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肝动脉化疗栓塞术后发生胆汁瘤1例报道

　　患者，女，42岁，因肝血管瘤行肝动脉化疗栓塞（TACE）后8个月，皮肤、巩膜黄染及肝内多发囊性占位4个月入院。患者入院前12个月MRI发现肝多发血管瘤（图1），最大3.5 cm×7 cm，无不适。入院前8个月行血管瘤TACE，术中予碘油16 ml栓塞，术后感乏力、纳差、肝区隐痛，化验“ALT 292 U/L、Bil正常”，予以甘利欣、凯西莱等治疗，ALT有所下降，但始终不正常。入院前4个月出现皮肤及巩膜黄染、尿黄，化验“ALT 153.2 U/L， TBil 95 μmol/L, DBil 79.9 μmol/L”， B超: “肝血管瘤栓塞术后，肝内囊性占位”，应用胆维他、优思弗、思美泰等治疗，黄疸进行性加重，肝内囊性占位进行性增大入我院。化验肝功能： Alb 31 g/L， TBil 172.8 μmol/L, DBil 139.8 μmol/L，ALT 58 U/L， AST 97 U/L， ALP 321 U/L， GGT 238 U/L。B超: ①肝内多发囊性占位; ②肝大、脾大; ③血管瘤。CT（图2）: ①肝血管瘤栓塞术后改变; ②肝内多发囊性低密度影; ③脾大。诊断: ①肝内多发性囊性占位,胆汁瘤可能; ②肝血管瘤。遂行肝移植术，术后恢复良好。已切除病肝见囊肿内容物为混浊的有“渣”胆汁，分房状，不与胆管相通。病理提示： 病肝组织部分区域见内衬扁平细胞的由扩张血管构成的瘤样组织，少数管腔内含血栓成分； 部分区域间肝内和小胆管内多发性结石，并见较多胆汁湖形成，其周边部较易见泡沫细胞及巨嗜细胞，其余背景肝组织内部分肝细胞及毛细胆管侧胆汁淤积，毛细胆栓形成，较多胆管及细胆管增生，纤维组织增生并包绕肝小叶，部分区域见假小叶形成，内见胆管结石及部分残留胆管壁。诊断： ①肝海绵状血管瘤； ②肝内及小胆管内多发性胆管结石，继发性胆汁性肝硬变; ③胆汁瘤。 图1　MR示介入前多发血管瘤；图2　示介入后9个月肝内多发胆汁瘤(白箭为胆汁瘤,黑箭为血管瘤)。2A: 血管瘤和胆汁瘤; 2B: 胆汁瘤 　　讨论　TACE是医源性胆汁瘤的常见原因，其形成机理是由于TAE和（或）PEI的理化作用导致肿瘤或相应区域肝内胆管坏死。胆管周围毛细血管丛受损，可导致胆管坏死，胆汁经坏死的胆管漏向肝实质内，积聚成囊者为囊状胆汁瘤，沿坏死的胆管壁积聚者为柱状胆汁瘤。若囊肿与胆管的瘘口封闭则囊肿内壁内皮化，并产生分泌功能，分泌液体积蓄，导致囊肿越来越大； 较大的囊肿可压迫毗邻的胆管，使之梗塞，形成“软藤状”的胆管扩张。如果囊肿与胆管潜在相通，则在达到一定压力时，囊肿内液体进入胆管内，故囊肿不会明显增大。另一方面，这类与胆管相通的囊肿，因不断有胆汁在囊肿压力较低时自胆管进入囊肿，故引流亦未必能有效缩小囊肿。本例患者为肝血管瘤栓塞治疗后形成胆汁瘤，其CT平扫表现为椭圆形或分叶状的低密度病灶，其密度接近于胆囊内的密度，囊壁菲薄而不易发现，增强后扫描囊内不强化，囊壁不强化或轻度强化。故肝血管瘤行栓塞治疗方法值得进一步商榷。因此凡是反复进行TAE、PEI治疗的患者一般情况稳定，突然并发梗阻性黄疸，ＣＴ提示肝内囊性占位，应考虑有胆汁瘤形成的可能。

