肝硬化腹水治疗进展

null肝硬化腹水的治疗 【 The Guidelines of 2006 】肝硬化腹水的治疗 【 The Guidelines of 2006 】０６级全科住院医师　　韩静 流行病学调查 No1. About cirrhosis流行病学调查 No1. About cirrhosis　 　4% general population 　 abnormal liver function or liver disease (non-alcoholic fatty liver disease, alcoholic liver disease, and chronic hepatitis) 10–20% develop cirrhosis over a period of 10–20 years null我国肝硬化患者占内科总住院人数的4.3%~14.2% 发病高峰年龄 35~48岁 男女比例 3.6~8：1流行病学调查 No2. About ascites流行病学调查 No2. About ascitesThe majority (75%) of patients with ascites have underlying cirrhosis,the remainder being due to malignancy(10%), heart failure (3%), tuberculosis(2%), Pancreatitis(1%), and other rare causes 50% of cirrhosis patients over 10 years of follow up 50% mortality over two years-the need to consider liver transplantation as a therapeutic null机制：门脉高压、低蛋白血症、淋巴液生成过多，、继醛、抗利尿激素等 诊断：病史，查体，X线，B超，CT。 关于腹水的检查：蛋白定量、中性粒细胞计数、腹水培养、SAAG；淀粉酶；细胞学血清腹水白蛋白浓度梯度（SAAG）血清腹水白蛋白浓度梯度（SAAG） nullThe initial ascitic fluid analysis should include serum ascites-albumin gradient in preference to ascitic protein. (Level of evidence: 2b; recommendation: B.) nullAscitic amylase should be measured when there is clinical suspicion of pancreatic disease. (Level of evidence: 4; recommendation: C.) nullAscitic fluid should be inoculated into blood culture bottles at the bedside and examined by microscopy for a neutrophil count. (Level of evidence: 2a; recommendation:B.) 肝硬化腹水的治疗肝硬化腹水的治疗１.　Bed rest　卧床休息　 ２.　Dietary salt restriction　限盐 ３.　Role of water restriction　限水 ４.　Management of hyponatraemia 　　　治疗低钠血症 ５.　Therapeutic paracentesis治疗性穿刺 6.　 TIPS　经颈静脉肝内门体分流术 7. SBP 自发性细菌性腹膜炎nullThere have　been no clinical studies to demonstrate increased efficacy of　diuresis with bed rest or decreased duration of hospitalisation ! VS Traditional recommendation: patients should be treated with diuretics while on bed rest null Bed rest is NOT recommended for the treatment of ascites. (Level of evidence: 5; recommendation: D. ) Back Dietary salt restriction限盐 Dietary salt restriction限盐　　　90 mmol/day (5.2 g) no-added salt diet 　 Certain drugs 　eg: 泡腾片,静脉用抗生素(2.1–3.6 mmol /g ),环丙沙星(30 mmol /200ml) hepatorenal syndrome or renal impairment with severe hyponatraemia ( International Ascites Club recommend infusion of normal saline) nullDietary salt should be restricted to a no-added salt diet of 90 mmol salt/day (5.2 g salt/day). (Level of evidence: 2b; recommendation: B.) BackRole of water restriction限水 Role of water restriction限水 There have been no studies on the benefits or harm of water restriction on the resolution of ascites. Ｂａｃｋnull Management of hyponatraemia in patients on diuretic therapy (Level ofevidence:5;　recommendation: D.) Diuretics　利尿剂 Diuretics　利尿剂 spironolactone螺内酯 frusemide呋赛米 amiloride阿米诺利 15–30 mg/day bumetanide布美他尼（丁尿胺） similar to frusemidenull Firstline treatment of ascites should be spironolactone　alone, increasing from 100 mg/day to a dose of　400 mg/day. If this fails to resolve ascites, frusemide 　　　should be　added in a dose of up to 　　　160mg/day, but this should　be done 　　　　　 with careful biochemical 　　　　　　　　　and clinical monitoring. 　　　　　　　　(Level of evidence: 1a; 　　　　　　　　　　　recommendation:A.)Backnull　　Therapeutic paracentesis 　　　　治疗性穿刺large or refractory ascites need for colloid replacement therapy. nullpost-paracentesis circulatory 　　　　　　　　　　　dysfunction ---Ｆailure to give volume expansion 　　　　　 ascites recurs (93%) --- if diuretic therapy is not reinstituted ；only 18% of patients treated with spironolactone ； Reintroduction of diuretics after paracentesis (usually within 1–2 days) does not appear to increase the risk of post－paracentesis circulatory dysfunctionnull Therapeutic paracentesis is the firstline treatment for patients with large or refractory ascites(Level of　evidence: 1a; recommendation: A.) Paracentesis of ＜5 litre of uncomplicated ascites　should be followed by plasma expansion with a　synthetic plasma expander and does not require 　volume expansion with albumin (Level of evidence:2b;　recommendation: B.)nullLarge volume paracentesis should be performed in a　single session with volume expansion being given once　paracentesis is complete, preferably using 8 g albumin/litre of ascites removed (that is, 100 ml of 20%albumin/　　3l ascites). (Level of evidence: 1b; recommendation:A.) BacknullTIPS can be used for the treatment of refractory ascites　requiring frequent therapeutic paracentesis or hepatic　hydrothorax with　appropriate assessment of risk 　benefit ratio. (Level of evidence: 1b; recommendation:B.) BackSpontaneous bacterial peritonitis (SBP) 　　自发性细菌性腹膜炎 Spontaneous bacterial peritonitis (SBP) 　　自发性细菌性腹膜炎 neutrophil count ≧250 cells/mm3 in the absence of an intra-abdominal and surgically treatable source of sepsis In patients with an ascitic fluid neutrophil count of 250 cells/mm3, empiric antibiotic therapy should be started. (Level of evidence:1b; recommendation: A.) nullThird generation cephalosporins such as cefotaxime（头孢噻肟 ) have been most extensively studied in the treatment of SBP and have been shown to be effective. (Level of evidence: 1a; recommendation: A.) Patients with SBP and signs of developing renal impairment should be given albumin at 1.5 g albumin/kg in the first six hours followed by 1 g/kg on day 3. (Level of evidence: 2b; recommendation: B.)nullPatients recovering from one episode of SBP should receive prophylaxis with continuous oral norfloxacin 400 mg/day (or ciprofloxacin at 500 mg once daily).(Level of evidence: 1b; recommendation: B.) All patients with SBP should be considered for referral for liver transplantation. (Level of evidence: 1c; recommendation: B.) null Thanks ！