自身免疫性肝炎和原发性胆汁性肝硬化重叠综合征17例

自身免疫性肝病是一组具有一定自身免疫基础的炎症性肝病,包括自身免疫性肝炎(Autoimmune hepatitis,AIH),原发性胆汁性肝硬化(Primary biliary cirrhosis,PBC)、原发性硬化性胆管炎(Primary sclerosing cholangitis,PSC)等,其共同特点是在肝脏出现病理性炎症损伤的同时,血清中     

Comparative quantitative evaluation of hepatic clearance of diethyl-IDA and para-butyl-IDA in jaundiced and non-jaundiced patients

A method for comparative measurement of hepatic clearance of different hepatobiliary agents is described and the clinical use of diethyl-IDA and parabutyl-IDA is discussed. The study was performed with both radiopharmaceuticals in 13 patients with hepatobiliary disease with serum bilirubin ranging from 0.3 to 16.4 mg/100 ml.Diethyl-IDA is preferable for a qualitative evaluation of hepatobiliary disease, because of its higher hepatic clearance and faster biliary excretion rate. Parabutyl-IDA is superior for measuring the hepatocytic uptake function, due to the low urinary excretion and the absence of an apparent re-entry from liver to plasma, even in patients with obstructive jaundice. In contrast, an appreciable re-entry can be demonstrated for diethyl-IDA.     

肝硬化结节与微小肝癌的彩超诊断与鉴别

目的:探讨联合应用二维超声、彩色多普勒、频谱多普勒、彩色能量多普勒等多种超声检查技术对肝硬化结节与微小肝癌的早期诊断与鉴别的临床意义。方法:对696例结节性肝硬化病人的临床检查中小于2 cm的异常回声结节进行进一步检查,筛选出微小肝癌结节,并与肝硬化结节鉴别。结果:肝硬化结节有细小而规则的结节及粗大的不规则的结节,而周边呈网格状增高回声,回声可较细而整齐,围绕不规则低回声区,境界清晰、中间类似正常肝组织回声,并有小血管的结构可见,周边无血流信号,无彩色多普勒能量成像;微小肝癌直径小于2 cm,癌结节的数目少,多为单发,76.5%呈低回声,病灶多为圆形或类圆形,边缘整齐,境界清楚,回声均匀,癌结节周边伴有声晕或后方伴增强效应,82.4%癌结节周边可见彩色血流环绕,内部见条状、树枝状、网篮状等彩色血流信号[5.4]。癌结节内血流呈高阻力动脉血流为主,88.2%的癌结节可出现彩色多普勒能量成像。结论:微小肝癌的早期诊断是早期治疗和改善预后的首要条件。联合应用多种超声技术可提高对微小肝癌的检出。超声检查无创伤、无痛苦、简便、可重复,目前已成为肝癌筛选检查的首选方法。     

Calculation of survival rates by the life table and other methods.

The last few years have seen the introduction of medical statistics into the curriculum for MB, BS and for the FFR. Also, an increasing number of clinical trials have considered statistics at the planning stage of the trial, rather than only at the end point. However, there is one particular aspect of medical statistics which has consistently been neglected, namely, technique in calculating survival rates for cancer patients. All too often, a direct method of calculation, see section 3.1, is used when a life table method would provide a better estimate. The life table, or actuarial method, was first described in a medical context by Greenwood (1926), and later by Merrell and Shulman (1955) and Cutler and Ederer (1958). It has however, not been explained in detail in a British journal. The objective of the present paper is to remedy, this fact so that it can be used more widely in the future in preference to a direct method.     

