非酒精性脂肪性肝病的诊断

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1、非酒精性脂肪性肝病的诊断与治疗川北医学院附属医院消化内科概念Fattyliver(hepaticsteatosis)Excessiveaccumulationoflipidinhepatocytes,themostcommonresponseofthelivertoinjury.脂肪肝(定义)疾病谱病因单纯性脂肪肝脂肪性肝硬化脂肪性肝炎酒精性肝病NAFLD原发性继发性流行病学*Definingnonalcoholicfattyliverdisease:implicationsforepidemi

2、ologicstudies.Gastroenterology.2003Jan;124(1):248-50.Review.Indeed,thepreponderanceofasymptomaticindividualswithfattyliverhastemptedsometoconcludethatfattyliveralonemaybeavariantofnormalcy,ratherthanatruediseaseHowever,applyingsimilarlogicwouldforceo

3、netoconcludethatasymptomaticindividualswithabloodpressureof180/100mmHg,afastingbloodsugarof180mg/dL,orlowdensitylipoproteinsof200mg/dL,whileabnormal,donothaveadiseasestate“stillwatersrundeep.”随着社会经济发展，非酒精性脂肪性肝病（NAFLD）患病率迅速增高，现已成为危害人类健康的三大肝病之一NAFLD与失代

4、偿期肝硬化、肝功能衰竭、原发性肝癌的发生密切相关在美国，NAFLD是转氨酶长期增高及隐源性肝硬化最常见的原因**ClarkJM,DiehlAM.Nonalcoholicfattyliverdisease:anunderrecognizedcauseofcryptogeniccirrhosis.JAMA,2003，289:3000-3004研究表明，肥胖是NAFLD的独立危险因素肥胖者中NAFLD的发生率约为50%，其中，单纯性脂肪肝30%，非酒精性脂肪性肝炎（NASH）24-30.5%，肝纤维化

5、28%，肝硬化1.5-8%这种与肥胖相关的NAFLD已成为全球普遍关注的医学问题和社会问题NAFLD可能为欧美等发达国家第一大肝病，成人脂肪肝患病率高达20％～30％，其中10％或2％～3％的成人为NASH，约1/3NASH病人并发进展性肝纤维化和肝硬化。肥胖人群的发生率更高儿童NAFLD/NASH发病率亦不断增高，NASH青少年肝纤维化发生率70%，并有肝硬化发生病理Twopatternsofhepaticsteatosis:(1)microvesicularsteatosis:thecyto

6、plasmisreplacedbybubblesoffatthatdonotdisplacethenucleus(2)macrovesicularsteatosis:thecytoplasmisreplacedbyalargebubbleoffatthatdisplacesthenucleustotheedgeofthecell*FromSanyalAJ.Nonalcoholicsteatohepatitis.ClinicalPerspectivesinGastroenterology.2000

7、;129Steatohepatitisisshownhere.Thehistologicfindingsshownincludemacrovesicularsteatosis,cytologicballooning,Mallorybodies,andscatteredlobularinflammationMallorybodyisshownwithinaballoonedhepatocytePericellularfibrosisisshown(Masson'strichromestain).T

8、hecollagenoustissue(showninblue)surroundsindividualhepatocytes,producingachicken-wireappearance.病因发病机制发病机制Day的二次打击学说NAFL初次打击主要是IR，IR通过促进外周脂肪分解和高胰岛素血症引起肝细胞脂肪变性，并启动细胞适应程序，而脂肪变性的肝细胞活力相对不足并为氧应激提供了足够的反应基质，结果脂肪变性的肝细胞对内、外源性损害因子的敏感性增强*DayCP,JamesOF.Steatohep