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摘要: 酒精性肝病（ALD）是由于长期大量饮酒导致的肝脏疾病。随着我国人民物质生活水平的提高，ALD的发病率也呈明显上升趋势。典型的ALD病变模式包括酒精性脂肪肝、酒精性脂肪性肝炎、肝纤维化以及酒精性肝硬化。然而，ALD组织病理形态的多样性、复杂性以及与其他肝病组织形态的相似性对于临床病理学诊断而言是一个巨大的挑战。本文就ALD的组织病理学形态、分级和分期系统以及鉴别诊断等作一综述。Abstract: Alcoholic liver disease （ALD） is a liver disease caused by long-term heavy drinking. With the improvement in the living standard of Chinese people， the incidence rate of ALD tends to increase significantly. The typical pathological patterns of ALD include alcoholic steatosis， alcoholic steatohepatitis， liver fibrosis， and alcoholic cirrhosis. The diverse and complex pathological morphology of ALD and its similarities with other liver diseases pose a great challenge to pathologists. This article reviews the histopathological morphology， grading and staging systems， and differential diagnosis of ALD.
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Key words:
- Liver Diseases， Alcoholic /
- Biopsy /
- Pathology /
- Diagnosis
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图 1 ALD的主要组织病理学特征
注： a，肝细胞大泡性脂肪变，绿色箭头示大泡性脂肪变中的大脂滴，红色箭头示小脂滴，但轮廓清晰仍属大泡性脂肪变，黑色箭头示脂质肉芽肿（HE染色，×400）；b，肝细胞微泡性脂肪变（HE染色，×1 000）；c，肝细胞气球样变伴Mallory小体形成（HE染色，×1 000）；d，免疫组化CK8/18染色，箭头所示为染色阳性的绳索样Mallory小体（DAB显色，×1 000）；e，巨线粒体（箭头所示）（HE染色，×1 000）；f，肝实质内中性粒细胞浸润，部分包绕在气球样变的肝细胞周围，被称为“卫星现象”（HE染色，×400）；g，ALD相关肝衰病例可见多量Mallory小体及中性粒细胞浸润（HE染色，×400）；h，窦周纤维化（Masson染色，×400）；i，中央静脉周围纤维化，箭头示胶原纤维在中央静脉外侧壁沉积，导致静脉壁明显增厚（HE染色，×400）；j，小叶中心硬化性玻璃样坏死（HE染色，×200）；k，小结节性酒精性肝硬化（网状纤维染色，×100）；l，汇管区星芒状纤维化（Masson染色，×200）。
Figure 1. Major histopathological features of ALD
图 2 ALD的其他病理学改变
注： a，汇管区水肿，伴显著的细胆管反应和中性粒细胞浸润，模拟大胆管梗阻样形态（HE染色，×400）；b，肝小叶3区毛细胆管淤胆（HE染色，×400）；c，汇管区细胆管增生伴扩张及淤胆（Lenta胆管炎）（HE染色，×400）；d，中度含铁血黄素沉积，位于汇管区周围（普鲁士蓝染色，×200）；e，肝细胞嗜酸性变（HE染色，×1 000）；f，高级别异型增生结节中的小细胞变（HE染色，×400）。
Figure 2. Other pathological findings of ALD
表 1 AHS与NASH的组织学特征比较
Table 1. Characteristic histologic features of ASH versus NASH
组织病理学 酒精性脂肪性 肝炎 非酒精性脂肪性肝炎 大泡性脂肪变 + ++ 微泡性脂肪变 +/- +/- 肝细胞气球样变 ++ + Mallory小体 ++ +/- 巨线粒体 +/-～+ +/- 中性粒细胞浸润 ++ + 肝细胞坏死/凋亡 ++ + 窦周纤维化 ++ + 中央静脉周围纤维化 +～++ + 硬化性玻璃样坏死 +/- - 胆汁淤积 +/-～+ - Lenta胆管炎 +/- - 糖原核 +/- + 汇管区细胆管反应 + +/- 汇管区炎症和纤维化 +～++ +/- 注：++，几乎总是存在；+，通常存在；+/-，偶然存在；-，通常缺乏。 
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