Development Status and Prospect of Donation after Cardiac Death

Interventive Effect of Xuebijing for Injection Combined with Nalmefene Hydrochloride Injection in Treatment of Acute Hepatocyte Functional Injury after Severe Thoracoab-dominal Injuries

ObjectiveTo investigate the interventive effect of xuebijing for injection combined with nalmefene hydrochloride injection in treatment of acute hepatocyte functional injury after severe thoracoabdominal injuries. MethodsClinal data of 169 patients with severe thoracoabdominal injuries who treated in The 253th Hospital of PLA between January 2009 and June 2013 were collected retrospectively. The trauma indexes of the 169 patients were all higher than 17 scores. Patients were divided into the intervention group (n=112) and the control group (n=57) according to their receptive treatment:patients of control group underwent traditional treatments such as antishock, hemostasis, and so on; but patients of intervention group received xuebijing for injection combined with nalmefene hydrochloride injection (intravenous infusion). Patients of intervention group were tested at the time of arriving at and leaving the emergency department to the inpatient department with alanine aminotransferase (ALT), aspartate aminotransferase (AST), tumor necrosis factor-α (TNF-α), lipopolysaccharide (LPS), and interleukin-6 (IL-6); the patients of control group were just tested at the time of leaving the emergency department to the inpatient department, then comparison of the indexes between the 2 groups was performed. ResultsIn intervention group, the levels of ALT, AST, TNF-α, LPS, and IL-6 after the interventive treatment were all lower than those of before interventive treatment (P<0.05). Compared with control group, there was no significant difference in the levels of ALT, AST, TNF-α, LPS, and IL-6 before the interventive treatment of intervention group (P>0.05); but the levels ALT, AST, TNF-α, LPS, and IL-6 were all lower after the interven-tive treatment (P<0.05). ConclusionsXuebijing for injection combined with nalmefene hydrochloride injection can evidently improve the acute hepatocyte functional injury after severe thoracoabdominal injuries, and improve the prognosis.

Research progress on the pathogenesis of chronic obstructive pulmonary disease complicated with lung cancer

[Abstract]Chronic obstructive pulmonary disease (COPD) occurs mostly in middle-aged and elderly people, and patients often have poor quality of life and can also induce a variety of other lung diseases. At the same time, the lung cancer with the highest morbidity and mortality in the world, has claimed the lives of countless patients. Since the incidence of lung cancer is much higher in patients with COPD than in the general population, there are many links between the two diseases that need to be studied and explored. Although many studies have explored the association between the two, there are few studies on the molecular level of them. This review will focuse on the latest research progress of the pathogenesis of COPD complicated with lung cancer from four aspects: the role of chronic inflammation, programmed cell death, gene and molecular role and lung microbiome imbalance, so as to provide a new reference for the prevention, diagnosis and treatment of COPD complicated with lung cancer.

Diagnosis and Treatment for Acute Graft Versus Host Disease after Liver Transplantation (Report of 2 Cases)

目的　探讨肝移植术后早期并发急性移植物抗宿主疾病(GVHD)的诊断和治疗。方法　回顾性分析我院2006年5月至2007年10月期间行肝移植手术50例，其中2例术后并发GVHD，分析该2例肝移植术后第14 d和第18 d以出现不明原因发热、皮疹、口腔多发溃疡、全血细胞减少、皮肤病理活检等临床资料为诊断依据和以不同的免疫抑制剂治疗的方案。结果　第1例患者加强免疫抑制剂治疗，发生败血症于术后67 d死于多器官功能衰竭； 第2例减少免疫抑制剂治疗，术后96 d治愈。结论　肝移植术后并发GVHD，减少免疫抑制剂方案可能是一种有效方案，但应警惕急性排斥反应和继发感染发生。

Investigation on the Correlation between Tumor Necrosis Factor-α, Interleukin-6, Phospholipase A2 and Acute Myocardial Cell Function Disorders after Severe Chest-abdomen Injury

