肝硬化及其并发症讲课课件.ppt

1、肝硬化及其并发症PptRemains positiveRight-sided cardiac failure（umol/L）同时输注清蛋白对存活率无影响活动性：进行性、静止性、退行性Nephrotic syndromeAlbumin infusion of 50 g can be considered for paracenteses 5 L食管静脉曲张破裂：肝硬化史结节直径不等，一般3mm，可达3cm肝硬化及其并发症Ppt血气测定,血清K+、Na+、Cl-，Cr，肝功能急性UGI250300ml呕血PVS的选择标准和相对禁忌肝硬化腹水存活差的预测因素Hyponatremia82 mm Hg扑

2、翼样震颤、肌张力增高调控转录因子表达（C-JUN，C/EBP）静脉注射后大视野照像闪烁扫描正常人空腹静脉血氨 23.肝损伤（手术、感染等）启动因素（TNF及未知因子）调控转录因子表达（C-JUN，C/EBP）早觉基因及细胞因子表达（IL-6等）多种基因激活，翻译后调控细胞G0-G1期转变，感受态形成生长因子（HGF、TGF-、EGF、FGF等）调控进入细胞增殖周期A级：56分B级：79分C级：1015分正铁血红素）血红蛋白胃酸(5-Day course高频电凝：高频交流电，37秒Relative contraindicationsGram-positive organisms(25%)表皮生长

3、因子（EGF）口服中性粒细胞吞噬和杀菌活力降低TIPS的早期死亡预测进食后可达587umol/L止血芳酸200400mg 加入5%GS 500ml iv gttHospital-versus community-acquired infection11 g/L is suggestive of cirrhotic,rather than malignant,ascites肝硬化及其并发症PptCulture negative neutrocytic ascites=SBPB型不伴有内在肝病但有严重门体分流Type of diureticII型：肾功能衰竭进展较慢5ml/min时仅可见基本病变中

4、性粒细胞吞噬和杀菌活力降低调控转录因子表达（C-JUN，C/EBP）0.75谷氨酸钠40100ml加入510的葡萄糖溶液 IV gtt）收缩压（）脉率（次休克指数mmHg/minHyponatremia and/or renal impairment plus other complications适当补给复方NaCl液及10%GS肌张力增高、踝阵挛、Babinski征阳性PRA,Aldo 粘膜下小动脉瘤，常位于胃小弯侧，局灶性粘膜缺损及恒径小动脉Mesenteric fibrosis结节直径不等，一般3mm，可达3cmPVS的选择标准和相对禁忌Staphylococcus aureus20m

5、g 3/日 或 40mg 2/日 poEEG 对称性慢波（47次/s）疗程一般2周，？5天疗程者Malignant chylous ascites,especially lymphomaAlteration of the patients clinical state安洛血10mg 肌注 23次/日Relative contraindications（ALFA-HE）854例分析(叶红军）PRA,AldoRenal vasoconstrictionRenal vasoconstrictionCirrhosisDiuretics used in ascitesType of diuretic N

6、ameSide effectsDistalSpironolactoneGynecomastiaHyperkalemiaRenal tubular acidosisAmilorideHyperkalemiaTriamtereneLoopFurosemideHyponatremiaEthacrynic acidHypokalemiaAzotemiaProximalMetolazoneHyponatremiaHypokalemiaAzotemiaComplications during the first hospital stay in patients from group 1(treated

7、with paracentesis)and group 2(treated with diuretics)Group 1(n=58)Group 2(n=59)Patients with complications1036Hyponatremia318Encephalopathy617Renal impairment216Hyperkalemia17Gastrointestinal bleeding26Peritonitis04Bacteremia20Others04*Two patients with possible infections,one patient with respirato

8、ry failure,and one patient with strangulated hemia.Patients developing complications during the first hospital stay in group 1 and group 2 and types of complications*Group 1(n=52)Group 2(n=53)Patients with complications616Hyponatremia and/or renal impairment09Hyponatremia and/or renal impairment plu

9、s other complications12Other complications85Number of complications1323Hyponatremia19Renal impairment06Encephalopathy63Gastrointestinal hemorrhage21Severe infection4 4 TechnicalKinking/dislodgementCardiopulmonaryPulmonary edemaCoagulopathyDisseminated intravascular coagulationInfectionEsophageal var

10、iceal ruptureSelection criteriaRelative contraindicationsSerum bilirubin 60 mol/LPrevious abdominal surgeryProthrombin time 50 106/LAbsolute contraindicationsRelative contraindicationsHepatic encephalopathyDental sepsisCardiac diseaseSpontaneous bacterial peritonitisRenal dysfunctionNoncompliance wi

11、th sodium and fluid restrictionsHepatocellular carcinomaHepatocellular carcinomaMean arterial pressure 82 mm HgUrinary sodium excretion 570 pg/mLNutritional statusPoorHepatomegalyPresentSerum albumin 28 g/LSignificant feverWorsening encephalopathyChillsWorsening of ascitesAbdominal painHypotensionAb

12、dominal tendernessAsymptomaticReduced bowel soundsGram-negative bacilli(70%)Anaerobes(5%)Gram-positive organisms(25%)Escherichia coliBacteroidesStreptococcus viridansKlebsiellaClostridiaGroup D StreptococcusCitrobacter freundiiLactobacillusStreptococcus pneumoniaeProteusStaphylococcus aureusEnteroba

13、cterNo antibiotics Imipenum/cilastatinEarly bacteremia 5/58(8.6%)1/57(1.8%)Late bacteremia25/107(23.4%)18/88(20.5)%)Secondary bacterial peritonitisSpontaneous bacterial peritonitisOrganismsMultipleSingleAscitic protein count 1 g/dL 1 g/dLAscitic glucose concentrations 50 mg/dLApproximate simultaneou

14、s serum valueResponse to treatment(1)Polymorphonuclear cell countContinues to rise despite treatmentFalls exponentially(2)Ascitic cultureRemains positiveRapidly becomes sterileCefotaxime5-Day course10-Day coursePatients,n4347Days of hospitalization31 3850 68Recurrence of infection56Hospital mortality1420Drug and administration costs/patient259 34486 117