病理學(xué)：消化系統(tǒng)疾病

消化系統(tǒng)攝食、消化、吸收、排泄、內(nèi)分泌上消化道：口腔?十二指腸下消化道：空腸以下消化管

消化腺

大消化腺：大唾液腺、肝、胰小消化腺：消化管粘膜內(nèi)的小腺體包括消化管和消化腺兩大部分功能口腔→咽→食管→胃→小腸（十二指腸、空腸和回腸）→大腸（盲腸、闌尾、結(jié)腸、直腸和肛管）→肛門3DiseasesoftheGITractEsophagus

StomachSmallandlargeintestines

AppendixBarrettesophagusPepticulcerIBDEsophagealCaGastricCaColorectalCaAnatomic/Development/motorDisordersInflammatoryDiseases

Esophagitis

GastritisEnterocolitisAppendicitisTumorsAdenomaReflux~

Chronic~NETs膈氣管左主支氣管賁門胃第二狹窄第三狹窄第一狹窄食管的起始處，距中切牙約15cm；食管在左主支氣管的后方與其交叉處，距中切牙約25cm；食管通過膈的食管裂孔處，距中切牙約40cm狹窄部是食管異物易滯留和食管癌的好發(fā)部位Normalanatomyoftheesophagus5NormalhistologyoftheesophagusEsophagogastricjunction≠Squamous-columnarjunction6EsophagitisInflammationoftheesophagealmucosaCausedbyavarietyofagentsBiologicPhysicalChemicalRefluxofgastriccontentsisthemostimportantcauseofesophagitis(refluxesophagitis)7

Refluxesophagitis(返流性食管炎)ElongationofthelaminapropriapapillaeExtendingintothetopthirdoftheepitheliumBasalcellhyperplasia>1/5oftheepithelialthicknessIntraepithelialinflammatorycellsEosinophils,neutrophilsandlymphocytes89Refluxesophagitis

ClinicalfeaturesAgeOver40yOccasionallyseenininfantsandchildrenDominantmanifestationHeartburn(燒心)Regurgitationofasourbrash(返酸)PotentialconsequencesBleeding,ulceration,strictureAtendencytodevelopBarrettesophagus10Barrettesophagus(巴雷特食管)DefinitionThereplacementofthenormaldistalstratifiedsquamousmucosabymetaplasticcolumnarepithelium,usuallycontaininggobletcellsAcomplicationoflong-standinggastroesophagealreflux11DiagnosticcriteriaEndoscopicevidenceofcolumnarepithelialliningabovethegastroesophagealjunctionHistologicevidenceofintestinalmetaplasiainthebiopsyspecimensfromthecolumnarepithelium.12BarrettesophaguswithdysplasiaThemostimportantriskfactorforesophagealadenocarcinoma13CarcinomasoftheesophagusWorldwide,squamouscellcarcinomasconstitute90%ofesophagealcancersMainlyinnorthChinaandMiddleEastAsiaAccountfor20%ofcancerdeathsButinmostofthewesterncountries……AdenocarcinomaSCC14DietaryDeficiencyofvitamins(A,C,B1,B2,B6)Deficiencyoftraceelements(zinc,molybdenum鉬)FungalcontaminationoffoodstuffsHighcontentofnitrites(亞硝酸鹽)/nitrosamines(亞硝胺)LifestyleBurning-hotbeveragesorfoodAlcoholconsumptionTobaccouseEsophagealDisordersLong-standingesophagitisAchalasia(賁門失遲緩癥)Plummer-VinsonsyndromeGeneticPredispositionRacialdispositionFactorsAssociatedwiththeDevelopmentofSquamousCellCarcinomaoftheEsophagusIntraepithelialneoplasia(上皮內(nèi)瘤變)<1/2,lowgrade>1/2,highgrade(includingCainsitu)16CarcinogenesisofesophagealCaLowgradeneoplasiaSquamousepitheliumEsophagitisSCCHyperplasiaMetaplasia(Barrettesophagus)HighgradeneoplasiaAdenoCa17CarcinomasoftheesophagusClinicalfeaturesAge:middletoelderageGender:Male>Female(4-5:1)Insidiousinonset,dysphagia(吞咽困難),obstruction,progressiveweightloss,…RoutinescreeningproceduresarerequiredforpatientswithchronicesophagitisandBarrettesophagusLocationSCC:Upperthird20%,Middlethird50%,Lowerthird30%Adenocarcinoma:lowerthird18EarlyCaAcarcinomaconfinedtothemucosaormucosaandsubmucosaThefive-yearsurvivalrate:75%AdvancedCaThefive-yearsurvivalrate:10%-20%1920Squamouscarcinoma21Adenocarcinoma22Adenocarcinoma2324DiseasesoftheGITractEsophagus