肝炎、肝纤维化和早期肝硬化阶段肝脏CT灌注实验动物的初步研究

目的探讨螺旋CT灌注成像对肝炎、肝纤维化和早期肝硬化诊断的应用价值。方法分别对二乙基亚硝胺诱导的14只肝炎、肝纤维化和早期肝硬化时期的Wistar雄性大鼠和14只正常对照组大鼠行单层动态螺旋CT肝脏灌注扫描,用肝脏灌注分析软件取得不同病变阶段肝实质的灌注参数,并与病理改变作对照研究和统计学分析。结果时间密度灌注曲线合乎数据分析要求。自实验组肝炎到早期肝硬化时期,正常对照组的肝动脉血流(hepaticarterialflow,HAF)呈轻度下降趋势,平均通过时间(meantransittime,MTT)以及肝血流量(bloodflow,BF)、肝血容积(bloodvolume,BV)都有升高趋势;实验组HAF呈升高趋势,肝炎期、肝纤维化期和早期肝硬化期的平均HAF值分别为(0.33±0.23)%、(0.55±0.13)%、(0.70±0.24)%;MTT呈明显延长,3个病变阶段分别为(6.60±2.39)s、(11.41±3.92)s、(15.02±5.21)s;BV和BF都有下降,从肝炎期的(18.05±3.27)ml·100g-1和(152.84±59.12)ml·100g-1·min-1降为肝硬化期的(9.51±3.61)ml·100g-1和(117.59±78.66)ml·100g-1·min-1。统计结果显示实验组在不同时期的HAF和MTT的差异均有统计学意义(P值均<0.05);肝炎和早期肝硬化、肝纤维化和早期肝硬化阶段各实验组间BV和BF的差异有统计学意义(P值均<0.05);肝炎和肝纤维化间差异无统计学意义。肝炎阶段相应灌注层面肝脏的病理改变主要为肝细胞肿大;肝纤维化和早期肝硬化阶段主要是窦隙毛细血管化、血管外Disse间隙胶原沉积。结论CT肝脏灌注扫描能反映肝炎、肝纤维化和早期肝硬化的一些血液动力学改变。动态的肝脏血流灌注参数改变应对临床的早期诊断、治疗和疗效观察有重要价值。     

Diagnosis of pyogenic hepatic abscesses by percutaneous transhepatic cholangiography.

Four of 83 patients undergoing percutaneous transhepatic cholangiography were demonstrated to have hepatic abscesses communicating with the biliary tract. The abscesses resulted from obstruction of the common bile duct. The etiologies of the obstructions were chronic pancreatitis, recurrent cholangiocarcinoma. Radiographic demonstration of suppurative cholangitis is associated with a very poor prognosis.     

99mTc-HEPIDA hepatic clearance as a diagnostic tool: usefulness of plasma and hepatic clearance for assessment of hepatic parenchyma performance

Plasma clearance of (99m)Tc-HEPIDA (Cl(Pl)) has been used for two decades for assessment of liver function in patients with diseases of this organ. A specific determination of (99m)Tc-HEPIDA liver clearance (Cl(Hp)) has been developed that provides more direct possibility to evaluate performance of liver parenchyma. Both tests have been studied in healthy volunteers of varying age (48 individuals) and in 83 patients with varying degree of liver damage. The liver damage has been evaluated on the basis of 5 biochemical tests (AspAT, ALAT, GGTP, bilirubine serum concentration, proteinogram) and a score system used for total impairment, which was calculated for each patient. Normal range of Cl(Pl) and Cl(Hp) was determined from a study on healthy individuals (volunteers). The results seem independent of age, but show sex differences. The following values (mean +/- SD) of Cl(Hp) were found in males and females of: (181 +/- 31) ml//min/1.73 m(2) and (158 +/- 22) ml/min/1.73m(2), and of Cl(Pl) were (224 +/- 33) ml/min/1.73 m(2) and (202 +/- 25) ml/min/1.73 m(2) respectively. Accepted lower boundaries of both quantities (mean -2SD) are 115 ml/min/1.73 m(2) and 150 ml/min/1.73 m(2) correspondingly. Negative correlation of individual values of both clearances in all patients with individual score of liver damage were highly significant and correlation coefficients obtained were higher for Cl(Hp) (r = -0.63) than those for Cl(Pl) (r= -0.56). Factorial analysis was performed with the intention of seeing which of the studied factors had the highest factor loading for parenchyma performance that was assumed as the common factor responsible for correlations. The highest value was obtained for hepatic clearance (Cl(Hp)) of (99m)Tc-HEPIDA. In conclusion this quantity seems highly promising as a clinically useful test for assessment of liver performance, both in screening for liver damage and for monitoring of organ conditions during therapy and follow-up of patients.     

CT诊断日本血吸虫病肝硬变

The CT findings of hepatic cirrhosis caused by schistosomiasis Japonica comprise in addition to common manifestations of cirrhosis, the peculiar septal and capsular calcifications resulting in a map-like appearance. In advanced cases, septal fibrotic scar retracts the surface of liver and forms shallow notches, giving rise to pseudolobulated contour. Carcinoma may complicate hepatic schistosomiasis japonica with cirrhosis, but large ova-nodule can mimic cancer on CT image.     

CT and MRI of siderotic regenerating nodules in hepatic cirrhosis.

