2002年度《消化病诊断和治疗》节目单二

0肝瘩的栓塞治疗肝疡的检塞治疗机制肝疮的检塞治疗的适应证、禁忌证肝疮的栓塞治疗方法肝疮的栓塞后注意事项肝痛的栓塞治疗后常见并发症及处理肝痛的检塞治疗的疗效评价丙型病毒性肝炎与自身免疫性肝炎药物诱导的自身免疫性肝炎自身免疫性肝炎的免疫抑制治疗肝移植后复发性自身免疫性肝炎OHBV相关性肝病肝移植的诊断和治疗.HBV相关性肝病肝移植的适应证与手术时机HBV相关性肝病肝移植HBV相关性肝病肝移植术后乙型肝炎复发、HBV再感染的后果与诊断移植肝乙型肝炎与排斥反应的病理学鉴别HBV相关性肝病肝移植术后预防乙型肝炎复发的…     

病毒性肝炎复发患者再次肝移植的预后

目的 分析病毒性肝炎复发导致移植肝肝功能衰竭患者再次肝移植的预后情况.方法 回顾性分析2003年1月20日至2012年11月20日215例再次肝移植患者的临床资料,比较18例因肝炎复发(其中丙型肝炎8例,乙型肝炎10例)再次肝移植患者与115例因胆道并发症再次肝移植患者的移植肝的生存情况,比较丙型肝炎与乙型肝炎复发患者首次肝移植后的移植肝失功情况和再次肝移植的生存情况.预后分析采用Kaplan-Meier方法绘制生存曲线进行比较.结果 215例再次肝移植患者的病因中,胆道并发症最多,为115例(53.5％),肝炎复发18例(8.4％).肝炎复发与胆道并发症患者第2个移植肝的生存率比较差异无统计学意义(P=0.543).部分丙型肝炎复发导致的移植肝失功在首次肝移植后早期(3个月内)即出现,乙型肝炎复发患者的移植肝失功几乎全出现在首次肝移植2年后.8例丙型肝炎复发患者中,5例第2个移植肝存活＞1年,10例乙型肝炎复发患者的第2个移植肝均存活＞1年,两者比较差异无统计学意义(P=0.060).结论 肝炎复发患者与胆道并发症患者的再次肝移植预后相似.乙型肝炎复发再次肝移植患者预后良好.     

肝移植后慢性移植肝失功的病因诊断和治疗18例

目的:探讨肝移植后慢性移植肝失功的病因诊断和治疗.方法:回顾性分析我院1996-01/2006-12完成的291例原位肝移植中18例肝移植后慢性移植肝失功患者的临床资料,总结肝移植后慢性移植肝失功的病因及诊断和治疗.结果:18例肝移植后慢性移植肝失功患者发生反复胆道感染2例、胆管广泛胆泥2例、胆管吻合口狭窄1例、胆管非吻合口狭窄4例、乙型肝炎复发3例、丙型肝炎复发1例、胆汁性肝硬化1例、肝动脉狭窄1例、巨细胞病毒(CMV)感染1例和慢性排斥反应2例.通过各种内科支持治疗、介入治疗或再次肝移植.11例好转,4例病情反复,3例死亡.结论:根据肝移植后慢性移植肝失功的不同病因,可采取不同的治疗手段;对于不可逆转的移植肝功能衰竭,应进行再次肝移植.     

肝移植术后急性排斥反应的病理诊断--200例次肝穿刺活检的病理组织学分析

目的观察同种异体肝移值术后急性排斥反应病理组织学表现,探讨相关的病理鉴别诊断。方法对136例(200例次)同种异体肝移植术后肝组织穿刺活检明确诊断为急性排斥反应的病理组织学资料进行回顾性分析。结果同种异体肝移植术后的急性排斥反应病理组织学表现为：汇管区内炎细胞浸润136例(200例次);小叶间静脉和(或)中央静脉内皮炎116例(170例次);小叶间胆管上皮变性和(或)炎细胞浸润136例(200例次);肝细胞和毛细胆管淤胆103例(151例次);肝细胞水肿和气球样变性83例(126例次);肝细胞嗜酸性变和点、灶性坏死76例(161例次)。结论同种异体肝移植术后肝组织穿刺活检的病理组织学变化对急性排斥反应的诊断及术后各种并发症的鉴别诊断具有重要价值。     