StomachSmallandlargeintestines

AppendixBarrettesophagusPepticulcerIBDEsophagealCaGastricCaColorectalCaAnatomic/Development/motorDisordersInflammatoryDiseases

Esophagitis

GastritisEnterocolitisAppendicitisTumorsAdenomaReflux~

Chronic~NETs25Normalanatomyofthestomach胃底賁門幽門部幽門幽門管幽門竇胃體中間溝28GastritisDefinition:InflammationofthegastricmucosaAcutegastritisFocaldamagetothegastricmucosa,withacuteinflammation,erosionandhemorrhage,usuallytransientClinicalmanifestation:rangefromentirelyasymptomatictofatalEtiology:drugs(aspirin),smoking,alcohol,severestress,infection,etc.29GastritisChronicgastritis

ThepresenceofchronicmucosalinflammatorychangesleadeventuallytomucosalatrophyandintestinalmetaplasiaEtiologyHelicobacterpylori(幽門螺桿菌)Autoimmune

GastroduodenalrefluxHotfoodsorbeveragesAlcoholMalnutrition30Sea-gullorS-shapedGramnegativeSilverstainMotilityElaborationofureaseExpressionofbacterialadhesinsExpressionofbacterialtoxins,egcytotoxin-associatedgeneA31MacroscopicappearanceUsuallyreddenedandcoarseSometimesthickenedWithlong-standingatrophicdisease,themucosamaybecomethinnedandflattenedChronicgastritis32Chronicgastritis

Chronicsuperficial/non-atrophicgastritis(慢性淺表性/非萎縮性胃炎)Inflammatoryinfiltrate:lymphocytesandplasmacellsinthelaminapropriaNoevidenceofglandlossandmucosalatrophy

33InflammatoryinfiltrateAtrophy:glandlossWith/withoutMetaplasiaIntestinal~(腸上皮化生)Pyloricgland~(幽門腺化生)With/withoutDysplasiaChronicatrophicgastritis34TypeAAutoimmune-relatedPerniciousanemia(惡性貧血)APCA+,IFA+Body/fundusDiffusedlesionTypeBH.PyloriassociatedNoanemiaAPCA-,IFA–Antrum/pangastritisFocaldistributionChronicatrophicgastritis35ClinicalfeaturesUpperabdominaldiscomfortNauseaandvomitingPerniciousanemia----autoimmunegastritisComplicationsPepticulcersCarcinomaLymphoma-MALToma36Pepticulcer(消化性潰瘍)AbreachinthemucosaofthealimentarytractthatextendsthroughthemuscularismucosaintothesubmucosaordeeperMostcommonlyintheduodenumandstomachErosionvsUlcerErosionreferstoepithelialdisruptionwithinthemucosabutnobreachofthemuscularismucosa37Pathogenesisofpepticulcers