The demonstration by CT of siderotic regenerating liver nodules in cirrhosis was evaluated and compared with that of MR imaging retrospectively in 27 patients with histologically diagnosed hepatic cirrhosis. Only in one of the two patients with marked iron deposits in regenerating nodules did CT demonstrate multiple high density nodules. In the other patient with marked iron deposits and in seven of the nine patients with moderate iron deposits, the liver parenchyma on CT was demonstrated as heterogeneous and of slightly high density without focal nodules. In 8 patients with mild to moderate iron deposits and in the 10 with no iron deposits, the liver parenchyma was homogeneous on CT. Multiple low intensity nodules in the liver were seen on fast low-angle shot (FLASH) MR images in all 17 patients with iron deposits in regenerating nodules. No low intensity nodules were seen on FLASH MR images in the 10 patients with no iron deposits. If there are iron deposits above a certain level, siderotic regenerating nodules may appear as nodules of high density on CT or as heterogeneous regions of high density liver parenchyma. Magnetic resonance is more sensitive than CT in demonstrating siderotic regenerating nodules.     

Alterations in liver blood flow and reticuloendothelial function in progressive cirrhosis in the rat

Cirrhosis of the liver was induced in rats by twice weekly inhalation of carbon tetrachloride in conjunction with sodium phenobarbitone administration. At sequential time intervals during induction, liver blood flow and extraction efficiency of colloid were assessed in order to elucidate changes in these parameters which occur with cirrhosis. Liver samples were also taken for histologic examination and graded for extent of disease. Initially there was a fall in extraction efficiency (and thus reticuloendothelial function), associated with early histologic change. Subsequently extraction efficiency recovered, as regeneration was observed on histologic specimens. From 4 wk and onward, blood flow gradually fell, as did extraction efficiency. These changes were associated with increasing severity of disease as demonstrated by histologic sections.     

Identification of hepatic cirrhosis by duplex doppler ultrasound value of the hepatic artery resistive index

Pulsed Doppler Ultrasound was used to analyze hepatic artery wave forms near the porta hepatis. The Resistive Index (RI) = [peak systolic frequency shift (A)--minimum diastolic frequency shift (B)]/[peak systolic frequency shift (A)] has been calculated from this information. Two populations have been compared; 30 fit hospital staff members, 23 male, 7 female, age mean 37 years and range 19 to 73 years, and 33 cirrhotic potential liver transplant recipients, 16 male, 17 female, age mean 48 years and range 11 to 78 years. The RI was successfully obtained in 94% of the potential transplant patients. There is a significant difference between the RI of the controls (mean = 0.72, SE = 0.2, n = 27) and the cirrhotics (mean = 0.82, SE = 0.2, n = 31), P less than 0.0001. Using a cut off of greater than 0.77 this index has a sensitivity, specificity and overall accuracy of 68%, 70% and 69% respectively.     

Diagnosis of sellar and parasellar lesions by computed tomography and other diagnostic modalities.

A review of 5,000 computed tomographic (CT) brain scans revealed 76 patients with proved pathology involving the sellar and parasellar areas. The overall diagnostic accuracy of CT scanning was 93.4%, whereas the accuracy of isotope scanning, angiography, and pneumoencephalography was 55.4, 81 and 100% respectively. The criteria used in making the diagnosis with CT scanning are listed. The results indicate that CT scanning is the initial diagnostic procedure of choice, but that other modalities, particularly angiography, are still required for more accurate evaluation in the majority of cases.     

Measurement of Gd-DTPA dialysis clearance rates by using a look-locker imaging technique

The exponential clearance rate constant, (k), and filtration fraction (FF) have been measured for dialysis of Gadoliniumdiethylenetriaminepentaacetic acid (Gd-DTPA) (Magnevist, Berlex, Wayne, NJ) solutions by using a Look-Locker imaging technique under conditions of flow. The measured values of k for the Baxter CA-50, CA-110, and CA-210 filters were 0.0037 ± 0.0003, 0.0057 ± 0.0017, and 0.0092 ± 0.0018 min⁻¹, respectively, for dialysis of 4.0 liters of aqueous Gd-DTPA solutions. The measured values of FF for the Baxter CA-110 and CA-210 filters were 0.060 ± 0.013 and 0.089 ± 0.015, respectively, for dialysis of aqueous Gd-DTPA at 350 ml/min. The k and FF measurements agree with values that use inversion recovery (IR) on static samples obtained by drawing aliquots of solution during the course of dialysis. This in vitro experiment suggests that accurate in vivo measurements of filtration fraction and glomerular filtration rate (GFR) may be possible.     