甲型、乙型和非甲非乙型暴发性肝炎的临床与预后的差异

本文观察暴发性肝炎(暴肝)73例,其中甲型肝炎(HA)23例(31.5％),乙型肝炎(HB)18例(24.7％),非甲非乙型肝炎(NANB)32例(43.8％)。三组病例在年龄、性别上无显著差异。无1例对巨细胞病毒、EB病毒和单纯疱疹病毒等可能引起肝炎的其它病毒     

乙型肝炎表面抗原阳性供肝在肝移植中的应用

目的 探讨HBsAg阳性供肝在成人肝移植中应用的安全性及其对患者预后的影响.方法 回顾性分析本中心2007年1月至2010年2月23例接受HBsAg阳性供肝的成人肝移植患者临床资料,患者全部为男性,中位年龄42.5岁(29 ～ 61岁),原发病均为乙型肝炎相关终末期肝病,其中13例术前HBsAg、HBeAg和抗-HBc为阳性,10例术前HBsAg、抗-HBe和抗-HBc为阳性.供体HBsAg均为阳性,术后口服恩替卡韦0.5mg,1次/d,静脉滴注乙型肝炎免疫球蛋白(HBIG),术后1周每天滴注2000 IU.术中及术后采用无激素的免疫抑制方案,术后第1、7、14、21、30天检测患者血清HBsAg、抗-HBs、HBeAg、抗-HBe、抗-HBc、HBV DNA水平,并行肝脏彩色多普勒超声检查.1个月后每月检测及检查1次,并记录患者术后肝功能、肾功能、急性排斥反应、感染、血管并发症、胆道并发症、乙型肝炎复发、肿瘤复发及患者生存等数据.结果 围手术期2例患者死于严重肺部感染,其余21例患者随访至2010年12月(10 ～ 38个月),所有患者术后乙型肝炎未转阴,其中1例患者于术后5个月因胆道缺血再次行肝移植,3例肿瘤患者分别于术后9、14、18个月死于肿瘤复发,18例患者生存,肝功能良好,彩色多普勒超声监测显示肝脏形态、质地良好,HBV DNA监测显示其均为阴性.随访期内,23例患者的生存率为78.3％(18/23),移植肝生存率为73.9％(17/23),未出现乙型肝炎复发所致的肝功能异常、移植肝丢失和病死患者.结论 HBsAg阳性供肝可以安全地应用于乙型肝炎相关终末期肝病的患者.     

肝移植慢性排斥反应早期病理组织学分析

目的通过观察慢性排斥反应导致同种异体肝移植术后移植肝功能丧失患者的连续肝穿刺活检病理组织学资料,探讨慢性排斥反应早期的病理组织学表现.方法分析18例由于慢性排斥反应导致移植肝功能丧失患者连续76次肝穿刺活检的病理组织学资料.结果移植肝慢性排斥反应早期53例次活检中出现小叶间胆管损伤50例次(94.34%);小叶中央坏死性炎症48例次(90.57%);汇管区炎细胞浸润42例次(79.25%).此外,还有小叶间动脉损伤、肝细胞变性和淤胆以及纤维组织增生等病理组织学表现.结论同种异体肝移植术后肝穿刺活检中出现小叶间胆管损伤、小叶中央坏死性炎症和汇管区炎细胞浸润对慢性排斥反应的早期诊断具有重要价值.     

婴儿巨细胞病毒性肝炎临床病理分析

目的 分析婴儿巨细胞病毒(CMV)性肝炎的临床病理表现,以提高对该病的认识.方法 30例CMV性肝炎患儿临床资料分析并行肝穿刺活组织检查,光镜及电镜观察肝细胞的特征性改变.结果 婴儿CMV肝炎的临床主要表现为黄疸、肝脾肿大及伴发症状、体征;实验室检查肝功能异常、CMV相关病毒检查阳性;影像学检查显示肝脏增大;肝穿刺活组织光镜观察显示肝细胞变性,坏死、纤维化、淤胆等一般性损伤,特征性改变为肝细胞内病毒包涵体、巨细胞样肝细胞形成和局部"假腺管"样排列,电镜观察找到病毒颗粒.结论 CMV DNA和抗体检查对于婴儿CMV性肝炎的诊断应用有限,疑似病例的肝穿刺活组织检查有助于明确CMV性肝炎的诊断.     

