【正文】 n overload Vensection. Deferoxamine ~1g/kg Copper overload penicillamine ~ g/day α 1 antitrypsin deficiency ? Transplant Tyrosinaemia Withdraw dietary tyrosine Galactosaemia Withdraw milk and milk products Cholestasis Relieve biliary obstruction BuddChiari syndrome Relieve main venous block Immunological factors Prednison or predisolon 20~60 mg/day Toxins and drugs Identify and stop Cryptogenic Antifibrotic drugs ? Penicillamine Primary biliary cirrhosis Wilson’s disease Inhibiting the formation of crosslinks of collagen ? Colchicine Inhibiting assembly of collagen Increasing collagenase production Management of ascites ? Ascites with severe, acute liver disease Improvement of liver function ? Ascites with stable or steadily worsening liver function Maximal reabsorption rate: 700~900 ml/day Goal of management: weight loss (ascites + peripheral edema) weight loss (ascites) Management of ascites ? Sodium restriction ? Fluid restriction ? Diuresis ? Paracentesis ? Sidetoside portacaval shunt ? Peritoneovenous shunt ? Transjugular intrahepatic portosystemic shunts (TIPS) Sodium restriction ? 1g sodium retaines 200 ml fluid ? g will result in ascites in cirrhotic patients ? g/d (22 mEg), restricted in patients without ascites ? Strict bed rest improving renal clearance in the supine position Fluid restriction ≈1000 ml/day Diuresis ? If sodium restriction are failed ? Diuretic for ascites Urine loss loop diuretic Na++ K++ Furosemide (呋塞米） Bumetamide（丁苯氧酸） Distal diuretic Na+ K Spironolactone （安體舒通） Triamterene （氨苯碟啶） Amiloride （阿米洛利） Diuresis ? Drugs of choice: Spironolactone ?Inhibiting aldosterone synthesis ?Causing natriuresis with sparing potassium 100mg~400mg/d may induce diuresis ? Furosemide and/or thiazides both natriuresis and potassium wasting ? Spironolactone(distal diuretic)+Furosemide(loop diuretic) sufficient to initial diuresis Paracentesis ? Paracentesis of 1~2 L of ascitic fluid effective, less costly ? Albumin or plasma infusion expensive ? Ascites reinfusion inexpensive for refractory or massive ascites Portalsystemic shunts ? Sidetoside portacaval shunts ? Peritoneovenous shunts (Le Veen shunt) ? Transjugular intrahepatic portosystemic shunts (TIPS) Management of plications Variceal bleeding: ? General managements maintain intravascular volum close monitoring blood pressure, urine output and mental status ? Medical managements use of vasoconstrictors (vasopression or somatostatin) sclerotherapy band ligation betaadrenergic blockade Management of plications Spontaneous bacterial peritonitis: ? Empirical therapy with cefotoxanine or ampicillin and an aminoglycoside ? Specific antibiotic therapy are selected ? 10~14 days duration ? Recurrent episodes are high Management of plications Hepatic encephalopathy Hepatorenal syndrome Treatment is usually unsuccessful Liver transplantation ? Latest advance in management of cirrhosis ? Frequently done in Western country Summary ? Definition fibrosis + nodular regeneration ? Viral hepatitis (China) alcohol (Western Country) ? Micro , Macro and mixed cirrhosis ? Depensated stage: Deterioration of liver function Portal hypertension ? Complications ? Hepatic function: ChildPugh score ? Sodium, fluid restriction, diuresis (Spirolactone)