上海交通大學(xué)醫(yī)學(xué)院內(nèi)科學(xué)課件livercirrh-文庫吧在線文庫
【正文】 g factor ? Infection ? GI hemorrhage ? Prerenal azotemia ? Sedatives ? Constipation ? Lactulose (adjust to 23 bowel movements/day) ? Protein restriction, shortterm (if at all) TREATMENT OF HEPATIC ENCEPHALOPATHY Hepatic Encephalopathy Precipitants GI bleeding Excess protein Sedatives / hypnotics TIPS Diuretics Serum K+ Plasma volume Azotemia Temp Infections HEPATIC ENCEPHALOPATHY PRECIPITANTS Actions of Lactulose Lactulose Lactic acid Decreased pH NH3 Ureaseproducing bacteria Increase cathartic effect NH3 NH4+ ACTIONS OF LACTULOSE Hepatic Encephalopathy Treatment: Summary Decrease ammonia production in gut: ? Lactulose ? Antibiotics ? Adjustment in dietary protein Increase ammonia fixation in liver: ? Ornithine aspartate ? Benzoate Shunt occlusion or reduction HEPATIC ENCEPHALOPATHY – TREATMENT SUMMARY Flumazenil 。 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。ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE Hepatic cirrhosis Ma Xiong, ., Associate Professor Shanghai Institute of Digestive Disease, Renji Hospital Shanghai Jiao Tong University School of Medicine Hepatic Cirrhosis ? End stage of any chronic liver disease ? Characterized histologically by regenerative nodules surrounded by fibrous tissue ? Clinically there are two types of cirrhosis: ? Compensated ? Depensated DEFINITION OF CIRRHOSIS Cirrhosis Normal Nodules Irregular surface GROSS IMAGE OF A NORMAL AND A CIRRHOTIC LIVER Cirrhotic liver Nodular, irregular surface Nodules GROSS IMAGE OF A CIRRHOTIC LIVER Cirrhosis Normal Nodules surrounded by fibrous tissue HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER HISTOLOGICAL IMAGE OF CIRRHOSIS Fibrosis Regenerative nodule PATHOGENESIS OF LIVER FIBROSIS Hepatocytes Space of Disse Sinusoidal endothelial cell Hepatic stellate cell Fenestrae Normal Hepatic SInusoid Retinoid droplets PATHOGENESIS OF LIVER FIBROSIS Alterations in Microvasculature in Cirrhosis ? Activation of stellate cells ? Collagen deposition in space of Disse ? Constriction of sinusoids ? Defenestration of sinusoids Compensated cirrhosis Depensated cirrhosis Death 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。 23:164 DEFINITION AND TYPES OF REFRACTORY ASCITES PeritoneoVenous Shunt (PVS) is Useful in the Treatment of Refractory Ascites Use of jugular vein will hinder TIPS placement Intraabdominal adhesions may plicate liver transplant surgery Oneway valve PERITONEOVENOUS SHUNT (PVS) IS USEFUL IN THE TREATMENT OF REFRACTORY ASCITES Treatment of Ascites Hepatorenal Syndrome Refractory Ascites Unplicated Ascites Portal Hypertension No Ascites 1) LVP + albumin 2) TIPS 3) PVS (in nonTIPS, nontransplant candidates) LVP = large volume paracentesis TIPS = transjugular intrahepatic portosystemic shunt TREATMENT OF REFRACTORY ASCITES 44 Spontaneous Bacterial Peritonitis (SBP) Complicates Ascites and Can Lead to Renal Dysfunction SBP HVPG 10 mmHg Extreme Vasodilation HVPG 10 mmHg Severe Vasodilation HVPG 10 mmHg Moderate Vasodilation HVPG 10 mmHg Mild Vasodilation Hepatorenal Syndrome Refractory Ascites Unplicated Ascites Portal Hypertension No Ascites SPONTANEOUS BACTERIAL PERITONITIS (SBP) COMPLICATES ASCITES AND CAN LEAD TO RENAL DYSFUNCTION Early Diagnosis of SBP ? Diagnostic paracentesis: ? If symptoms / signs of SBP occur ? Unexplained encephalopathy and / or renal dys
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