1、肝硬化腹水及并发症的若干处理肝硬化腹水及并发症的若干处理猪肥牛壮家增猪肥牛壮家增福福康宁永享万事康宁永享万事安安肝硬化腹水概况肝硬化腹水概况1.Gines P,et al.Am J Med 1968;44:40620.2.Powell WJ,et al.Am J Med 1968;44:40620.3.DAmico G,et al.Dig Dis Sci 1986;31:46875.4.Llach J,et al.Gastroenterology 1988;94:4827.肝脏储备功能评估：肝脏储备功能评估：Child-Pugh（腹水腹水、胆红素、胆红素、PT、肝性脑病、白蛋白）；、肝性脑病、
2、白蛋白）；MELD（肌酐肌酐、PT、胆红素）；、胆红素）；MELD-Na肝硬化腹水处理的相关指南肝硬化腹水处理的相关指南世界胃肠病组织“”肝硬化腹水的分类肝硬化腹水的分类难治性腹水概况难治性腹水概况Erwin Biecker.Diagnosis and therapy of ascites in liver cirrhosis.World J Gastroenterol,2011,17(10):1237-1248.腹穿大量放腹水（腹穿大量放腹水（LVP）经颈静脉肝内门体静脉分流术（经颈静脉肝内门体静脉分流术（TIPS）经颈静脉肝内门体静脉分流术（经颈静脉肝内门体静脉分流术（TIPS）经颈静脉肝
3、内门体静脉分流术（经颈静脉肝内门体静脉分流术（TIPS）METHODS:Sixty cirrhotic patients with refractory ascites who presented with a Child-Pugh score of 11,serum bilirubin of 3 mg/dl and creatinine of 1.9 mg/dl were assigned randomly to TIPS(n=30)or large-volume paracentesis plus albumin(n=30).The primary endpoint was surviva
4、l.The secondary endpoints were response to treatment and development of hepatic encephalopathy.经颈静脉肝内门体静脉分流术（经颈静脉肝内门体静脉分流术（TIPS）CONCLUSIONS:In cirrhotic patients with refractory ascites who have good hepatic and renal function,TIPS improves survival and provides better control of ascites than large-
5、volume paracentesis.RESULTS:Seventeen patients treated with TIPS and 21 treated with paracentesis died during the study period.The cumulative probabilities of survival at 1 and 2 years were 80 and 64%in the TIPS group and 49 and 35%in the paracentesis group(p 0.005).TIPS was significantly superior t
6、o paracentesis in the control of ascites(p 0.005).Treatment failure was more frequent in the paracentesis group,whereas the frequency of hepatic encephalopathy was greater in the TIPS group.难难治治性性腹腹水水的的处处理理Erwin Biecker.Diagnosis and therapy of ascites in liver cirrhosis.World J Gastroenterol,2011,1
7、7(10):1237-1248.自发性腹膜炎（自发性腹膜炎（SBP）概况）概况SBP发生率与发生率与MELD评分显著相关评分显著相关肝硬化肝硬化SBP防治抗生素使用适应症防治抗生素使用适应症-来自福建医大附一院肝病中心的经验来自福建医大附一院肝病中心的经验肝硬化并肝硬化并SBP经验性抗生素治疗的适应症经验性抗生素治疗的适应症1、肝硬化腹水中性粒细胞计数、肝硬化腹水中性粒细胞计数250 个个/mm3；2、肝硬化腹水有典型的感染症状与体征，至少具有以下一、肝硬化腹水有典型的感染症状与体征，至少具有以下一项：项：腹膜刺激征；发热T37.8；外周血白细胞和/或中性粒细胞增高；3、肝硬化腹水有不典型的感
8、染症状与体征（可疑腹膜刺激征，或发热T37.8；或伴腹泻、呕吐），并且至少具有以下一项：伴肝肾综合征；伴不明原因的肝性脑病；MELD评分25或Child-Pugh C级；腹水蛋白浓度15g/L；有自发性腹膜炎病史；近期（2周）内胃肠道出血史；肝硬化并肝硬化并SBP预防性抗生素治疗的适应症预防性抗生素治疗的适应症1、肝硬化腹水无感染症状与体征，但既往有自发性腹膜炎病、肝硬化腹水无感染症状与体征，但既往有自发性腹膜炎病史或近期（史或近期（2周）内有胃肠道出血史；周）内有胃肠道出血史；2、肝硬化腹水无感染症状与体征，但至少具有以下一项：、肝硬化腹水无感染症状与体征，但至少具有以下一项：伴肝肾综合征；
