“基本正常肝组织”的病理鉴别诊断思路

张萌萌; 孟尧; 赵新颜

doi:10.3969/j.issn.1001-5256.2023.03.006

“基本正常肝组织”的病理鉴别诊断思路

DOI: 10.3969/j.issn.1001-5256.2023.03.006

首都医科大学附属北京友谊医院肝病研究中心，国家消化系统疾病临床医学研究中心，北京 100050

利益冲突声明：所有作者均声明不存在利益冲突。

作者贡献声明：张萌萌起草、撰写文章；孟尧论文修改及支持性贡献；赵新颜对文章的知识性内容作批评性审阅，指导，支持性贡献。

详细信息

通信作者:
赵新颜，zhao_xinyan@ccmu.edu.cn (ORCID: 0000-0002-8016-4368)

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出版历程
- 收稿日期: 2023-01-11
- 录用日期: 2023-02-18
- 出版日期: 2023-03-20

Differential pathological diagnosis of liver tissue with normal appearance

Liver Research Center, Beijing Friendship Hospital, Capital Medical University & National Clinical Research Center for Digestive Diseases, Beijing 100050, China

More Information

Corresponding author: ZHAO Xinyan, zhao_xinyan@ccmu.edu.cn (ORCID: 0000-0002-8016-4368)

摘要

摘要: 肝脏病理活检是明确肝脏疾病诊断的关键手段，对判断病情严重程度、决策治疗时机、预测疗效及预后具有重要价值。病理专家通过识别肝脏病理损伤模式判断病变性质，作为诊断及鉴别诊断依据，其中一类病理损伤模式，看似“基本正常”，实则需要细致入微地观察易被忽略的病理变化，从而减少误诊或漏诊。本文重点介绍了“基本正常”的肝组织病理诊断思路及鉴别诊断要点。
- 肝疾病 /
- 病理学 /
- 诊断, 鉴别
Abstract: Liver biopsy is a key method for clarifying the diagnosis of liver diseases and has an important value in determining disease severity, deciding treatment timing, and predicting treatment response and prognosis. By recognizing the pattern of liver pathological injury, pathologists evaluate the nature of lesions as the basis of diagnosis and differential diagnosis, and among these patterns, liver tissue with "normal appearance" requires careful observation of easily overlooked pathological changes, so as to reduce misdiagnosis or missed diagnosis. This article mainly introduces the thoughts in the pathological diagnosis of liver tissue with normal appearance and the key points in differential diagnosis.
- Liver Diseases /
- Pathology /
- Diagnosis, Differential

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图 1 基本正常肝脏病理的鉴别诊断思路

Figure 1. Differential pathological diagnosis of liver tissue with normal appearance

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图 2 甲基丙二酸血症、鸟氨酸氨甲酰基转移酶缺乏症及慢性HBV感染的肝脏病理特点

注：a，甲基丙二酸血症患者肝移植病肝活检未见异常(HE染色，×100)；b，慢性HBV感染患者肝细胞大小不等，可见毛玻璃样肝细胞(HE染色，×600)；c，毛玻璃样肝细胞HBsAg免疫组化染色阳性，呈包涵体样(免疫组化，×600)；d，鸟氨酸氨甲酰基转移酶缺乏症患者病肝组织病理特点呈区域性疏松水肿，汇管区均未见明显炎性细胞浸润(HE染色，×100)。

Figure 2. Liver pathological features of methylmalonic acidemia, ornithine carbamyltransferase deficiency and chronic HBV infection

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图 3 糖原贮积病及糖尿病的肝脏病理特点

注：a，Ⅰ型糖原贮积病肝脏病理组织可见小叶内肝细胞疏松水肿(马赛克征)，肝窦变窄消失(HE染色，×400)；b，肝糖原异常增多(PAS染色，×400)；c，糖尿病患者肝脏病理组织可见小叶内肝细胞普遍疏松水肿，部分肝窦受压变窄，糖原核肝细胞易见(HE染色，×400)。

Figure 3. Liver pathological features of glycogen storage disease and diabetes mellitus

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图 4 Dubin-Johnson综合征、血色病及Gilbert综合征的肝脏病理特点

注：a，Dubin-Johnson综合征病理特点为肝细胞内弥漫分布粗大色素颗粒，无折光性，聚集于中央静脉周围(HE染色，×200)；b，Schmorl染色可见色素颗粒沉积于中央静脉周围(Schmorl染色，×200)；c，血色病患者肝细胞镜下可见粗大的色素颗粒，具有折光性(HE染色，×200)；d，血色病病理特点为铁染色呈强阳性(普鲁士蓝染色，×200)；e，Gilbert综合征病理特点为肝小叶结构正常，肝细胞胞质内大小不一的胆色素颗粒，集中在中央静脉附近(HE染色，×400)。

Figure 4. Liver pathological features of Dubin-Johnson syndrome, hemochromatosis and Gilbert syndrome

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图 5 VBDS的肝脏病理特点

注：a，汇管区未见与小动脉伴行小胆管(HE染色，×400)；b，胆管染色证实小胆管缺失，周围肝细胞胆管化生(CK7染色，×400)。

Figure 5. Liver pathological features of VBDS

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图 6 PSVD及充血性心力衰竭的肝脏病理特点

注：a，PSVD病理特点，汇管区小胆管可辨，门静脉缺失(HE染色，×400)；b，汇管区间质纤维化(Masson染色，×400)；c，充血性心力衰竭导致的肝脏淤血，肝窦内可见大量红细胞沉积，肝细胞及汇管区未见明显异常(HE染色，×400)；d，肝窦扩张不伴淤血(HE染色，×400)。

Figure 6. Liver pathological features of PSVD and congestive heart failure

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