肝癌破裂出血的临床特点和诊治分析

肝癌破裂出血的临床特点和诊治分析[1]

郑惊雷 王在国 游志坚 陈刘镇 李庆贤

（广东省东莞市人民医院肿瘤外科，广东 东莞523059）

The study of the clinical features in the diagnosis and treatment for the ruptured liver cancer with hemorrhage. Zheng Jinglei,Wang Zaiguo,You Zhijian,et al.Oncology surgery, CancerCenter, Dong Guan People’s hospital,Guangdong523059

[Abstract] Objective To investigate the clinical features and efficacy of liver rupture in the diagnosis and treatment so as to provide future reference for their clinical treatment. MethodsThe clinical data of 87 cases of spontaneous rupture from 2003.1 to2010.7 inour hospital were investigated with a retrospective analysis. Among them, 28 cases were underwent emergency hepatectomy (6 cases of liver resection were appliacated in the homeostasis after bleeding control with intervention; one case was resected under the bleeding control with conservative treatment); 11 cases were treated with palliative surgery; 23 cases were underwent TAE (or TACE) ; 15 cases were treated by conservative treatment. Results In the 28 cases of emergency liver resection, there were14 cases operated by irregular hepatectomy (11 cases of right hepatoma, 3 cases of left), and there complications and mortality were low. Meanwhile the occurrence of liver failure and mortality were higher as contrasted to irregular hepatectomy. In the emergency liver resection, 2 patients died after operation, and the remained 26 cases were successful treatment with rebreeding after operation. Their incidences of liver failure were low relatively. The average 1-year survival rate of patients was 78.8%,and mean survival time was 437.2 ± 101.4 days. In the 11 patients of the palliative surgery group, 7 patients were hemostasis, 4 cases occurred rebreeding. Its average one-year survival rate was 18.2%, and the average survival time was 79.8 ± 48.6 days. In the 23 patients of the intervention group, the bleeding was stopped and control in 21 patients successfully, while 4 cases of death due to liver failure. In the patients of intervention group, 6 patients accepted hepatectomy after the control of bleeding by TACE and discharged successfully. Its one-year survival rate was 60.0%, and the average survival time was 289.5 ± 92.7 days. In the 15 patients of the conservative treatment group, only 6 patients were hemostasis, and the liver failure and mortality were 66%. Its 1-year survival rate was 15.4%, and the average survival time was 68.8 ± 37.1 days. Conclusion Spontaneous rupture of the liver cancer is one of the most lethal complications. A considerable number of patients of hepatocellular carcinoma occurs bleeding as the first symptom. Irregular liver resection is recommended and preferred surgical procedures as long as the patients conditions allow the emergency liver resection. Intervention of TACE is effective to patients with well hemostatic effect and could prolong survival period. The prognosis of palliative surgery is poor, so conservative treatment should not be recommended alone.

[Key words]primary liver cancer; rupture; bleeding; irregular hepatectomy; treatment

肝癌破裂出血由于具有发病急骤，病情重，病死率高的特点，是原发性肝癌最严重的并发症之一。我国肝癌病人由于大部分在肝炎、肝硬化的基础上发展而来，一般肝脏功能和全身情况较差，加上出血和肿瘤双重因素的打击，往往导致临床处理较为困难^【1,2】。因此早期明确诊断，及时制定有效治疗方案，尽早治疗有利于提高疗效，延长生存期和改善预后。我院2003年1月～2010年7月共收治肝癌破裂出血患者87例，现将其诊治情况报告如下。

1 资料与方法

1．1 一般资料

本组87例肝癌破裂出血患者中，男性63例，女性24例；年龄8～82岁(平均50.9±16.1岁)。既往有明确慢性乙型肝炎病史者57例，肝硬化病史者33例，肝癌家族史3例。

1．2临床表现

所有患者均有不同程度的急性腹痛病史，其中76例为突发性剧烈上腹疼痛（87.4％），45例以出血为首发临床表现(51.7％)，43例合并失血性休克(49.4％)，发热11例，黄疸9例，有明显贫血貌63例(72.4％)，腹部饱满或膨隆70例(80.5％)，有明显腹膜刺激征者62例（71.3％），移动性浊音阳性69例（79.3％），肠音减弱或消失78例 (89.7％ )，肝肿大及上腹部包块30例（34.5％）。所有病例均行腹腔穿刺，其中75例抽出不凝固血液（86.2％）。全部病例均行B超检查，提示肝脏占位病变83例（95.4％），合并不同程度腹腔积液81例（93.1％），肝包膜下积液14例（16.1％）；79例行上腹部CT平扫或增强扫描，均提示肝脏占位性病变（100%），腹腔积液76例（87.4％），可疑腹腔积液3例（3.4％）。癌结节直径3．0～15.6cm(平均直径9.1cm)，单发癌灶60例(69.0％)，多发癌灶27例(31.0％)；AFP>400μg／L者46例(52.9％)，AFP>200μg／L且≤400μg／L者18例(20.7％)；肝功能Child-Pugh A级39例(44.8％)，B组33例(37.9％)，C级15例(17.2％)。有外伤史2例，其余患者均无明确的外伤史。