9、伴不明原因的肝性脑病；MELD评分25或Child-Pugh C级；3、肝硬化腹水无感染症状与体征，腹水蛋白浓度1.2mg/dL（106umol/L）或血尿素氮25 mg/dL（8.8mmol/L）；血钠3 mg/dL（51.3 umol/L）；肝硬化低钠血症概况肝硬化低钠血症概况1 Angeli P.et al.Hyponatremia in cirrhosis:results of a patient population survey.Hepatology,2006,44:1535-1542.2 Londono MC,et a1.MELD score and serum sodium i
10、n the prediction of survival of patients with cirrhosis awaiting liver transplantation.Gut,2007,56:1283-1290.3 Iacob S,et al.MELD exceptions and new predictive score of death on long waiting lists for liver transplantation.Chirurgia,2009,104(3):267-273.高血容量性（稀释性）低钠血症与肝硬化高血容量性（稀释性）低钠血症与肝硬化患者生存期相关患者生存
11、期相关Pocel A,et al.Dilutional hyponatremia in patients with cirrhosis and ascites.Arch Intern Med.2002,162(3):323-328.高血容量性（稀释性）低钠血症的处理高血容量性（稀释性）低钠血症的处理*Gines P,et al.Effects of satavaptan,a selective vasopressin V2 receptor antagonist,on ascites and serum sodium in cirrhosis with hyponatremia:a rando
12、mized trial.Hepatology,2008,48:204-213.高血容量性（稀释性）低钠血症的处理高血容量性（稀释性）低钠血症的处理高血容量性（稀释性）低钠血症的处理高血容量性（稀释性）低钠血症的处理 2009年年5月美国月美国FDA批准了日本大冢制药托伐普坦片批准了日本大冢制药托伐普坦片(Samsca)用于治疗高容或等容性用于治疗高容或等容性低钠血症伴心力衰竭、肝硬化、抗利尿激素分泌异常综合征，低钠血症伴心力衰竭、肝硬化、抗利尿激素分泌异常综合征，2012年2月在中国上市。目前国产托伐普坦正进行3期临床药物试验。肝肾综合征概况肝肾综合征概况 HRS在肝硬化腹腔积液住院病人中的发
13、生率约为10%，肝硬化腹腔积液病人1年发生率约20%，5年发生率可达40%。治疗棘手、病死率高。Survival of patients with cirrhosis after the diagnosis of type 1 or type 2 HRS.Gines P,Guevara M,Arroyo V,Rodes J.Hepatorenal syndrome.Lancet 2003;362:18191827。肝肾综合征的预防处理肝肾综合征的预防处理1 Fernandez J,et al.Primary prophylaxis of spontaneous bacterial perito
14、nitis delays hepatorenal syndrome and improves survival in cirrhosis.Gastroenterology,2007,133:818-824.2 Lebrec D,et a1.Pentoxifylline does not decrease short-term mortality but does reduce complications in patients with advanced cirrhosis.Gastroenterology,2010,138:1755-1762.肝肾综合征的治疗肝肾综合征的治疗-缩血管药物缩血
15、管药物1 Martn-Llah M,et al.Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome:a randomized study.Gastroenterology 2008,134:1352-1359.2 Gins P,et al.Therapy with vasoconstrictor drugs in cirrhosis:The time has arrived.Hepatology,2007,46:1685-1687.肝肾综合征的治疗肝肾综合征的治疗-TIP
16、S1 Wong F,et al.Midodrine,octreotide,albumin,and TIPS in selected patients with cirrhosis and type l hepatorenal syndrome.Hepatology,2004,40:55-64.2 Brensing KA,et al.Long term outcome after transjugular intrahepatic portosystemic sten-shunt in non-transplant cirrhotics with hepatorenai syndrome:a phase II study.Gut,2000,47:288-295.肝肾综合征的治疗肝肾综合征的治疗-肝移植肝移植*Marik PE,et al.The course of type 1 hepatckrenal syndrome post liver transplantation.Nephrol Dial Transplant,2006,21:478-482.