38TherolesofH.pyloriinthepathogenesisofpepticulcers1Bacterialgeneproductscauseepithelialinjuryandinductionofinflammation2Enhancesgastricacidsecretionandimpairsduodenalbicarbonateproduction3Bacterialplatelet-activatingfactorpromotesthromboticocclusioninthesurfacecapillaries4Immunogenicproteinsevokerobustimmuneresponseinthemucosa39MorphologyofpepticulcersLocationsAnteriorandposteriorwallofthefirstportionoftheduodenumLessercurvatureofthestomachMacroscopicappearance2-4cmindiameterRoundtooval,sharplypunched-outNoelevatedmarginsSmoothandcleanbase40MicroscopyDefectsinthemucosapenetrateatleastintothesubmucosaNecroticfibrinoiddebrisNon-specificinflammatoryinfiltrate,predominatelyneutrophilsActivegranulationtissueinfiltratedwithmononuclearleukocytesFibroustissueorscar41MicroscopyDefectsinthemucosapenetrateatleastintothesubmucosaExudate:fibrinoiddebris,inflammatorycellsNecroticdebrisActivegranulationtissueinfiltratedwithmononuclearleukocytesFibroustissueorscar42ClinicalfeaturesSymptomsEpigastricgnawingBurningBoringpainComplicationsBleeding:15%-20%,1/4ofulcerdeathPerforation:5%,2/3ofulcerdeathObstruction:2%43GastriccarcinomasEpidemiologyThesecondmostcommontumorintheworld,verycommoninChinaMale:Female=2:1AsteadydeclineinboththeincidenceandthemortalityoverthepastsixdecadesRiskfactorsH.pyloriinfectionDietBilerefluxGenetics44MorphologyofgastriccarcinomasLocationThelessercurvatureoftheantropyloricregionMacroscopicappearance4546UlcerativeCavsbenignulcerBordersRoundtoovalwithstraightwallsLeveledwiththesurroundingmucosaBase:smoothandcleanGastricfolder:radiatingBordersIll-definedIrregular,heaped-upBase:shaggy,necroticGastricfolder:disappearorinterrupted47DiffusetypegastricadenocarcinomaLinitisplastica(皮革胃)----"leatherbottle"appearance48HistologicclassificationofgastriccarcinomasTheWHOclassificationPapillaryadenocarcinomaTubularadenocarcinomaMucinousCaSignetringcellCaanditsvariantsAdenosquamousCaSquamousCaUndifferentiatedCaOthers495051LaurénclassificationIntestinaltype

BecomposedofglandularstructuresElderlypatientsThroughthesequenceofchronicgastririsIMDysCaH.pyloriassociatedDiffusetypeBecomposedof

poorlydifferentiateddyscohesivemalignantcellsYoungerpatientsEtiologyandprecancerouslesionsunknown52ClinicalfeaturesWeightlossAnorexia(厭食),dyspepsia(消化不良),earlysatietyAnemia(irondeficiency),hematemesis(吐血)Leftsupraclavicular(鎖骨上)lymphnode(Virchownode,

魏爾嘯淋巴結(jié))enlargementKrukenbergtumor:intraperitonealspreadtobothovaries粘液胭脂紅染色54PrognosislargelydependsonthedepthofinvasionandtheconditionsofmetastasisEarlygastriccarcinoma:Caconfinedtothemucosaorsubmucosawith/withoutLNmetastasis,5ysurvivalrate90%-95%Advancedgastriccarcinoma:5ysurvivalrate15%55GastriclymphomaMostlyMALT(mucosaassociatedlymphoidtissue)lymphomaLow-gradeB-celllymphomaIndolentH.pyloriassociated56Lymphoma(MALToma)AdenocarcinomaLymphoidaggregatesIntestinalmetaplasiaH.pyloriinfectionChronicgastritisUlcer5757Forty-oneyear-oldmale,presentedwith

heartburn,regurgitation,andepigastricpain.EndoscopyrevealedalargeerythematousareainvolvingthedistalesophagusBiopsyspecimenswere

takenandshowed

featuresasfollowWhat’sthediagnosis?5858Thepatientwastreatedandgivenafollow-upappointmentinoneyearThepatientreturnedthreeyearslater,complainingofdysphagia（吞咽困難）,heartburn,andepigastricpainEndoscopywasagainperformed,andrevealedthatthedistalesophaguswasreplacedby

pinkvelvetymucosaBiopsyspecimensweretaken,

featuresasshownWhat’sthediagnosisthistime?