ObjectiveTo investigate the correlation between tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), phospholipase A2 (PLA2) and myocardial cell function disorders in severe chest-abdominal injury patients. MethodsEighty-two subjects with severe chest-abdominal injury were collected from January 2009 to June 2012, of whom the trauma index were all above or equal to 17 points. As the rescue and treatment were in progress, the patients were examined for their creatine kinase-MB (CK-MB), cardiac troponin T (cTnT), TNF-α, IL-6, and PLA2 for correlation analysis. Another 82 subjects undergoing physical examination during the same time were chosen as the controls, who were again divided into myocardial cell function control group with 46 subjects and injury factors control group with 36 subjects. ResultsFor the myocardial cell function control group, CK-MB was (8.13±3.64) U/L, and cTnT was (26.71±11.58) pg/mL; for the injury group, those two indexes were respectively (158.74±31.59) U/L and (496.25±58.46) pg/mL. For the injury factors control group, TNF-α was (1.28±0.59) ng/mL, IL-6 was (63.93±41.49) ng/mL, and PLA2 was (7.47±5.27) ng/mL; for the injury group, those three indexes were respectively (36.41±18.09) ng/mL, (393.83±143.86) ng/mL, and (41.35±14.26) ng/mL. For severer chest-abdominal injury patients, all correlation factors between CK-MB and TNF-α, IL-6, PLA2 were above 0.911, and the factors between cTnT and TNF-α, IL-6, PLA2 were all above 0.912, and all correlations were positive. ConclusionTNF-α, IL-6 and PLA2 all participate in the process of acute myocardial cell function disorders in severe chest-abdominal injury patients. Early intervention of TNF-α, IL-6, and PLA2 may reduce myocardial cell damage, and improve patients' survival rate.

Correlations between Lipopolysaccharide, Phospholipase A2 and Platelet-activating Factor with Coagulopathy after Severe Chest and Abdominal Injuries and Their Mechanisms

ObjectiveTo investigate the correlations between lipopolysaccharide(LPS), phospholipase A2 (PLA2) and platelet-activating factor (PAF) with coagulopathy after severe chest and abdominal injuries and their mechanisms. MethodsClinical data of 82 patients with severe chest and abdominal injuries whose trauma index (TI) was greater than or equal to 17 points in No. 253 Hospital of People's Liberation Army from January 2009 to June 2012 were retrospectively analyzed (severe chest and abdominal injury group). Those patients who had concomitant traumatic brain injuries or died in the Emergency Department were excluded from this study. There were 58 male and 24 female patients with their age of 16-76 (43.59±16.33)years. There were 17 patients with open injuries and 65 patients with closed injuries. There were 23 patients with fall injuries, 47 patients with traffic injuries, 8 patients with blunt force injuries, and 4 patients with penetrating injuries. Forty-two healthy volunteers who received routine medical examinations in the outpatient department of our hospital were chosen as the control group, including 27 males and 15 females with their age of 24-47 (37.32±10.45) years. Blood platelet (PLT) count, D-dimer (D-D), activated partial thromboplastin time (APTT), LPS, PLA2 and PAF were compared between the 2 groups, and linear correlation analysis was performed. ResultsPLT of the severe chest and abdominal injury group patients were significantly lower than that of the control group[(83.44±38.52)×109/L vs. (191.52±23.31)×109/L]. D-D[(1 823.89±608.02) U/L vs. (105.78±44.53) U/L], APTT [(68.24±24.12) s vs. (22.47±9.41) s], LPS[(438.66±106.02) U/L vs. (87.38±46.51) U/L], PLA2 [(41.35±14.26) ng/ml vs. (7.47±5.27)ng/ml] and PAF[(15 765.31±4 431.65) ng/L vs. (3 823.45±529.72) ng/L] of the severe chest and abdominal injury group patients were significantly higher than those of the control group(P < 0.001). PLT was significantly negatively correlated with LPS, PLA2 and PAF with all the respective correlation coefficient(r)less than-0.933 5. D-D and APTT were significantly positively correlated with LPS, PLA2 and PAF with all the respective r larger than 0.921 6. ConclusionLPS, PLA2 and PAF participate in the pathogenesis of coagulopathy in patients with severe chest and abdominal injuries. Early intervention against LPS, PLA2 and PAF may improve coagulopathy and survival rate of patients with severe chest and abdominal injuries.