Diagnosis of gallbladder dyskinesia by quantitative hepatobiliary scintigraphy

AIM: The aim of the present study was to develop a new pharmacologic method during hepatobiliary scintigraphy by which patients with functional and organic forms of gallbladder (GB) dysfunction can be differentiated. METHODS: Quantitative hepatobiliary scintigraphy (QHBS) was performed on 31 patients with impaired GB motility selected by cerulein-augmented ultrasonography. Nineteen patients had acalculous biliary pain (ABP) and suspected GB dyskinesia, 6 patients had celiac disease, and 6 patients had type II diabetes mellitus. Sixty minutes after the isotope administration, 1 ng/bwkg/min cerulein (CCK10) was infused for 10 minutes, and then from the 90th minute, an equivalent dose of CCK10 was infused in the presence of 0.5 mg sublingual glyceryl trinitrate (GTN) in 12 or placebo in 7 consecutive patients. The GB ejection fraction (GBEF) was calculated repeatedly in time periods from 60 to 90 and from 90 to 120 minutes. RESULTS: In the majority of patients with ABP and suspected GB dyskinesia, CCK10 and GTN coadministration normalized the previously impaired GB-emptying. When the cumulative results of all 12 patients were calculated, we demonstrated significant differences (P=0.003) in the GBEF between the first (CCK10) versus the second (CCK10 plus GTN) stimuli: 19+/-11% versus 40+/-17%, respectively. In contrast, in 12 patients with celiac sprue and diabetes mellitus, no differences in the GBEF were detected when the first (CCK10 alone) versus the second (CCK10 plus GTN) stimuli was compared: 21+/-10% versus 22+/-13%, respectively. Finally, placebo and CCK10 coadministration in 7 consecutive patients with ABP and suspected GB dyskinesia did not influence the GBEF as compared with CCK10 alone: 13+/-9% versus 15+/-10%, respectively. CONCLUSION: GTN and CCK10 coadministration induces a significant improvement of the GBEF in patients with GB dyskinesia. The application of this new pharmacologic test during QHBS permitted the noninvasive separation of those patients with secondary impaired GB-emptying as a result of GB dyskinesia from those with primary forms of GB hypokinesia.     

联合手术治疗原发性肝癌并肝硬化门脉高压症18例

 目的 探讨肝肿瘤切除术联合门奇静脉断流术治疗原发肝癌并肝硬化门脉高压症的临床疗效。方法 肝肿瘤切除手术完成后,再行脾切除或脾动脉结扎、胃冠状静脉离断术。结果 手术均获成功,无死亡病例,经1a以上随访12例,均无呕血及黑便。结论 该术式具有1次手术治疗2种疾病的优点,术前肝功能评估和准备、术中术式的正确选择是手术成功的重要因素。     

Diagnosis of liver cirrhosis by transit-time analysis at contrast-enhanced ultrasonography

Purpose

The aims of this prospective study were to evaluate analysis of sulfur-hexafluoride-filled microbubble contrast agent (Sonovue) transit times as a tool for differentiating liver cirrhosis from the noncirrhotic stage of liver disease and to compare its performance with that of conventional B-mode and Doppler ultrasonography (US).

Materials and methods

Contrast-enhanced hepatic ultrasonography with the US contrast agent Sonovue was performed on 38 patients with diagnoses of hepatic cirrhosis based on unequivocal clinical signs or liver biopsy findings (Child-Pugh classes A in 19, B in 16 and C in three), 31 patients with noncirrhotic diffuse liver disease (biopsy confirmed) and 14 controls without diffuse liver disease. Time curves of hepatic-vein signal intensity were analysed using objective criteria to determine the time of enhancement onset (hepatic-vein arrival time) and peak enhancement (hepatic-vein peak enhancement). Accuracy in diagnosing cirrhosis was compared with that based on B-mode and Doppler data.

Results

Hepatic-vein arrival time in cirrhotic patients was significantly shorter (p<0.01) than in noncirrhotic (chronic liver disease and controls) patients. Peak enhancement times in these three groups were not significantly different. An arrival-time cutoff of 17 s distinguished cirrhotic from noncirrhotic patients with high accuracy (100% sensitivity, 93.3% specificity, positive and negative predictive values 92.6% and 100%, respectively) and excellent reproducibility (kappa coefficients of 1.0 and 0.93 for intraand interobserver agreement). Contrast-enhanced US showed better sensitivity than the B-mode and Doppler data.

Conclusions

Analysis of the time of onset of US contrast enhancement of the hepatic vein appears to be a potentially useful noninvasive supplement to conventional sonography and Doppler in the follow-up of patients with chronic diffuse liver disease.