Andwhat’syoursuggestion

tothepatient?5959Sixyearslater,abiopsyspecimenstakenfromextensivevelvetyareaofthedistalesophagusshowedfeaturesasfollowWhat’syourdiagnosis?6060Oneyearlater,thepatientwasadmittedwithaone-monthhistoryofdysphagiaAnupperGIradiographsrevealeddistal

narrowingoftheesophagusEndoscopicexaminationoftheesophagus

revealedanulceratingmassinthedistal

esophagusAbiopsywasperformed.Thepatientwas

takentosurgery,whereanesophagog-

astrectomywasperformed6161What’syourdiagnosis?Andhowabouttheprognosisofthispatient?DiseasesofsmallandlargeintestinesIdiopathicinflammatoryboweldisease(IBD)CrohndiseaseUlcerativecolitisColorectalneoplasmsAdenomaCarcinomaInfectiousenterocolitisTyphoidfeverBacillarydysenteryPseudomembranouscolitisAmebiasisSchistosomiasis6363NormalanatomyandhistologyoftheintestinesSmallintestine64646565Largeintestine66666767CellsinVilli&cryptsAbsorptivecellsGobletcellsPanethcellsEndocrinecellsUndifferentiatedcells6868GUT:thelargestimmuneorgan6969EnterocolitisInfectiousenterocolitisTyphoidfever(腸傷寒)Bacillarydysentery(菌痢)Amebiasis(阿米巴病)Schistosomiasis(血吸蟲病)MalabsorptionSyndromes

Idiopathicinflammatoryboweldisease(特發(fā)性炎癥性腸病，IBD)Crohndisease(克羅恩病)Ulcerativecolitis(潰瘍性結(jié)腸炎)7070IdiopathicInflammatoryBowelDiseaseAheterogeneousgroupofdiseasescharacterizedbyanexaggeratedanddestructivemucosalimmuneresponseTwomaindisordersCrohndiseaseUlcerativecolitisPrimarilyoccurinWesterndevelopedpopulations7171Occuratanyage,peakagesarethe2ndand3rddecadesoflifeWhites>nonwhitesSystemicinflammatorydiseaseswithpredominantGIinvolvementUveitis(色素膜炎)Migratorypolyarthritis(游走性多關(guān)節(jié)炎)Erythemanodosum(結(jié)節(jié)性紅斑)Bileductinflammatorydisorders(膽管炎癥性病變)CommonfeaturesofCD&UC7272PathogenesisofIBDUnexplainedGeneticpredisposition:CD>UCImmunologicfactors:abnormalTcellresponseMicrobialfactors:providetheantigenictriggertoadysregulatedimmunesystemInflammationisthecommonfinalpathwayforthepathogenesisofIBD7373Distinctivefeatures7474SkiplesionsRubberyandthickenedintestinalwallwithnarrowingoflumenBeginsintherectumandextendsproximallyRed,granularappearanceofthemucosaMacroscopicappearance(CDvsUC)CDUCCD7575Aphthousulcers(阿弗他潰瘍)Linearulcers(線狀潰瘍)Fissures(裂隙潰瘍)Fistula(瘺管)CobblestoneappearanceSuperficialulcerswithislandsofsurvivingmucosaUCMacroscopicappearance(CDvsUC)7676Pseudopolyps(假息肉)MacroscopicappearanceUC7777CDTransmuralinflammationUlceration,penetrationNoncaseatinggranulomas(非干酪樣壞死性肉芽腫)MicroscopyUCDiffuse,universalinflammatoryinfiltrateinthelaminapropriaExtensiveandbroad-basedulceration

Cryptabscesses(隱窩膿腫)7878ClinicalfeaturesCDManifestationsRecurrentepisodesofdiarrheaFeverAbdominalpainComplicationsFistulaformationAbdominalabscessesorperitonitisIntestinalstrictureorobstructionUCManifestationsRelapsingbloodymucoiddiarrheaExtraintestinalmanifestationsaremorecommonComplicationsToxicmegacolonwithpotentialofruptureRiskofCaishigherthanCD79DysplasiainIBDIncreasedriskofcarcinomadevelopmentUC>CDLGHG8080ColorectalNeoplasms8181

