肝硬化及其并發(fā)癥

1、肝硬化 肝損傷（手術(shù)、感染等） 啟動因素（TNF及未知因子） 調(diào)控轉(zhuǎn)錄因子表達(dá)（C-JUN，C/EBP） 早覺基因及細(xì)胞因子表達(dá)（IL-6等） 多種基因激活，翻譯后調(diào)控 細(xì)胞G0-G1期轉(zhuǎn)變，感受態(tài)形成 生長因子（HGF、TGF-、EGF、FGF等）調(diào)控 進(jìn)入細(xì)胞增殖周期 A級：56分B級：79分C級：1015分 正鐵血紅素）血紅蛋白 胃酸 ( ）收縮壓（ ）脈率（次 休克指數(shù) mmHg /min 854例分析 (葉紅軍） Putative vasodilators Glucagon Prostaglandins Insulin GABA Substance P VIP Bile acids

2、Adenosine PRA, Aldo Renal vasoconstriction Renal vasoconstriction At first presentation of ascites Alteration of the patients clinical state Alteration of the patients clinical state Sudden increase in ascites Worsening of hepatic encephalopathy Presence of fever Cirrhosis Diuretics used in ascites

3、Type of diuretic Name Side effects Distal Spironolactone Gynecomastia Hyperkalemia Renal tubular acidosis AmilorideHyperkalemia Triamterene LoopFurosemideHyponatremia Ethacrynic acidHypokalemia Azotemia Proximal MetolazoneHyponatremia Hypokalemia Azotemia Complications during the first hospital stay

4、 in patients from group 1 (treated with paracentesis) and group 2 (treated with diuretics) Group 1 (n = 58)Group 2 (n = 59) Patients with complications1036 Hyponatremia318 Encephalopathy617 Renal impairment216 Hyperkalemia17 Gastrointestinal bleeding26 Peritonitis04 Bacteremia20 Others0 4* * Two pat

5、ients with possible infections, one patient with respiratory failure, and one patient with strangulated hemia. Patients developing complications during the first hospital stay in group 1 and group 2 and types of complications* Group 1 (n = 52) Group 2 (n = 53) Patients with complications616 Hyponatr

6、emia and/or renal impairment09 Hyponatremia and/or renal impairment plus other complications 12 Other complications85 Number of complications1323 Hyponatremia19 Renal impairment06 Encephalopathy63 Gastrointestinal hemorrhage21 Severe infection 4 4 TechnicalKinking/dislodgement CardiopulmonaryPulmona

7、ry edema CoagulopathyDisseminated intravascular coagulation Infection Esophageal variceal rupture Selection criteriaRelative contraindications Serum bilirubin 60 mol/LPrevious abdominal surgery Prothrombin time 50 106/L Absolute contraindications Relative contraindications Hepatic encephalopathyDent

8、al sepsis Cardiac diseaseSpontaneous bacterial peritonitis Renal dysfunction Noncompliance with sodium and fluid restrictions Hepatocellular carcinoma Hepatocellular carcinoma Mean arterial pressure 82 mm Hg Urinary sodium excretion 570 pg/mL Nutritional statusPoor HepatomegalyPresent Serum albumin

9、28 g/L Significant feverWorsening encephalopathy ChillsWorsening of ascites Abdominal painHypotension Abdominal tendernessAsymptomatic Reduced bowel sounds Gram-negative bacilli (70%)Anaerobes (5%)Gram-positive organisms (25%) Escherichia coliBacteroidesStreptococcus viridans KlebsiellaClostridiaGro

10、up D Streptococcus Citrobacter freundiiLactobacillusStreptococcus pneumoniae ProteusStaphylococcus aureus Enterobacter No antibiotics Imipenum/cilastati n Early bacteremia 5/58 (8.6%)1/57 (1.8%) Late bacteremia25/107 (23.4%) 18/88 (20.5)%) Secondary bacterial peritonitis Spontaneous bacterial perito

11、nitis OrganismsMultipleSingle Ascitic protein count 1 g/dL 1 g/dL Ascitic glucose concentrations 50 mg/dLApproximate simultaneous serum value Response to treatment (1) Polymorphonuclear cell count Continues to rise despite treatment Falls exponentially (2) Ascitic cultureRemains positiveRapidly becomes sterile Cefotaxime 5-D