上海交通大學(xué)醫(yī)學(xué)院內(nèi)科學(xué)課件livercirrh(編輯修改稿)
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【文章內(nèi)容簡(jiǎn)介】 IAL WORKUP OF ASCITES: DIAGNOSIS PARACENTESIS Diagnostic Paracentesis Indications Contraindications ? Newonset ascites ? Admission to hospital ? Symptoms/signs of SBP ? Renal dysfunction ? Unexplained encephalopathy ? None DIAGNOSTIC PARACENTESIS Cirrhotic ascites Cardiac ascites Peritoneal malignancy 0 Serum – ascites albumin gradient (g/dL) SerumAscites Albumin Gradient is High in Portal Hypertensive Causes of Ascites Runyon, Ann Intern Med 1992。 117:215 SERUMASCITES ALBUMIN GRADIENT (SAAG) IS HIGH IN PORTAL HYPERTENSIVE CAUSES OF ASCITES Activation of neurohumoral systems Site of Action of Different Therapies for Ascites Cirrhosis Intrahepatic resistance Arteriolar resistance (vasodilation) Sinusoidal pressure Ascites Sodium and water retention TIPS TIPS Diuretics PVS PVS Albumin LVP Effective arterial blood volume MECHANISM OF ACTION OF THE DIFFERENT THERAPIES FOR ASCITES Management of Unplicated Ascites Definition: Ascites responsive to diuretics in the absence of infection and renal dysfunction Sodium restriction ? Effective in 1020% of cases ? Predictors of response: mild or moderate ascites, Urine Na excretion 50 mEq/day Diuretics ? Should be spironolactonebased ? A progressive schedule (spironolactone ? furosemide) requires fewer dose adjustments than a bined therapy (spironolactone + furosemide) MANAGEMENT OF UNCOMPLICATED ASCITES Sodium Restriction ? 2 g (or g of dietary salt) a day ? Fluid restriction is not necessary unless there is hyponatremia (125 mmol/L) ? Goal: negative sodium balance ? Side effect: unpalatability may promise nutritional status Management of Unplicated Ascites MANAGEMENT OF UNCOMPLICATED ASCITES: SODIUM RESTRICTION 40 Diuretic Therapy Dosage ?Spironolactone 100400 mg/day ?Furosemide (40160 mg/d) for inadequate weight loss or if hyperkalemia develops ? Increase diuretics if weight loss 1 kg in the first week and 2 kg/week thereafter ? Decrease diuretics if weight loss kg/day in patients without edema and 1 kg/day in those with edema ? Side effects ?Renal dysfunction, hyponatremia, hyperkalemia, encephalopathy, gyneastia Management of Unplicated Ascites MANAGEMENT OF UNCOMPLICATED ASCITES: DIURETIC THERAPY Definition and Types of Refractory Ascites Occurs in ~10% of cirrhotic patients ? Diureticintractable ascites Therapeutic doses of diuretics cannot be achieved because of diureticinduced plications ? Diureticresistant ascites No response to maximal diuretic therapy (400 mg spironolactone + 160 mg furosemide/day) 20% 80% Arroyo et al. Hepatology 1996。 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 dysfunction ? At any hospital admission ? Diagnosis based on ascitic fluid PMN count 250/mm3 Rimola et al., J Hepatol 2022。 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
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