AdenomaAnintraepithelialneoplasm,characterizedbyhypercellularitywithenlarged,hyperchromaticnuclei,varyingdegreesofnuclearstratificationandlossofpolarityIncidenceAgerelated:<40y20%-30%;>40y40%-50%Familialpredisposition:a4-foldgreaterriskamongfirstdegreerelativesLocation:66%-77%inrectosigmoidCorrelationswithCRC80%sporadicCRCarisefromadenomasFour-foldgreaterriskforCRCAdenoma

vs

Polyp8282MacroscopicappearancePedunculatedNon-pedunculatedSessileFlat8383MicroscopyFormationofglandortubule----tubular~Formationoffinefingerletsorformationofvilli----villous~Mixtureoftheabove----tubulovillous~84848585ColorectalAdenocarcinomaOneofthemostcommonneoplasmsPeakageofincidence:60-70yClinicalfeaturesHematochezia(便血)Anaemia(貧血)Changesinbowelhabitfever,weightloss,abdominalpain,etc.8686ColorectalAdenocarcinomaPredisposingfactorsAdenomatouspolypsDietandlifestyleHighcontentofrefinedcarbohydratesHighfatcontentLowcontentofunabsorbablevegetablefiberDecreasedintakeofprotectivemicronutrients

AlcoholconsumptionSmokingLong-standingUCorCDIrradiation:rare8787Macroscopicappearance8888Microscopy(WHOclassification)AdenocarcinomaNOSMedullarycarcinomaMucinousadenocarcinomaSerratedadenocarcinomaSignetringcellcarcinomaAdenosquamouscarcinomaSquamouscarcinomaSpindlecellcarcinomaUndifferentiatedcarcinoma8989T=PrimaryTumorTisCarcinomainsitu,invasionoflaminapropriaT1 TumorinvadessubmucosaT2TumorinvadesmuscularispropriaT3TumorinvadesthroughthemuscularispropriaintopericolorectaltissuesT4aTumorpenetratesthevisceralperitoneumT4bTumordirectlyinvadesorisadherenttootherorgansorstructuresN=RegionalLymphNodesN0NoregionallymphnodemetastasisN1Metastasisin1-3lymphnodesN2aMetastasisin4-6lymphnodesN2bMetastasisinmorethan7lymphnodesM=DistantMetastasisM0NodistantmetastasisM1aMetastasisconfinedtooneorganorsiteM1bMetastasesinmorethanoneorgan/siteortheperitoneumTNMStaging9090TNMstagingand5-yrsurvivalrateStageTNM0TisN0M0IT1-2N0M0IIAT3N0M0IIBT4aN0M0IICT4bN0M0IIIAT1-2T1N1N2aM0IIIBT3-T4aT2-3T1-2N1N2aN2bM0IIICT4aT3-4aT4bN2aN2bN1-2M0IVAnyTAnyNM19191TwomainpathwaysforthecarcinogenesisofCRCChromosomalinstabilitypathway(染色體不穩(wěn)定途徑)(Wnt/β-cateninpathway)Involvedin80%ofsporadicCRCFamilialadenomatouspolyposis(FAP)Microsatelliteinstabilitypathway(微衛(wèi)星不穩(wěn)定途徑)Involvedin10%-15%ofsporadicCRCHereditarynonpolyposiscolorectalcancer(HNPCC,Lynchsyndrome)9292Familialadenomatouspolyposis

