脂肪性肝炎教案.ppt

磁共振检查 数字减影血管造影 鉴别 局灶性脂肪肝或弥漫性脂肪肝伴正常肝岛 肝占位 B超诊断 B超诊断 弥漫性脂肪肝的特征性声像学改变： 肝区前场弥漫性点状高回声（明显高于脾脏和肾脏） 肝区后场回声衰减，光点稀疏 肝内管道结构显示不清 肝脏轻度或中度肿大，肝前缘变钝。 凡具备第1项加其余1项以上者可确诊为脂肪肝，仅具备第1项者作为疑似诊断。 B超诊断 按脂肪肝超声特征可大致判断病变之程度。 光点细密，近场回声增强，远场回声轻度衰减，血管结构清晰者为轻度； 光点细密，近场回声增强，远场衰减明显，血管结构不清者为中度； 光点细密，近场回声显著增强，远场回声显著衰减，血管结构不能辨认者为重度。 B超诊断 肝硬化和弥漫性肝癌均有近场回声增强，远场回声衰减表现，故需与脂肪肝相鉴别。 局灶性脂肪肝为肝实质内出现相对回声增强的光团。但其边界较清楚，呈椭圆形，后方无衰减，周围无声晕，可与肝癌或肝血管瘤相鉴别。 弥漫性脂肪肝伴正常肝岛以及局灶性脂肪肝也不少见，可为相对低回声。 Fatty liver Fatty liver showing posterior sonic attenuation Fatty liver obliterating borders of portal vein and diaphragm Focal spared fatty liver. CT诊断 CT诊断 肝脏密度（CT值）低于脾脏或肝/脾CT值之比≤1即可诊断为脂肪肝，或作为随访疗效的依据。 严重程度的判断 肝/脾CT比值≤1.0为轻度 肝/脾CT比值≤0.7，肝内血管密度等于肝密度，肝内血管显示不清者为中度； 肝/脾CT比值≤0.5，肝血管密度明显高于肝密度者为重度。 严重者所见肝脏犹如一片脂肪组织，呈“鱼网”状 如果肝小叶内仅有不到1/3的肝细胞有脂肪变则仅称为肝细胞脂肪变性 正常肝组织 正常肝细胞索 病理学 非酒精性脂肪性肝炎： 1大泡性脂肪变 2肝细胞气球样变 3小叶内混合性炎症细胞浸润 4肝腺泡3区窦周纤维化 5糖原核 6小叶内脂肪性肉芽肿 Liver biopsy findings in NASH are similar to those in alcoholic hepatitis and include hepatocellular steatosis, lobular inflammation, Mallorys bodies, and pericellular fibrosis in the area around the central vein (Figure). The diagnostic criteria for NASH are expected to evolve over the next decade as specific causes of this clinical entity are defined. The biopsy findings of nonalcoholic steatohepatitis (NASH) are shown with Masson trichrome stained sections (20x and 40x). Hepatocyte fat accumulation is seen as clear holes within cells that vary in size from smaller than nuclei to larger than a normal cell. Focal neutrophilic infiltrates can be found in areas of focal necrosis; mononuclear cell infiltration is a component of the inflammation. The pattern of liver fibrosis (stained blue) in NASH is similar to the early fibrosis of alcoholic liver disease, with collagen extending around hepatocytes producing a chicken-wire appearance. Figures courtesy of Dr. Elizabeth Brunt. 病理学 非酒精性脂肪性肝炎： 7散在性嗜酸小体和枯否细胞以及脂肪囊肿 8Mallory小体 9门脉周围肝细胞铁染色阳性 10肝细胞巨大线粒体 这些病变并非诊断NASH的必备条件。 透明小体（ Mallory小体）和活动性炎症均为NA