一种简便、实用的铜染色法在Wilson病肝穿病理诊断中的应用

目的探讨红氨酸铜染色法(rubeanicacidcopperstaining)的关键技术环节、注意事宜及在Wilson病肝穿病理诊断中的应用。方法应用红氨酸铜染色法对58例Wilson病肝穿组织作铜染色,并进行效果评价,以10例原发性胆汁性肝硬化(PBC)、10例其他胆汁淤积性肝病、10例慢性乙型病毒性肝炎及5例健康肝移植供体肝组织作对照。结果红氨酸溶液配制、恒温过夜及防组织脱片等是保证红氨酸铜染色效果的关键环节;本文58例Wilson病穿刺肝组织中87.3%铜染色阳性,表现为肝细胞内较弥漫性粗大铜颗粒沉积,而对照组PBC、其他胆汁淤积性肝病及慢性乙型病毒性肝炎肝组织内仅有少数肝实质细胞内检出疏细铜颗粒,5例健康肝移植供体肝组织内均未见红氨酸铜染色阳性着色。结论红氨酸铜染色法是一种用于遗传代谢性肝病组织铜显示与评价的简便、实用性染色方法。     

666例肝穿活体组织检查病理分析

目的 分析肝穿活检肝组织病理及临床检查结果，了解其中各种肝病的构成比，提高临床诊疗水平，减少漏诊及误诊。方法 采用1秒钟快速肝穿刺活检术，肝组织行HE、Masson染色；对病毒性肝炎、脂肪肝的符合率进行比较。结果 经病理证实ASC及病毒性肝炎占96．5％，脂肪肝占1.9％，其它肝病占1．9％。病毒性肝炎临床与病理诊断符合率为71．9％。病毒性肝炎合并脂肪肝共48例，病理检查前经B超证实仅有7例。结论 ASC及病毒性肝炎仍居住院患者之首；无症状乙型肝炎病毒携毒者，病毒性肝炎轻中重度、重型肝炎、肝硬化之间临床与病理学检查诊断一致性还存在差异。病毒性肝炎是否合并脂肪肝须行肝组织病理才能明确。非病毒性肝炎及其它肝病行病理学检查有助于减少误诊。提示临床诊断与病理诊断相结合，有助于提高各种肝病的诊断准确率。     

Liver biopsy in evaluation of complications following liver transplantation

AIM: To analyze the role of liver biopsies in differential diagnosis after liver transplantation. METHODS: A total of 50 biopsies from 27 patients with liver dysfunction out of 52 liver transplantation cases were included. Biopsies were obtained 0-330 d after operation, in which, 44 were fine needle biopsies, another 6 were wedge biopsies during surgery. All tissues were stained with haemotoxylin-eosin. Histochemical or immunohistochemical stain was done. RESULTS: The rate of acute rejection in detected cases and total transplantation cases was 48.2% and 25.0%, chronic rejection rate in detected cases and total transplantation cases was 14.8% and 7.7%, preservation-reperfusion injury in detected cases and total transplantation cases was 25.9% and 13.5%, hepatic artery thrombosis rate in detected cases and total transplantation cases was 11.1% and 5.8%, intrahepatic biliary injury rate in detected cases and total transplantation cases was 7.4 % and 3.8%, CMV infection rate in detected cases and total transplantation cases was 3.7% and 1.9%, hepatitis B recurrence rate in detected cases and total transplantation cases was 3.7% and 1.9%, the ratio of suspicious drug-induced hepatic injury in detected cases and total transplantation cases was 11.1% and 5.8%. CONCLUSION: Acute rejection and preservation-reperfusion injury are the major factors in early liver dysfunction after liver transplantation. Hepatic artery thrombosis and prolonged cold preservation may result in intrahepatic biliary injury. Acute rejection and viral infection may involve in the pathogenesis of chronic rejection. Since there are no specific lesions in drug-induced hepatic injury, the diagnosis must closely combine clinical history and rule out other possible complications.     

