上海交通大學(xué)醫(yī)學(xué)院內(nèi)科學(xué)課件livercirrh-wenkub
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【正文】 Chronic liver disease Natural History of Chronic Liver Disease Development of plications: ? Variceal hemorrhage ? Ascites ? Encephalopathy ? Jaundice NATURAL HISTORY OF CHRONIC LIVER DISEASE 60 40 80 100 120 140 160 0 40 60 80 20 20 0 100 Months Probability of survival All patients with cirrhosis Depensated cirrhosis 180 Depensation Shortens Survival Gines et. al., Hepatology 1987。 319:983 Variceal hemorrhage Varix with red signs PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE Tension (T) Wall thickness (w) Groszmann, Gastroenterology 1984。 32:142 EARLY DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS (SBP) TREATMENT INDICATED Diagnosis and Management of Spontaneous Bacterial Peritonitis Diagnostic Paracentesis PMN250? Culture Positive? TREATMENT NOT INDICATED NO Repeat Paracentesis YES PMN250? Culture Positive? NO NO YES YES YES NO MANAGEMENT ALGORITHM IN SPONTANEOUS BACTERIAL PERITONITIS (SBP) Treatment of Spontaneous Bacterial Peritonitis ? Remended antibiotics for initial empiric therapy ? . cefotaxime, amoxicillinclavulanic acid ? oral nofloxacin (unplicated SBP) ? avoid aminoglycosides ? Minimum duration: 5 days ? Reevaluation if ascitic fluid PMN count has not decreased by at least 25% after 2 days of treatment Rimola et al., J Hepatol 2022。 362:1819 Type 1 Cirrhosis Intrahepatic resistance Sinusoidal pressure Arteriolar resistance (vasodilation) Effective arterial blood volume Ascites Sodium and water retention Activation of neurohumoral systems Renal vasoconstriction Renal dysfunction NSAIDs Diuretics Diarrhea Hemorrhage Vasodilators LVP w/o albumin Infection THERE ARE MANY CONDITIONS OTHER THAN HEPATORENAL SYNDROME THAT CAN LEAD TO RENAL FAILURE IN PATIENTS WITH CIRRHOSIS Cirrhosis Intrahepatic resistance Sinusoidal pressure Arteriolar resistance (vasodilation) Effective arterial blood volume Ascites Sodium and water retention Activation of neurohumoral systems Renal vasoconstriction Renal dysfunction NSAIDs Diuretics Diarrhea Hemorrhage Vasodilators LVP w/o albumin Infection Hepatorenal Syndrome HEPATORENAL SYNDROME (HRS) IS A DIAGNOSIS OF EXCLUSION Natural History of Hepatorenal Syndrome (HRS) Arroyo et al., Gastroenterology 2022。 35:716 HEPATIC ENCEPHALOPATHY – NOMENCLATURE ? Treatment: rarely effective short of liver transplant Characteristics of Type A vs. Type C Hepatic Encephalopathy ? Gradual onset ? Rarely fatal ? Main cause: shunting / toxin ? Precipitant ? Treatment: usually effective ? Rapid onset ? Frequently fatal ? Main cause: cerebral edema Type A Type C CHARACTERISTICS OF TYPE A VS. TYPE C ENCEPHALOPATHY Type C Hepatic Encephalopathy is the Encephalopathy of Cirrhosis ? Neuropsychiatric plication of cirrhosis ? Results from spontaneous or surgical / radiological portalsystemic shunt + chronic liver failure ? Failure to metabolize neurotoxic substances ? Alterations of astrocyte morphology and function (Alzheimer type II astrocytosis) TYPE C HEPATIC ENCEPHALOPATHY IS THE ENCEPHALOPATHY OF CIRRHOSIS Hepatic Encephalopathy Pathogenesis Bacterial action Protein load Failure to metabolize NH3 NH3 Shunting GABABD receptors Toxins PATHOPHYSIOLOGY OF HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy Is A Clinical Diagnosis ? Clinical findings and history important ? Ammonia levels are unreliable ? Ammonia has poor correlation with diagnosis ? Measurement of ammonia not necessary ? Number connection test ? Slow dominant rhythm on EEG HEPATIC ENCEPHALOPATHY IS A CLINICAL DIAGNOSIS Stage Mental state Neurologic signs 1 Mild confusion: limited attention Incoordination, tremor, span, irritability, inverted sleep impaired handwriting pattern 2 Drowsiness, personality changes, Asterixis, ataxia, dysarthria intermittent disorientation 3 Somnolent, gross disorientation, Hyperreflexia, muscle marked confusion, slurred speech rigidity, Babinski sign 4 Coma No response to pain, decerebrate posture Stages of Hepatic Encephalopathy STAGES OF HEPATIC ENCEPHALOPATHY STAGES OF HEPATIC ENCEPHALOPATHY Confusion Drowsiness Somnolence Coma 1 2 3 4 Stage Stages of Hepatic Encephalopathy Asterixis ASTERIXIS IS THE HALLMARK IN THE DIAGNOSIS OF HEPATIC ENCEPHALOPATHY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Begin End Time to plete____________________ Number Connection Test (NCT) Sample handwriting Draw a star NUMBER CONNECTION TEST 70 Electr
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