硬化型肝癌与肝内肿块型胆管癌的影像征象及病理学对比分析

目的 探讨硬化型肝癌(SHCC)与肝内肿块型胆管细胞癌(IMCC)的临床及影像表现的异同.方法 回顾性分析48例SHCC及97例IMCC患者的临床及CT、MRI影像表现,分析各自特征及二者间的差异.患者年龄及肿瘤直径的比较采用独立样本的t检验,率的比较采用x2检验.结果 SHCC患者发病年龄较IMCC略小(t=-2.735,P=0.007),二者肿瘤平均直径比较无明显差异(t=1.328,P=0.186),而前者更常见于病毒性肝炎患者(x2 =10.810,P=0.001).两种肿瘤发生部位均以肝脏边缘为主(x2 =2.933,P=0.087),且多伴有邻近肝包膜皱缩(x2=0.522,P=0.470),组间比较均无明显差异.两种肿瘤的CT及MRI平扫影像表现无明显差异,动态增强扫描影像表现主要分为2种类型,即典型强化和不典型强化,典型强化常见,二者间出现概率无明显差异(x2=0.028,P=0.876).两种肿瘤的不典型强化表现部分重合,但SHCC的不典型强化方式更为复杂且部分具有特征性.动态增强影像表现随肿瘤细胞和纤维间质分布、所占比例、血供情况及肿瘤出血坏死程度的不同而变化.两种肿瘤中门静脉受侵(x2 =0.358,P=0.549)及淋巴结转移(x2=0.000,P=0.982)出现的概率无明显差异,而IM-CC出现周围胆管扩张较SHCC更常见(x2=5.011,P=0.025).结论 SHCC与IMCC均为富含纤维间质的肝脏原发恶性肿瘤,二者临床及影像表现相近.充分认识二者影像表现的异同并结合临床对正确诊断及鉴别诊断具有重要意义.     

熊去氧胆酸改善妊娠期肝内胆汁淤积症患者妊娠结局的Meta分析

目的：评价熊去氧胆酸对妊娠期肝内胆汁淤积症患者妊娠结局的影响。方法：检索Pubmed、Medline、中国期刊文献数据库、维普中文科技期刊全文数据库、万方数据库及中国生物医学文献数据库,纳入熊去氧胆酸治疗妊娠期肝内胆汁淤积症的随机对照临床试验（RCTs）研究文献并评价其质量,用Stata12.0统计软件进行分析。结果：共纳入12个随机对照试验,包括664例妊娠期肝内胆汁淤积症患者。Meta分析结果显示：1）熊去氧胆酸组在降低早产率[RR=0.49, 95%CI=0.28~0.84, P=0.01]和胎儿窘迫发生率[RR=0.45, 95%CI=0.20~0.99, P=0.04]方面优于S-腺苷基蛋氨酸组,在剖宫产率、羊水粪染率、5分钟Apgar评分小于7人数及入住新生儿重症监护室发生率方面无显著性差异;2）熊去氧胆酸组在降低早产率[RR=0.50, 95%CI=0.34~0.73, P=0.0001]、胎儿窘迫发生率[RR=0.52, 95%CI=0.29~0.94, P=0.02]、5分钟Apgar评分小于7人数[RR=0.26, 95%CI=0.10~0.69, P=0.006]以及入住新生儿重症监护室发生率方面[RR=0.39, 95%CI=0.17~0.88, P=0.02]优于安慰剂组,而在降低剖宫产率、羊水粪染率方面无显著性差异;3）熊去氧胆酸组在降低早产率方面优于消胆胺组[RR=0.50, 95%CI=0.27~0.94, P=0.03];4）熊去氧胆酸组与地塞米松组相比,各项指标均无显著性差异。结论：熊去氧胆酸对改善妊娠期肝内胆汁淤积症患者妊娠结局有一定的效果,但由于纳入的研究少,仍需更高质量、大样本及多中心的随机双盲对照试验来进一步验证和支持。     

Vitamin E in New‐Generation Lipid Emulsions Protects Against Parenteral Nutrition–Associated Liver Disease in Parenteral Nutrition–Fed Preterm Pigs

