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1、王炳元 教授中国医大一院老年消化内分泌科主任 教授、博士生导师,中国医师协会脂肪肝专家委员会 副主任委员中国老年医学学会消化分会 常委中华消化学会老年协作组 副组长中华消化学会肝胆协作组 委员中华医学会辽宁省消化分会 副主任委员辽宁省中西医结合肝病学会 副主任委员辽宁省医学会肝病分会 常委辽宁省免疫学会老年免疫分会 主任委员,Wang Bing Yuan (王炳元)Department of Geriatric Gastroenterology, The First Hospital of China Medical University, Shenyang, CHINA （中国医科大学附属第
2、一医院老年消化科, 沈阳，中国）,脂肪肝诊治进展,什么是脂肪肝？,肝细胞内脂质积聚超过肝湿重的5%称之脂肪肝。正常人肝脏内脂质含量占肝湿重的2%4%，其中2/3为磷脂，此外尚有胆固醇、中性脂肪，主要是构成细胞膜及其他细胞器的膜。大多数脂肪肝属于三酰甘油含量异常增高，根据脂肪含量，可将脂肪肝分为轻型(含脂肪5%10%)，中型(含脂肪10%25%)，重型(含脂肪25%50%或30%)三型。,病理切片：每个视野下脂肪变的细胞33%称为脂肪肝33%-67% 中度脂肪肝；67% 重度脂肪肝,中国脂肪肝有何特点？,Prevalence of non-alcoholic fatty liver diseas
3、e in various high-risk groups compared with the general adult population.,Digestive and Liver Disease 47 (2015) 9971006,导致脂肪肝的原因和危害因素？,脂肪肝分几大类？,酒精性脂肪肝（酒精）非酒精性脂肪肝（遗传环境与代谢）其他脂肪肝（病因明确）,非酒精性脂肪性肝病（即脂肪肝）是如何发生的？,Figure 1: Overlap in Pathogenesis in NAFLD and ALD,Hepatology. 2017 Jan 18.,Multiple hit,In the
4、 first hit, there is an accumulation of triglyceride as lipid droplets within the cytoplasm of hepatocytes (steatosis) in more than 5% of hepatocytes. Insulin resistance contributes to this hepatic steatosis. This phase of benign hepatic steatosis is reversible and can be self-limited but makes the
5、liver susceptible to the second hit which advances the liver to a necroinflammatory stage, i.e., NASH.,Multiple hit,The second hit includes oxidative stress (free radical formation due to excessive fatty acid oxidation), cardiolipin (present on inner mitochondrial membrane) peroxidation leading to m
6、itochondrial dysfunction and more reactive oxygen species formation, pro-inflammatory cytokine formation, apoptosis and gut-derived bacterial endotoxinemia.,Multiple hit,The third hit includes palatine-like phospholipase 3 (PNPLA3) gene involvement, and impaired hepatocyte regeneration. Certain sing
7、le nucleotide polymorphisms (SNPs) have been found to be associated with higher frequency, severe histologic changes and more progression of NAFLD. Variant SNPs in PZP and PNPLA3 genes were found to be independent risk factors for the development of NAFLD. Hence genetics play an important role along
8、 with metabolic factors in the development of NAFLD.,A total of 7 observational studies met criteria for inclusion (one for cardiovascular endpoints and 6 forliverendpoints). There was a positive association between moderate alcohol use and decreased NASH and fibrosis, however heavy episodic drinkin
9、g may accelerate fibrosis progression and in patients with advanced fibrosis moderate alcohol use may increase the risk of hepatocellular carcinoma.,Hepatology. 2017 Jan 18.,酒精对脂肪肝的影响,2022/11/30,19,可编辑,脂肪肝的结局,Progression of non-alcoholic fatty liver disease (NAFLD) to non-alcoholic steatohepatitis (
10、NASH) with or without fibrosis, cirrhosis, and hepatocellular carcinoma.,J. Hepatol.2015;62:11481155. Hepatol.2015;13:643654.,脂肪肝的必要检查,人体学,血压、脉搏、呼吸、身高、体重、腰围、臀围病史：年龄性别、文化程度、职业；饮酒史、肥胖史、疾病史、用药史；饮食结构、运动方式 和程度化验检查：肝功能、血脂、血常规、尿常规、尿酸、病毒学、胰岛功能、血糖（0和120min）、肾功能,Simple steatosis NASH cirrhosis. NASH classific
11、ation: type 1: Simple steatosis;type 2: steatosis + inflammation (lobular and portal) NASH; type 3: steatosis + ballooned hepatocytes NASH; type 4: steatosis + fibrosis NASH.,安全、准确、标准量化、无创？,影像检查,影像检查,脂肪肝的对策,2. 药物治疗策略,抗炎保肝药物的分类,.王宇明.抗炎保肝药物的作用机制及地位.中华肝脏病杂志,2011,19(1):76-77.,继续巩固治疗6-12个月,药物治疗的疗程,总结,脂肪肝已经成为我国第一大肝病必须了解和重视脂肪肝的危害要认真进行脂肪肝的检查充分利用脂肪肝无创检查的手段加强患者的健康指导和彻底治疗,Thank You !,脂肪肝诊治进展王炳元 中国医科大学附属第一医院老年消化科 ,2022/11/30,38,可编辑,