1．3 治疗方法

本组患者中行肝切除术35例（包括6例为介入止血后施行肝癌根治性切除，1例保守治疗止血后行肝癌切除），姑息性手术11例，介入治疗23例，单纯内科保守治疗15例。

2讨论

肝癌破裂是肝癌的一项致命性并发症，该病起病急，病情重，如得不到及时有效治疗，临床死亡率极高，可达95％以上^【1,2】。我国是肝癌的高发区，肝癌破裂出血约占肝癌死因的15％～20％，是导致肝癌病人临床死亡的最重要原因之一。因此早期诊断并及早治疗十分重要。

2．1 肝癌破裂的机制及预防

肝癌破裂的机制目前还没完全清楚，目前认为与肿瘤区静脉受阻结节内出血时使瘤体内部压力增加，肿瘤受到轻微的外力即可引起破裂，位于右膈下的肿瘤甚至呼吸是膈肌的活动也有可能使之破裂。另外，肝癌边缘门静脉常与动脉直接交通，门静脉压力增加，管壁变薄，也容易使肿瘤破裂出血^【3】。朱立新等^【4,5】研究认为肝癌破裂的原因是由于病人中存在第VIII因子相关抗原(vwF)在血管内皮细胞的表达量下降，胶原酶过度分泌及胶原纤维降解等，导致肝癌病人的血管壁较脆弱，稍有外力或血压升高的作用，易发生破裂出血，而凝血功能的低下，又使出血难以自止。本组有2例患者有明确外伤史，分别为摔倒着地和撞击季肋部后出现上腹剧烈疼痛。尽管有明确外伤的人数在全组总病例数中比例不大，但也一定程度上提示外力是引起和加速肝癌发生破裂的原因之一，肝癌患者须注意预防外伤性肿瘤破裂。

2．2 肝癌破裂出血的诊断

肝癌破裂出血大多以急性腹痛起病，其中有相当一部分患者就诊之前并未知自身癌灶存在，而以癌肿破裂出血腹痛为首发症状^【6】，故一般以急腹症就诊。突发性腹痛并腹腔内出血是其主要临床表现。对原因不明的上腹突然剧烈持续性疼痛，伴有面色苍白，出冷汗、脉搏增快，血压进行性下降等内出血症状，甚至休克，查体有明显腹膜刺激征，移动性浊音阳性，腹腔穿刺抽出不凝固血液者，应考虑本病。由于大多数患者有肝炎，肝硬变病史，因而对有明确肝癌病史或慢性肝病背景者尤应高度考虑本病的可能性。对无肝病史的“健康人”，有时易被误诊为急性胆囊炎胆道感染、胃十二指肠溃疡、急性阑尾炎、急性胰腺炎、肝脓肿、宫外孕等其他腹盆腔部疾病，这就需详问病史，细心观察和检查加以鉴别，如检查有无巩膜黄染、肝掌、蜘蛛痣等易忽略的体征。最简单快捷而有效的诊断和鉴别诊断方法是行腹腔穿刺。所有患者在行常规检查的同时应检测血清AFP水平，行腹部B超和上腹部CT，以明确肿物性质、大小、出血部位、肝硬化程度及有无远处转移，为选择治疗方式提供最直接的依据。本组所有患者均有不同程度的急性腹痛病史，其中87.4％患者表现为突发性剧烈上腹疼痛， 51.7％临床病人以出血为首发临床表现，有明显腹膜刺激征者占71.3％。腹腔穿刺阳性率达86.2％；B超检查确诊率93.1％，CT平扫或增强扫描对肝脏占位确诊率高达100%）；AFP显著升高者(>200μg／L)达70％以上。从本组结果可以看出，肝癌破裂出血一般诊断并不困难，AFP、腹腔穿刺、B超、CT均是有效诊断和鉴别诊断的有效手段。

2．3 肝癌破裂出血的处理

迅速控制出血、维持生命征稳定和保肝是治疗肝癌破裂出血的关键。肝癌破裂出血临床处理较为棘手，破裂部位常位于肝脏表面，出血不易自止。我国是肝癌的高发区，肝癌病人大部分在肝炎、肝硬化的基础上发展而来，一般肝脏功能和全身情况较差，加上出血和肿瘤双重因素的打击，易致肝肾功能恶化，病人愈后不理想，因此应合理选择的治疗方式。目前治疗方法主要有内科保守治疗、急诊肝切除手术、姑息性手术和介入治疗等，选用具体治疗措施应视病情实际而定。

对符合如下条件者，可考虑急诊根治性手术：(1)年龄小于60岁，一般情况较好；(2)肝功能Child分级为A级或B级，肝脏无明显萎缩或健侧代偿性增大；(3)术前影像学检查及术中证实为单个癌结节，无远处转移，有根治性切除可能者。也可术中同时行肝动脉和（或）门静脉置管皮下化疗泵埋置术，术后行区域性灌注化疗^【10,11】。

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[1] 【作者】郑惊雷 E-mail: jlzheng@126.com