Introduction: Parenteral nutrition (PN) in preterm infants leads to PN‐associated liver disease (PNALD). PNALD has been linked to serum accumulation of phytosterols that are abundant in plant oil but absent in fish oil emulsions. Hypothesis: Whether modifying the phytosterol and vitamin E composition of soy and fish oil lipid emulsions affects development of PNALD in preterm pigs. Methods: We measured markers of PNALD in preterm pigs that received 14 days of PN that included 1 of the following: (1) Intralipid (IL, 100% soybean oil), (2) Intralipid + vitamin E (ILE, d‐α‐tocopherol), (3) Omegaven (OV, 100% fish oil), or (4) Omegaven + phytosterols (PS, β‐sitosterol, campesterol, and stigmasterol). Results: Serum levels of direct bilirubin, gamma glutamyl transferase, serum triglyceride, low‐density lipoprotein, and hepatic triglyceride content were significantly lower (P < .05) in the ILE, OV, and PS compared to IL. Hepatic cholesterol 7‐hydroxylase and organic solute transporter–α expression was lower (P < .05) and portal plasma FGF19 higher in the ILE, OV, and PS vs IL. Hepatic expression of mitochondrial carnitine palmitoyltransferase 1A and microsomal cytochrome P450 2E1 fatty acid oxidation genes was higher in ILE, OV, and PS vs IL. In vivo ¹³C‐CDCA clearance and expression of pregnane X receptor target genes, cytochrome P450 3A29 and multidrug resistance‐associated protein 2, were higher in ILE, OV, and PS vs IL. Conclusions: α‐tocopherol in Omegaven and added to Intralipid prevented serum and liver increases in biliary and lipidemic markers of PNALD in preterm piglets. The addition of phytosterols to Omegaven did not produce evidence of PNALD.     

妊娠期肝内胆汁淤积症对分娩结局影响的出生队列研究

目的 探讨孕中期和孕晚期妊娠期肝内胆汁淤积症(ICP)对分娩结局的影响。方法 在马鞍山市优生优育队列(MABC)中,将孕周≤14周、符合入组标准的孕妇共3 474人纳入队列,在首次产检时收集孕妇的一般人口学信息,并收集孕中期和孕晚期血清总胆汁酸(TBA)的检测结果,符合临床诊断的作为病例,采用logistic回归分析孕中期和孕晚期ICP对分娩结局的影响。结果 最终分析的样本人数为2 978人,ICP发生率为6.5%(n=196),其中孕中期和孕晚期ICP发生率分别为1.4%(n=43)和5.1%(n=153)。控制了潜在的混杂因素后,孕中期和孕晚期ICP均增加胎儿早产、低出生体重(LBW)、胎儿窘迫和羊水粪染的风险,OR值(95% CI)分别为6.42(2.59~15.93)和3.73(2.07~6.72);6.52(2.19~19.45)和4.90(2.43~9.90);2.91(1.27~6.67)和1.88(1.11~3.19);2.34(1.19~4.61)和1.66(1.11~2.48),并且孕中期ICP组发生上述不良分娩结局的风险远远高于孕晚期ICP组。结论 孕中期和孕晚期ICP均显著增加胎儿不良分娩结局的风险,孕中期ICP尤其值得关注,早期发现和干预对降低不良分娩结局的发生意义重大。     

精准肝切除术与非规则性肝切除术治疗肝内胆管结石的临床分析

目的 比较精准肝切除术(precise hepatectomy,PH)与非规则性肝切除术(irregular hepatectomy,IH)治疗肝内胆管结石(intrahepatic bile duct stone,IBDS)的疗效.方法 选择2014年6月至2015年12月在成都医学院第一附属医院肝胆外科治疗的IBDS患者86例,依据计算机生成随机数字分为PH组和IH组,各43例.记录两组术中出血量、手术时间、当日引流量、治疗费用、术后住院时间,检测术前及术后1周两组肝功能指标变化,评价临床疗效,计算结石残留率及术后并发症发生率.结果 PH组术中出血量、当日引流量、术后住院时间及治疗费用均低于IH组,手术时间长于IH组,两组比较,差异有统计学意义(P＜0.05).术前及术后1周,两组ALT、ALB、APTT、TBIL、AST水平比较,差异均无统计学意义(P＞0.05).PH组优良率(95.35％)高于IH组(74.42％)(P＜0.05).PH组术后并发症发生率(18.60％)低于IH组(46.51％)(P＜0.05).PH组结石残留率(6.98％)也低于IH组(25.58％)(P＜0.05).结论 PH治疗IBDS可减少手术创伤,降低术后并发症发生率和结石残留率,有利于患者康复.     

