【正文】 C: 12~15 scores Differential diagnosis ? Hepatomegaly ? Ascites ? Complications Upper GI bleeding Hepatic encephalopathy Hepatorenal syndrome Hepatomegaly ? Chronic hepatitis ? Primary liver cancer ? Parasitization ? Hemologic diseases (leukemia, lymphoma) ? Metabolic diseases Ascites ? Tuberculous peritonitis ? Constrictive pericarditis ? Chronic glumerulonephritis ? Intraperitoneal tumors Upper GI bleeding ? Peptic ulcer, acute erosive gastritis, gastric cancer and esophageal varices are four major sources of upper GI bleeding ? In cirrhotic patients, bleeding are not entirely due to varices Hepatic encephalopathy ? Hypoglycemia ? Uremia ? Diabetic ketoacidosis ? Nonketonic hyperosmolar syndrome Hepatorenal syndrome ? Prerenal azotemia ? Acute tubular necrosis ? Drug nephrotoxicity ? Diagnosis is supported by avid urinary sodium retention Urine sodium concentration 5 mmol / L unremarkable urinary sediment Treatment ? Supportive therapy ? Eliminating the specific causes ? Using antifibrotic drugs ? Management of ascites ? Management of plications ? Liver transplantation Supportive therapy ? Appropriate rest 1g protein/kg, 2022 Calories daily Vitamin(s), thiamine, vitamin K, iron and folic acid ? Removal of exogenous aggravating agents liver tonics, offending drugs control of infection and electrolyte ? Correction of hypoalbuminemia and coagulation fresh frozen plasma, platelet concentrates or prothrombin plex Etiology and definitive treatment of cirrhosis Etiology Treatment Virus hepatitis ? Antivirals Schistosomiasis Praziquantel 60~80mg/kg for 2 days Alcohol Abstention Iron 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