Correlations between Tumor Necrosis Factor-α and Lipopolysaccharide with Acute Myocardial Dysfunction after Severe Thoraco-abdominal Injuries and Their Mechanisms

ObjectiveTo investigate the correlations between tumor necrosis factor-α (TNF-α) and lipopolysaccharide (LPS) with acute myocardial dysfunction after severe thoraco-abdominal injuries and possible mechanisms. MethodsClinical data of 82 patients with severe thoraco-abdominal injuries who were admitted to the 253rd Hospital of People's Liberation Army from January 2009 to June 2012 were retrospectively analyzed,whose trauma index (TI) were all above or equal to 17 points. Patients with concomitant brain injuries and patients who were brought in dead were excluded from this study. There were 58 male and 24 female patients with their age of 16-76 (43.59±16.33) years. There were 17 patients with open injuries and 65 patients with closed injuries. There were 23 patients with fall injuries,47 patients with traffic injuries,8 patients with blunt injuries,and 4 patients with penetrating injuries. The time from injury to admission was 1.51±0.52 hours. Blood creatine kinase-MB (CK-MB) cardiac troponin T (cTnT) TNF-α and LPS were examined during emergency treatment,and the correlations between the results were analyzed. ResultsMyocardial dysfunction was shown by CK-MB of 158.74±31.59 U/L and cTnT of 496.25±58.46 pg/ml. Injury factors were TNF-α of 36.41±18.09 ng/ml and LPS of 343.66±106.02 U/L. CK-MB was positively correlated with TNF-α and LPS with the correlation coefficient (r) of 0.923 1and 0.883 2 respectively. cTnT was also positively correlated with TNF-α and LPS with r of 0.955 6 and 0.889 1 respectively. ConclusionBoth TNF-α and LPS participate in the pathogenesis and development of acute myocardial dysfunction after severe thoraco-abdominal injuries. Early intervention against TNF-α and LPS may alleviate acute myocardial dysfunction and improve patients' survival rate after severe thoraco-abdominal injuries.

Study on Correlation Between The Lipopolysaccharide， Interleukin-6，Platelet Activating Factor，and Coagulation Dysfunction after Severe Thoracic and Abdominal Trauma

目的　探讨脂多糖（LPS）、白细胞介素-6（IL-6）和血小板活化因子（PAF）与重症胸腹创伤后凝血功能紊乱发生的相关性及可能的致病机理。方法　收集2009年1月至2011年12月期间在中国人民解放军第二五三医院急诊科就诊、创伤指数≥17分且除外合并颅脑损伤及在急诊科内死亡的胸腹创伤患者62例，在予以抢救、治疗的同时抽血检查血小板计数（PLT）、血浆D-二聚体（D-D）、部分活化凝血酶原时间（APTT）、凝血酶原时间（PT）、LPS、IL-6和PAF，并对其结果进行相关性分析。结果　本组患者就诊时检测的PLT为（157.73±78.11）×109/L， D-D为（1 023.88±208.72） U/L，APTT为（46.95±17.85） s，PT为（19.44±6.95） s，TT为（58.27±12.44）s，除PLT降低外，其余4项指标均升高或延长； LPS为（322.85±104.54） U/L，IL-6为（285.51±81.46） ng/mL，PAF为 （14 714.70±4 427.95） ng/L， 三者均升高； PLT与LPS、IL-6和PAF之间呈负相关关系（P＜0.001），而D-D、APTT、PT和TT与LPS、IL-6和PAF之间均呈正相关关系（P＜0.001）。结论　LPS、IL-6及PAF可能参与了重症胸腹创伤后凝血功能障碍的发生；重症胸腹损伤后出现的微循环障碍及内毒素血症是凝血功能障碍发生的重要机理。针对LPS、IL-6和PAF进行早期干预，有可能改善重症胸腹创伤患者的凝血功能障碍。