MRI多序列结合MRCP对肝内胆管结石并胆道梗阻的诊断价值

目的探讨MRI多序列扫描结合MRCP在肝内胆管结石并胆道梗阻诊断中的价值。方法回顾性分析2013年1月至2016年5月在本院进行了MRI影像检查并经手术病理确认的50例肝内胆管结石并胆道梗阻患者的临床和影像资料,同时对结石的影像表现、分布及其他临床表现进行归类分析。结果 MRI多序列扫描结合MRCP对于肝内胆管结石并胆道梗阻的整体确诊率为94%。对不同位置结石确诊率为:肝左叶确诊率96.7%;肝右叶患者确诊率87.5%;左右肝内胆管均有结石确诊率91.7%,诊断结果与手术确认结果相比,差异无统计学意义(P0.05)。结论 MRI多序列扫描结合MRCP对于肝内胆管结石并胆道梗阻的诊断具有较高的准确率,对临床手术治疗能起到较好的指导作用。     

超声诊断周围型肝内胆管细胞癌

目的:探讨超声检查对周围型肝内胆管细胞癌的诊断价值.方法:对84例经手术及病理证实周围型肝内胆管细胞癌病例用超声检查观察病灶大小、边界、形态、回声,并结合患者的临床表现及实验室检查进行诊断.结果:二维声像图显示病灶最小20 mm×20 mm,最大为130mm×100mm,单发78例(92.8％),多发6例(7.2％),共92个病灶;病灶发生在右叶40例,左叶48例,中叶4例,病灶表现为低回声的56个(60.9％),回声不均匀的75个(81.5％),边界模糊的70个(76.1％);肿块呈分叶状的55个(59.8％).乙型肝炎表面抗原(HBsAg)阳性者15例(17.9％),甲胎蛋白升高者20例(23.8％),糖类抗原19-9(CA19-9)升高者72例(85.7％);有胆道手术史及结石者50例(59.5％).超声诊断的符合率为85.7％(72/84).结论:周围型肝内胆管细胞癌的超声表现具有一定的特征,结合临床表现及实验室检查可提高对该病的诊断率.     

Clinical characterization of patients developing histologically‐proven fibrosing cholestatic hepatitis C post‐liver transplantation

Aim: Fibrosing cholestatic hepatitis C (FCH) post‐liver transplantation (LT) is an uncommon disorder with extremely poor outcome. Using stringent histological criteria, we sought to identify cases of FCH to better characterize its incidence, clinical features and outcomes. Methods: From January 1991 to December 2007, 973 LT for hepatitis C virus (HCV) were performed at our center. Using the pathology database, 51 cases with a provisional diagnosis of FCH were identified. FCH was diagnosed histologically by cholestasis accompanied by thin periportal fibrous septa, ductular reaction and mild inflammation. Results: FCH was reconfirmed in 24 recipients; seven had concurrent biliary problems. Twenty‐seven cases were excluded; biopsy was unavailable in nine cases, 15 did not meet the histological criteria of FCH and three had missing clinical information. All received deceased donors at a mean age of 64.4 years (15/17 aged >50 years). Mean time from LT to FCH was 7.6 months with 16 of 17 diagnosed within 1 year of LT. At diagnosis, mean viral load was 14.4 million IU/mL, bilirubin 16.2 mg/dL, aspartate aminotransferase 262 IU/mL, alanine aminotransferase 192 IU/mL and alkaline phosphatase 299 IU/mL. All 17 patients died or required re‐LT a mean of 7.8 months after the FCH diagnosis. Conclusion: FCH occurs infrequently and is typified by hyperbilirubinemia, donor age of more than 50 years, extremely high HCV RNA and specific histological changes occurring within the first several months post‐LT with extremely poor patient and graft survival. Histology alone is not reliable for the diagnosis of FCH, especially in the setting of recurrent HCV with concurrent biliary problems.