Histopathology of Post-Transplant Liver Biopsies,the First Report From Iran

Background

Evaluation of a transplanted liver by Imaging techniques and enzyme changes is sensitive to hepatocellular or biliary problems, but in most instances liver allograft biopsies are performed in order to find out the final reason for these changes.

Objectives

It’s been about 17 years (with more than 1326 cases) since the first liver transplantation in the Namazi Hospital of Shiraz University of Medical Sciences while during the last five years the number of post liver transplant biopsies have increased. Until now there has been no report of the pathological results of post liver transplant needle biopsies from Iran.

Materials and Methods

During the last 5 years, there have been 382 post liver transplant biopsies. We studied the clinical charts and pathological results of all needle biopsies.

Results

A total of 382 needle biopsies were performed on 287 patients aged between 1 and 64 years old. The earliest specimen was obtained within the first few hours following transplantation, and the last was gathered 3209 days (261 ± 523) post-transplantation. Acute rejection was the most common diagnosis, which occurred in 180 (47%) of specimens. Among other complications were vascular problems (8.6%), preservation/reperfusion (I/R) injury (7%), chronic rejection (5.2%), biliary injury/obstruction (3.4%), recurrence of primary disease (2.6%), drug-induced hepatic injury (1.8%), cirrhosis (1.6%), sepsis (1.4%), cytomegalovirus hepatitis (1.4%), post-transplantation lymphoproliferative disease (1%) and Venous outflow obstruction (0.5%).

Conclusions

The most common pathological diagnosis of post-transplant liver needle biopsies has been acute rejection, followed by ischemia due to hepatic artery thrombosis, preservation/reperfusion injury, and chronic rejection.     

原位肝移植术后高胆红素血症的原因及处理

目的 探讨原位肝移植术后高胆红素血症的原因和治疗手段.方法 对2004年1月-2005年12月中山大学附属第一医院施行的368例同种原位肝移植患者的临床资料进行回顾性分析.结果 368例肝移植患者中累计发生高胆红素血症396例次,其发生原因分别为术前高胆红素血症183例(46.2%,183/396),单纯供肝热、冷缺血再灌注损伤46例(11.6%,46/396),急性排斥反应36例次(9.1%,36/396),胆道并发症36例发生高胆红素血症78例次(19.7%,78/396),血管并发症24例(6.1%,24/396),原发病复发23例(5.8%,23/396)和药物毒性反应6例(1.5%,6/396);均予针对病因为主的综合治疗,并辅以护肝、退黄疸等对症治疗.结论 肝移植术后高胆红素血症的病因多样而复杂,临床上应首先明确其病因,及时作出正确诊断,并选择合理的治疗方案,才能使移植患者症状缓解、获得长期生存.     

肝移植术后丙型肝炎复发受者肝组织病理学特征分析

目的：探讨肝移植术后丙型肝炎复发时受者肝组织病理学特征。方法收集28例明确诊断为肝移植术后丙型肝炎复发患者的54份肝组织病理学资料,回顾性分析丙型肝炎复发时肝组织病理学特点。结果肝移植术后丙型肝炎复发的主要病理学特点是：肝细胞变性和坏死,汇管区以淋巴细胞为主的炎性细胞聚集,以及较早出现的肝纤维化,同时部分病例合并有排斥反应和药物性肝损伤的组织学特点;移植术后远期（大于12 m）丙型肝炎复发者肝纤维化程度较近期（小于12 m）复发者严重[肝纤维化计分为（1.82±1.12）对（1.13±1.08）,P＜0.05;不同丙型肝炎病毒基因型导致的丙型肝炎在病理学表现上的差异无统计学意义;合并排斥反应及药物性肝损害患者肝炎活动度评分分别为（2.32±0.64）和（2.33±0.88）,显著高于无合并组患者（1.64±0.59）,（P＜0.05）。结论肝移植术后丙型肝炎复发时有特征性的肝脏病理学改变,肝组织病理学检查对移植术后丙型肝炎复发的病情判断具有重要的价值。     