(家族性腺瘤性息肉病,FAP)AnautosomaldominantdisorderRelativelyrare(1in8000individuals)Numerousadenomatouscolorectalpolyps,moreinthedistalcolonHaveanintrinsictendencytoprogresstoCa(<40y),accountfor1%ofCRC9393Extra-IntestinalManifestationsofFamilialAdenomatousPolyposisGastric:FundicGlandPolyps(胃底腺息肉)Pancreas:Pancreatoblastoma(胰母細(xì)胞瘤)Liver:Hepatoblastoma(肝母細(xì)胞瘤)Eye:CongenitalHyperpigmentationofRetina(先天性視網(wǎng)膜色素沉著)Nasopharynx:JuvenileNasalAngiofibroma(幼年性鼻血管纖維瘤)Thyroid:PapillaryCarcinoma(乳頭狀癌)Brain:Medulloblastoma(髓母細(xì)胞瘤)Skin:EpidermalCyst(表皮樣囊腫)SoftTissue:Fibromatosis(纖維瘤病)Bone:Osteoma(骨瘤)9494Causedbyagermlinemutation(胚系突變)

inAdenomatousPolyposisColi(APC)geneon5q21-22ServeasthemodelfortheWnt/β-cateninpathwayofcarcinogenesisinthelargebowel9595Adenoma-carcinomasequenceGerm-lineorsomaticmutationProoncogenesmutationLOHofadditionalcancersuppressorgeneAdditionalmutationGrosschromosomalalterations(aneuploid)Wnt/β-cateninpathway962007-1Screeningbeginsatage10-15yChemopreventionProphylactictotalcolectomyFAP9797Lynchsyndrome

(Hereditarynonpolyposiscolorectalcancer,HNPCC)AnautosomaldominantdisorderCharacterizedbythedevelopmentofcolorectalcarcinomaandcancersofotherorgansAstrongfamilyhistoryofdevelopingcolorectalcanceratanearlyage(average46years)Accountfor~2%ofcolorectalcarcinomas9898RapidprogressionfromadenomatocarcinomaPredominantlyright-sidedIncreasedproportionofmucinousorpoorlydifferentiatedtumorsWithmarkedhost-lymphocyticinfiltrationBetterprognosis

CausedbygermlinemutationsinDNAmismatchrepairgenesleadingtoahighfrequencyofMSILynchSyndrome9999MismatchrepairandMicrosatelliteMSI100100TheMSIpathwayofcarcinogenesisinthelargebowelNoclearlyidentifiablemorphologiccorrelatesMSIDiploid101101102GastrointestinalneuroendocrineneoplasmsCarcinoid=carcinoma-likeNeuroendocrinecellsCellsgeneratingbioactivecompounds,particularlypeptideandnonpeptidehormonesAbundantinotherorgans,butmostofthetumorsdevelopfromthesecellsariseinthegutSomeneoplasmsareassociatedwithadistinctivecarcinoidsyndrome

103GastrointestinalneuroendocrineneoplasmsClassificationandGradingNeuroendocrinetumor(NET)

(G1,G2)Neuroendocrinecarcinoma(NEC)

(G3)MixedadenoneuroendocrinecarcinomaRobbinsbasicpathology8eRobbinsbasicpathology8eTyphoidfeverAninfectiousdiseasecausedbythebacteriumSalmonellatyphi

Infectionoccursthroughoral-fecalcontaminationEnlargementoflymphoidandmononuclear-phagocytictissuesthroughoutthebodyClinicalfeaturesProlongedfever,abdominalpain,rash,plenomegaly,bowelhaemorrhageChroniccarrier:gallbladdercolonizationMacroscopicappearanceInthegut,fourpathologicalstagescanbedifferentiated:Lymphoidhyperplasia,formingplaque-likeelevationsNecrosisOvalulcersparalleltothelongaxisofthegutHealingMicroscopyProliferationofmacrophages,lymphocytesandplasmacellsinthegut,spleen,liver,bonemarrowandlymphnodesTyphoidcells:redcellsandnucleardebriswithinthecytoplasmofmacrophagesTyphoidnodules/granulomas:collectionsof"typhoidcells"BacillarydysenteryAcommoninfectioncausedbyShigellaorganismsInfectionoccursthroughoral-fecalcontaminationClinicalfeaturesHeadache,fever,bloodandpusinthestoolMainlyaffectsthedistalintestine----tenesmusFibrinopurulentexudateonthemucosalsurfaceformingapseudomembranePseudomembranouscolitisAninfectioncausedbytheovergrowthofcytotoxin-producingstrainsofanormalgutorganism----ClostridiumdifficileOccurrsaftersystemicantibioticusePseudomembrane:plaquelikeadhesionoffibrinopurulentdebrisandmucustothedamagedsuperficialmucosaAmebiasisAninfectiousdiseasecausedbyprotozoalparasite----EntamoebahistolyticaInfectionoccursthroughoral-fecalcontaminationFlask-shapedulcerVerylittleinflammatoryinfiltrate“Jam-likestool”----liquefiedtissue+hemorrhage40%forminghepaticabscessesSchistosomiasisAparasiticdiseasecausedbybloodflukes,trematodewormsofthegenusSchistosoma

