Electrolyte acid-base imbalance,hypokalemia,metabolic alkalosis Evoked Potentials EEG Psychological Aptitude Test Imaging 45肝癌肝昏迷医学知识讲座Diagnosis Serious liver

31、 disease +precipitating factors +Neuropsychiatric symptoms +Exclude other diseases 46肝癌肝昏迷医学知识讲座Differential diagnosis Cerebrovascular accident:Age,high blood pressure,Hemiplegia Diabetic coma:glucose ,urine glucose,urine ketone(+)Uremia:History of kidney disease,edema,anemia,high blood pressure,uri

32、nary changes,renal function damaged Poisoning 47肝癌肝昏迷医学知识讲座Treatment 一、一、The elimination of incentives and treatment of primary disease:1.Avoid sedatives and drugs which damaged liver function.2.Hemostasis,removal of intestinal hemorrhage.3.Correct water and electrolyte acid-base disturbance.4.Preve

33、ntion and control infection.5.Improve liver function.48肝癌肝昏迷医学知识讲座Treatment二、二、Reducing intestinal ammonia production and absorption:1.Restricted protein diet 2.Intestinal cleansing 3.Lactulose,lactitol 4.Inhibited bacterial growth 5.Probiotic preparations 49肝癌肝昏迷医学知识讲座 Treatment 三、三、To promote meta

34、bolism of ammonia in vivo:1.L-ornithine-L-aspartate(OA)2.Ornithine-ketoglutarate 3.Sodium benzoate 4.Glutamate 5.Arginine 四、四、GABA/BZ receptor antagonist flumazenil composite.五、五、Antagonist to false neurotransmitter 50肝癌肝昏迷医学知识讲座Treatment六、六、other treatment 1.Artificial liver.2.Liver transplantation

35、.3.Prevention and treatment of cerebral edema,and protecting brain cells function.4.To maintain airway.51肝癌肝昏迷医学知识讲座小小 肝肝 癌癌52肝癌肝昏迷医学知识讲座大大 肝肝 癌癌53肝癌肝昏迷医学知识讲座大大 肝肝 癌癌54肝癌肝昏迷医学知识讲座大大 肝肝 癌癌55肝癌肝昏迷医学知识讲座大大 肝肝 癌癌56肝癌肝昏迷医学知识讲座57肝癌肝昏迷医学知识讲座58肝癌肝昏迷医学知识讲座59肝癌肝昏迷医学知识讲座61肝癌肝昏迷医学知识讲座62肝癌肝昏迷医学知识讲座63肝癌肝昏迷医学知识讲座64肝癌肝昏迷医学知识讲座65肝癌肝昏迷医学知识讲座66肝癌肝昏迷医学知识讲座67肝癌肝昏迷医学知识讲座68肝癌肝昏迷医学知识讲座69肝癌肝昏迷医学知识讲座70肝癌肝昏迷医学知识讲座71肝癌肝昏迷医学知识讲座结结 节节 型型 肝肝 癌癌72肝癌肝昏迷医学知识讲座73肝癌肝昏迷医学知识讲座74肝癌肝昏迷医学知识讲座75肝癌肝昏迷医学知识讲座