186例药物性肝损伤组织病理学及临床特征分析

目的探讨药物性肝损伤的组织病理学特点及临床特征,为早期诊治提供帮助。方法回顾性分析186例经肝活组织穿刺病理学诊断的药物性肝损伤患者的用药史、病理特点、临床表现、生化、血清学标志以及治疗转归等。结果引起药物性肝损伤前3位的药物是中药91例（49％）、抗生素41例（22％）、解热镇痛药23例（12．4％）;临床分类：药物性肝功能衰竭8例（4．4％）、急性药物性肝损伤93例（50％）、慢性药物性肝损伤83例（44．6％）、药物性肝硬化2例（1．1％）;临床分型：肝细胞损伤型98例（52．7％）、胆汁淤积型35例（18．8％）、混合型55例（29．6％）。病理学特征主要表现为：肝细胞坏死、汇管区扩大、肝细胞脂肪变性、汇管区或窦周混合炎细胞浸润、嗜酸性粒细胞浸润、肝细胞胆汁淤积、肝细胞凋亡、可见吞噬色素的Kuffer细胞。治愈79例（42．5％）,好转102例（54．8％）,无效5例（2．7％）。无一例患者死亡或病情恶化。结论引起药物性肝损伤的首位药物为中药,临床表现无特异性,但组织病理学改变有一定特征。     

Biopsy of the right ventricle endomyocardium. Experience at the Santa Marta Hospital

OBJECTIVE: To review the experience of Santa Marta Hospital in the right ventricle endomyocardial biopsy technique. DESIGN: Retrospective analysis of the results, diagnostic value and complications of the myocardial biopsies performed between April/87 and March/90. PATIENTS AND INTERVENTIONS: 255 biopsies were performed; 221 on 13 patients submitted to orthotopic heart transplantation (nine male and four female, aged between 21 and 55 years old), and the remaining on 34 patients (22 male and 12 female aged between 15 and 64 years old), mainly on cardiomyopathies. RESULTS: In 221 biopsies performed in heart transplant recipients, we found: 109 with no rejection, 21 with moderate rejection, 57 with mild rejection and only one case showed severe rejection. In this group six biopsies were considered inconclusive. In the group of patients not submitted to heart transplantation the histological findings were inespecific in the great majority of the cases. In the 255 procedures four complications were detected (1.56%), with no mortality; two hemopericardium with tamponade (0.78%), one pneumothorax and one atrial fibrillation. CONCLUSIONS: Endomyocardial biopsy essential for histological diagnosis of acute rejection following heart transplantation has revealed to be a save procedure with a small number of complications.     

Diagnosis of drug-induced liver injury in Japanese patients by criteria of Consensus Meetings in Europe

Eighty-five Japanese patients with drug-induced liver injury were assessed by criteria of Consensus Meetings in Europe on causality assessment of drug-induced liver injury. Histopathological investigation was performed for all patients to confirm the diagnosis. We divided these patients into two groups by the date of disease onset. Cases before 1989 were defined as past cases, and those after 1990 as recent cases, because the clinical-pathological characteristics of drug-induced liver injury have changed due to the ability to diagnose hepatitis C virus infection since 1990. Fifty-seven patients with drug-induced liver injury were enrolled as past cases, and 28 as recent cases. For past cases, the results of assessment by the criteria of Consensus Meetings in Europe were as follows: ‘very likely’: 14 patients (25%), ‘likely’: 23 patients (40%), ‘possible’: 15 patients (26%), ‘dubious’: five patients (9%), and ‘unlikely’: none (0%). For recent cases, the results were as follows: ‘very likely’: six patients (22%), ‘likely’: 14 patients (42%), ‘possible’: six patients (22%), ‘dubious’: two patients (7%), and ‘unlikely’: none (0%). There were no differences between the past and recent cases in distribution of assessment. More than 90% of patients were assessed as ‘possible’ or more, and the remaining seven patients were assessed as ‘dubious’. No patients were assessed as ‘unlikely’. Five of seven patients assessed as ‘dubious’ had long-term cholestasis, and two had alcohol consumption. These results indicated that the criteria of Consensus Meetings in Europe were useful for diagnosing drug-induced liver injury in Japanese patients.     