Prevalence:Asia,somePacificislands,Africa,theWestIndies,SouthAmerica,SouthEuropeSymptoms:skineruption,fever,diarrhea,andcirrhosisoftheliverThediseasecanbecuredwiththedrugpraziquantel,butreinfectioncanoccurPreventionEradicatethesnailhostsPropersanitationanddisposalofhumanwastes

schistosomiasisThediseaseiscausedbyinflammatoryresponsetotheeggsratherthantotheadultsAcuteAppendicitis

Mostfrequentlyinthe2ndand3rddecadesoflifeMaybecausedbyobstruction,mostoftenbyafecolith,resultinginbacterialproliferationMacro:congested,swollen,purulentexudateontheserosaandinthelumenMicro:suppurativeorgangrenousinflammationClinicalfeatures

ManifestationsAnorexia,nausea,vomitingAbdominalpain,firstperiumbilicalthenlocalizingtotherightlowerquadrantMildfeverElevationofWBC“eithertheeasiestorthemostdifficultofabdominalDx”ComplicationsPerforation:mortalityapprox.2%Liverabscess:rareTheliverandthebiliarytractViralhepatitisAlcoholicliverdiseaseCirrhosisPortalhypertensionPrimarycarcinomaoftheliverCholecystitisCholelithiasis(gallstones)AnatomyandfunctionsRightlobeFalciformligamentLeftlobeThelargestparenchymalorganinthebodyProcessesdietarynutrientsSynthesisofserumproteinsDetoxification&excretionofendogenouswasteproductsandpollutantxenobioticsNormalhistologyHepaticAcinusItocellGeneralresponsesoflivertoinjuriesCelldegeneration&celldeathInflammationRegenerationFibrosis&cirrhosisDegenerationBallooning~:edemaFeathery~:retainedbiliarymaterialSteatosis:accumulationoffatdropletsMicrovesicularsteatosisMacrovesicularsteatosisNecrosis&ApoptosisAccordingtothenatureofcelldeathCoagulativenecrosisApoptoticcelldeath:CouncilmanbodyLyticnecrosisAccordingtodistributionCentrilobularnecrosisSpotty/focalnecrosis“Piecemeal"necrosis----interfacehepatitisBridgingnecrosisSubmassivenecrosisMassivenecrosisNecrosis&ApoptosisInflammationNecrosisincitesinflammatoryreactionCytotoxiclymphocytesattackantigen-expressinglivercellsLymphocytescollectintheportaltractKupffercellsengulfapoptoticcellsGranulomatousreactionRegenerationHepatocellularproliferationDuctalreaction

Whenhepatocelluarnecrosisoccursandleavestheconnectivetissueframeworkintact,almostperfectrestitutionoftheliverstructurecanoccurFibrosisandcirrhosisResponsetoinflammationordirecttoxicinsulttotheliverDepositionofcollagenGenerallyirreversibleViralHepatitisInfectionofthelivercausedbyagroupofviruseshavingaparticularaffinityfortheliverHepatitisAHepatitisBHepatitisCHepatitisDHepatitisE

