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肝移植术后复杂胆汁淤积型肝损伤的多学科综合诊疗

黄鹤宇 孙晓东 陈玉国 夏旭翔 吕国悦

黄鹤宇, 孙晓东, 陈玉国, 等. 肝移植术后复杂胆汁淤积型肝损伤的多学科综合诊疗[J]. 器官移植, 2021, 12(6): 720-726. doi: 10.3969/j.issn.1674-7445.2021.06.012
引用本文: 黄鹤宇, 孙晓东, 陈玉国, 等. 肝移植术后复杂胆汁淤积型肝损伤的多学科综合诊疗[J]. 器官移植, 2021, 12(6): 720-726. doi: 10.3969/j.issn.1674-7445.2021.06.012
Huang Heyu, Sun Xiaodong, Chen Yuguo, et al. Multi-disciplinary team of complex cholestatic liver injury after liver transplantation[J]. ORGAN TRANSPLANTATION, 2021, 12(6): 720-726. doi: 10.3969/j.issn.1674-7445.2021.06.012
Citation: Huang Heyu, Sun Xiaodong, Chen Yuguo, et al. Multi-disciplinary team of complex cholestatic liver injury after liver transplantation[J]. ORGAN TRANSPLANTATION, 2021, 12(6): 720-726. doi: 10.3969/j.issn.1674-7445.2021.06.012

肝移植术后复杂胆汁淤积型肝损伤的多学科综合诊疗

doi: 10.3969/j.issn.1674-7445.2021.06.012
基金项目: 

吉林省科技发展计划项目 20190201268JC

详细信息
    作者简介:

    黄鹤宇,女,1986年生,硕士,主治医师,研究方向为肝移植,Email: 1286220318@qq.com

    通讯作者:

    吕国悦,男,1977年生,博士,主任医师,研究方向为肝移植,Email: lgy08@sina.com

  • 中图分类号: R617, R575

Multi-disciplinary team of complex cholestatic liver injury after liver transplantation

More Information
  • 摘要:   目的  探讨多学科综合诊疗(MDT)在肝移植术后复杂胆汁淤积型肝损伤中的作用。  方法  对吉林大学第一医院肝移植中心2020年6月23日收治的1例肝移植术后复杂胆汁淤积型肝损伤病例进行MDT讨论,明确病因及治疗策略,并总结MDT在肝移植术后复杂胆汁淤积型肝损伤治疗中的作用。  结果  患者肝移植术后肝功能异常,先后明确诊断为胆道狭窄、排斥反应及胆道感染,内镜逆行胰胆管成像(ERCP)支架内外双引流、糖皮质激素冲击、抗感染等治疗效果不佳。经MDT讨论,明确诊断为肝移植术后复杂胆汁淤积型肝损伤,建议在病理辅助排除排斥反应基础上优化免疫抑制方案,行针对性抗感染治疗,并预防可能伴随出现的药物性肝损伤。后患者恢复良好,治愈出院。  结论  肝移植术后复杂胆汁淤积型肝损伤病因复杂,病情动态变化,通过MDT讨论可提高对该疾病的认知和加强对诊治思路的梳理,提高治疗的针对性和有效性。

     

  • 图  1  患者MDT讨论前影像学表现

    Figure  1.  Imaging findings of the patient before MDT consultation

    图  2  首次ERCP后移植肝病理学表现

    注:A图示肝腺泡/小叶结构维持正常,肝细胞胆汁淤积、毛细胆管胆栓,汇管区扩张,可见重度混合性炎症细胞浸润(苏木素-伊红,×100);B图为A图箭头处放大,肝窦略有扩张,中央静脉管腔扩张,周围融合坏死伴有出血,中央静脉内皮炎(苏木素-伊红,×200);C图为A图星号处放大,汇管区可见中度混合性炎症细胞浸润,未见明显界面炎,汇管区小胆管可辨,轻度增生,炎症细胞攻击小胆管,致胆管上皮排列不整,未见明显门静脉支内皮炎,汇管区间质未见明显纤维组织增生(苏木素-伊红,×400)。

    Figure  2.  Pathological manifestations of liver allograft after the first ERCP

    图  3  第2次ERCP后移植肝病理学表现

    注:A图示肝腺泡/小叶结构维持正常,肝细胞胆汁淤积、毛细胆管胆栓,肝窦略有扩张,汇管区轻度扩张,可见轻度混合性炎症细胞浸润(苏木素-伊红,× 200);B图示肝细胞胆汁淤积、毛细胆管胆栓,部分肝小叶内见胆汁湖形成(苏木素-伊红,× 200);C图示汇管区可见中度混合性炎症细胞浸润,未见明显界面炎,汇管区小胆管轻度增生,胆管上皮排列不整齐,较多中性粒细胞围绕胆管,并见胆栓,未见明显门静脉支内皮炎,汇管区间质未见明显纤维组织增生(苏木素-伊红,× 200)。

    Figure  3.  Pathological manifestations of liver allograft after the second ERCP

    表  1  患者不同时期肝功能变化情况

    Table  1.   Changes of liver function of the patient in different periods

    日期 AST(U/L) ALT(U/L) GGT(U/L) ALP(U/L) TB(μmol/L) DB(μmol/L) TBA(μmol/L)
    7月6日(第1次ERCP术后) 318 45 275 605 101.5 66.2 107.0
    7月11日(激素冲击治疗后) 128 32 434 690 181.6 109.8 122.1
    7月20日(第2次ERCP术后) 69 46 450 365 210.2 116.1 22.7
    7月23日(MDT讨论后1 d) 59 43 456 396 196.0 102.5 24.3
    7月31日(MDT讨论后1周) 71 38 514 403 159.7 80.3 49.3
    8月14日(MDT讨论后3周) 36 25 452 386 69.7 53.3 6.5
    8月24日(出院) 32 15 419 452 52.1 29.2 59.8
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  • 收稿日期:  2021-08-05
  • 刊出日期:  2021-11-15

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