Diagnostic value of transjugular liver biopsy in liver transplant recipients

Liver biopsy after hepatic transplantation essential for the correct diagnosis of grant dysfunction. However, seriously imparied coagulation or massive ascites contraindicate percutaneous liver biopsy. In these cases transjugular liver biopsy may be valid alternative. in this study the efficacy, feasibility and safety of 69 transjugular biopsies carried out in 56 liver transplant recipients are evaluated. The suprahepatic veins were catheterized in 100% of the patients and histological samples were obtained in 63 (91.3%). The number of portal tracts was greater than six in 20.6% of the samples, lower than three in 35% and oscillated between four and six in 44%. The specimens obtained were sufficient for diagnosis in 82.5% of the patients, the overall diagnostic efficacy being 75.4%. The most common histological diagnosis (28.8%) was graft damage, while rejection represented 7.7%. Only one patient (1.18%) suffered a serious complication after transjugular biopsy. Transjugular biopsy is feasible and effective in liver transplant recipients with severely imparied coagulation.     

肝移植后乙型肝炎复发的临床与病理特点分析

目的探讨我国乙型肝炎（乙肝）相关性肝移植有效预防后，乙肝复发的临床规律、特点及与病理改变的相关性。方法回顾性分析2007年6月-20HD9年8月我院移植内科收治的16例确诊为术后乙肝复发患者的临床和病理资料。结果复发时间为术后4～48（21．2±13．2）个月。16例中有12例在服用拉米夫定8～46个月出现YMDD变异，2例肿瘤复发行化疗后乙肝复发，2例在服用拉米夫定2年停用后复发。临床类型包括：①纤维化胆汁淤积型肝炎1例，病情凶险，病死率高。②慢性肝炎15例，其中轻度慢性肝炎8例，中度慢性肝炎6例，重度慢性肝炎1例；病理诊断为轻、中度的分别有13、2例。11例临床与病理诊断相符，其中8例临床与病理均诊断为慢性肝炎轻度。4例伴BanffI-I级急性排异反应。3例伴轻度药物性肝损伤。早期抗病毒治疗后预后良好。结论肝移植后乙肝复发多发生在移植术后2年内。YMDD变异是肝移植后乙肝复发的主要原因，化疗亦易致乙肝复发。肝移植术后应长期抗病毒治疗。乙肝相关性肝移植后乙肝复发病毒载量高，临床表现及病理损害重。     

The usefulness of transjugular hepatic biopsy in the evaluation of liver disease in candidates for heart transplantation

Heart transplantation is a universally accepted procedure in the treatment of terminal heart diseases. However, the presence of advanced liver disease in the potential receptors represents a contraindication for heart transplantation. On the other hand, the true diagnosis of liver disease not secondary to heart disease may be difficult requiring confirmatory liver biopsy. Nonetheless, percutaneous liver biopsy may be difficult to perform due to presence of coagulation alterations, marked dilatation of the hepatic veins, etc. The aim of this study was to evaluate the efficacy and safety of transjugular hepatic biopsy in the presence of severe coagulopathy in potential heart transplantation receptors with suspicion of liver disease and contraindication of percutaneous liver biopsy. Over a 9-year period, 350 potential heart transplantation patients were evaluated. In 23 patients (6.7%) transjugular hepatic biopsy was performed with aspiration needle followed by a hemodynamic study in 17 cases. The transjugular hepatic biopsy was completed in 22 cases (95.6%) with adequate material for the diagnosis being obtained in 21 (91.3% of the total cases indicated). Histologic study showed significant inflammatory infiltrates or alteration of the hepatic architecture in 4 patients (18%), all being positive for some viral markers (AgHBs or anti-HCV). The obtaining of a certain histologic diagnosis modified the consideration of liver disease as a definitive contraindication and allowed the performance of heart transplantation in 17 patients (73.9%). No complications were observed in association with the procedure. The transjugular hepatic biopsy is a feasible, effective and safe alternative for obtaining liver tissue in patients under evaluation for heart transplantation with suspicion of severe liver disease. The establishment of a correct histologic diagnosis may modify the clinical decision in an important number of patients.