肝炎病毒命名傳染常見肝硬肝

及病毒核酸時(shí)間方式病型變癌甲型肝炎HAVRNA1973消化道2～7周急性肝炎無無乙型肝炎HBVDNA1963非消化道8～26周急、慢5%-10%有丙型肝炎HCVRNA1989非消化道7～8周急、慢＞50%有丁型肝炎HDVRNA1986非消化道4～7周急、慢

有

＜5%(共同感染）

80%(重疊感染）戊型肝炎HEVRNA1990消化道2～9周急無無HAV:糞--口傳播，自限性肝炎，短期內(nèi)即恢復(fù)正常。HBV:經(jīng)血傳播為主，經(jīng)口傳播為次，生活中的密切接觸是重要的傳播方式，患者血液、唾液、膽汁、乳汁、尿、精液內(nèi)均含有病毒。HCV：經(jīng)血傳播，多隱匿起病，轉(zhuǎn)變?yōu)楦卫w維化及肝癌的機(jī)會(huì)多。HDV：D是缺陷病毒，常與B型病毒共同感染引起急性和亞急性肝壞死，主要經(jīng)血傳播，乙型肝炎病毒攜帶者為易感人群。

HEV：糞--口傳播（水污染）,孕婦感染死亡率高。viralhepatitis潛伏期HepatitisAvirusAsmall,naked,single-strandedRNApicornavirusFecal-oraltransmissionIncubationperiod:15-45dNochronichepatitisNocarrierstateLifetimeprotectiveimmunityDoublestrandedDNAvirusHepatitisBvirusNon-protectiveProtectiveX-proteinTranscriptionaltransactivatorofhostgenesTwophasesofHBVinfectionsProliferativephaseHBV-DNAinepisomalformwithformationofcompletevirionsandallassociatedantigensHBsAgandHBcAgleadtoactivationofCD8+TlympocyteswhichthencausehepatocytesdamageIntegrativephaseHBV-DNAmaybeincorporatedintothehostgenomeViralreplicationisstoppedandliverdamagesubsidedbuttheriskofhepatocellularCapersistsTransmission:bloodandbodyfluidsVertical:mothertoneonateHorizontal:transfusion,dialysis,drugabuse,sexIncubationperiod:4-26wks0.5-1%/

year0.02%/

year2.5%/

yearHepatitisCvirusAsmall,single-strandedRNAviruswithenvelopeTransmission:parenteral(transfusion,sexual,vertical)Themostfrequentcauseoftransfusion-mediatedhepatitisIncubationperiod:2to26wksNon-protectiveFrequentlyprogressestochronicliverdisease1-4%/yAverysmall,sphericalvirusconsistingofasingleRNAstrandandtheassociateddeltaproteinantigen(HDAg),surroundedbyaproteinaceouscoatofHBsAgReplicationdefective:absolutelydependentonHBVinfectionTransmission:parenteralIgManti-HDV:themostreliableindicatorofrecentHDVexposureUsuallycausesillnessmoreseverethanHBVinfectionaloneHepatitisDvirusHepatitisEvirusAnunenveloped,single-strandedRNAvirusTransmission:enterical,waterborneIncubationperiod:15-60daysDosenotleadtochronicliverdiseaseHighmortalityrate(20%)amongpregnantwomenClinicalSyndromesAnumberofclinicalsyndromesmaydevelopfollowingexposuretohepatitisvirusesAsymptomaticinfection:serologicevidenceonlyCarrierstate:withoutapparentdisease/withsubclinicalchronichepatitisAcutehepatitis:anictericorictericChronichepatitis:withorwithoutprogressiontocirrhosisFulminanthepatitis:withmassivetosubmassivehepaticnecrosisThecarrierstateHarboroneofthevirusesbutsufferfewornoadverseeffectsHavenonprogressiveliverdamagebutareessentiallyfreeofsymptomsordisabilityHBVandHCVcanproducea~HDV:notclearHAVandHEV:noAcuteviralhepatitisAnyoneofthehepatotropicvirusescancausesymptomaticacuteviralhepatitis,althoughun