上海交通大學(xué)醫(yī)學(xué)院內(nèi)科學(xué)課件livercirrh(存儲(chǔ)版)
【正文】 。38:266 VARICES INCREASE IN DIAMETER PROGRESSIVELY A Threshold Portal Pressure of ~12 mmHg is Necessary for Varices to Form P 5 10 12 15 25 30 35 20 Hepatic Venous Pressure Gradient (mmHg) GarciaTsao et. al., Hepatology 1985。 12:716 NORFLOXACIN REDUCES RECURRENCE OF SPONTANEOUS BACTERIAL PERITONITIS (SBP) Indications for Prophylactic Antibiotics to Prevent Spontaneous Bacterial Peritonitis ? Cirrhotic patients hospitalized with GI hemorrhage (shortterm) ? Norfloxacin 400 mg . BID x 7 days ? Patients who have recovered from SBP (longterm) ? Norfloxacin 400 mg . daily, indefinitely ? Weekly quinolones not remended (lower efficacy, development of quinoloneresistance) INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS TO PREVENT SPONTANEOUS BACTERIAL PERITONITIS (SBP) 50 Characteristics of Hepatorenal Syndrome ? Renal failure in patients with cirrhosis, advanced liver failure and severe sinusoidal portal hypertension ? Absence of significant histological changes in the kidney (“functional” renal failure) ? Marked arteriolar vasodilation in the extrarenal circulation ? Marked renal vasoconstriction leading to reduced glomerular filtration rate CHARACTERISTICS OF HEPATORENAL SYNDROME (HRS) Two Types of Hepatorenal Syndrome Type 1 ? Rapidly progressive renal failure (2 weeks) ? Doubling of creatinine to or halving of creatinine clearance (CrCl) to 20 ml/min Type 2 ? More slowly progressive ? Creatinine mg/dL or CrCl 40 ml/min ? Associated with refractory ascites Arroyo et al., Hepatology 1996。 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 Electroencephalogram in Hepatic Encephalopathy ELECTROENCEPHALOGRAM IN HEPATIC ENCEPHALOPATHY Minimal Hepatic Encephalopathy ? Occurs in 3070% of cirrhotic patients without overt hepatic encephalopathy ? Detected by psychometric and neuropsychological testing ? May improve with lactulose or synbiotics (probiotics and fermentable fiber) MINIMAL HEPATIC ENCEPHALOPATHY Minimal Hepatic Encephalopathy Abnormalities on testing ? Attention and cognitive deficits ? Visualspacial perception impaired ? Defects in visual constructive ability ? Impaired driving ability ? Evoked potentials and spectral electroencephalography abnormal MINIMAL HEPATIC ENCEPHALOPATHY – ABNORMALITIES ON TESTING Treatment of Hepatic Encephalopathy ? Identify and treat precipitatin
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