嗜酸性粒细胞性胃肠炎伴腹水1例报道

嗜酸性粒细胞性胃肠炎(eosinophilic gastroenteritis,EG)是一种以胃肠道组织中嗜酸性粒细胞异常浸润为特征的罕见胃肠道疾病。随着医务工作者对该病的认识不断深入,该病的文献报道逐渐增多。到目前为止,国内已有100余例报道[1],但因其临床表现缺乏特异性,故该病误诊率仍较高。本文报道我院2013年接诊的1例EG伴腹水的病例。     

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM:To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. METHODS:Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n= 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were:technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney Utest and the χ 2 test as appropriate. RESULTS:No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P= 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. CONCLUSION:RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.     

血清腹水白蛋白梯度与肝硬化食管静脉曲张程度的相关性

目的:探讨血清腹水白蛋白梯度(serum-ascites albumin gradient,SAAG)与肝硬化食管静脉曲张程度之间的相关性.方法:收集诊断明确的肝硬化合并腹水患者,根据食管静脉曲张程度分为无或轻度组、中度组和重度组,采用单因素方差分析、相关分析、构建受试者工作特征曲线(receiver operating characteristic,ROC)曲线等方法进行统计学分析.结果:共纳入43例患者,单因素方差分析显示3组之间存在显著差异(F=26.317,P<0.001),Spearman相关系数r=0.759,P<0.001,提示SAAG与食管静脉曲张具有正向相关性.构建ROC曲线得到曲线下面积为0.926,当SAAG取值为20.5g/L时是诊断中重度食管静脉曲张的最佳界值,此时敏感度为87.1%,特异度为83.3%.结论:SAAG与食管静脉曲张具有较好的相关关系,该指标对于中重度食管静脉曲张具有诊断价值.     

腹腔镜胆囊切除术后腹水形成1例报告并文献复习

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)后腹水形成的原因及治疗措施。方法:分析1例LC术后腹水形成患者的临床资料,并结合文献复习进行分析讨论。结果:患者经腹腔穿刺抽液、利尿、营养支持等治疗后腹水减少,最终痊愈,保守治疗有效。结论:LC是有效、安全的微创术式,腹水形成是其术后罕见并发症,其发生原因与机制尚不明确,但保守治疗有效,目前的共识为保守治疗是其首选治疗方式。     

SYSMEX XN-1000血球仪在脑脊液和胸腹水白细胞计数中的可行性探讨

目的：探讨SYSMEX XN-1000血液分析仪(简称SYSMEX XN-1000)的体液模式在脑脊液和胸腹水白细胞计数中应用的可行性。方法分别采用手工显微镜镜检法和SYSMEX XN-1000对183例脑脊液和胸腹水标本进行白细胞计数,将所测结果按A：(0~1000)×106/L,B：(1001~5000)×106/L,C：>5000×106/L分为三组,分别进行统计学分析。结果与手工显微镜镜检法相比,SYSMEX XN-1000所测结果差异无统计学意义(P>0.05)。A、B、C三组的相关系数分别为0.993、0.984、0.996,A组回归方程为y=1.007x-1.072,B组回归方程为y=1.003x+19.776,C组回归方程为y=1.241x-1419.365。结论 SYSMEX XN-1000血液分析仪可用于临床脑脊液和胸腹水中白细胞计数,其操作简单易行,结果稳定可靠,但如果仪器进行样品检测时报警,应当手工镜检复核,以提高结果的准确性和可靠性。     

青年人腹腔积液46例病因分析

目的 探讨青年人腹腔积液的病因及临床特点,为进一步诊断治疗提供依据.方法 年龄35岁以下腹腔积液待查患者46例,均进行腹腔积液常规生化、病理及超声、CT、血肿瘤系列等多项检查,部分患者行胃肠镜及剖腹探查术.结果 46例患者中结核性腹膜炎21例(45.6%),结肠癌2例(4.3%),肝硬化2例(4.3%),恶性腹膜间皮瘤2例(4.3%),Budd-chiari综合征2例(4.3%),肝豆状核变性2例(4.3%),卵巢癌1例(2.1%),腹膜假性粘液瘤2例(4.3%),恶性淋巴瘤2例(4.3%,其中1例合并淋巴细胞性白血病),系统性红斑狼疮2例(4.3%),胃平滑肌肉瘤1例(2.1%),产后低蛋白血症1例(2.1%).特发性门静脉高压1例(2.1%),嗜酸细胞性胃肠炎l例(2.1%),病因未明4例(8.7%).结论 以腹腔积液待查就诊的青年患者,病因学分析最多为结核性腹膜炎,占45.6%,其次为与门静脉高压有关的腹腔积液、恶性肿瘤及结缔组织病,还有一些少见病因如嗜酸细胞性胃肠炎、腹膜假性粘液瘤等.     

胆固醇、SAAG、CEA和CA199对良恶性腹水鉴别诊断意义

目的探讨癌胚抗原(CEA)、癌抗原199(CA199)、胆固醇(Ch)和血清-腹水白蛋白梯度(SAAG)检测对良恶性腹水的鉴别价值。方法检测54例恶性腹水、48例良性腹水中CEA、CA199、Ch和ALB水平,同时在±0.5h内检测血清ALB,计算SAAG。并计算CEA、CA199、Ch和SAAG诊断性能指标。结果恶性腹水CEA、CA199、Ch和SAAG检测水平明显高于良性腹水,差异有极显著性(P<0.001)。从敏感性和有效率看,均以Ch最高,CA199最低,但CA199特异性为100%。CEA+CA199+Ch联合检测敏感性为90.7%,特异性为100%。结论CEA、CA199、Ch和SAAG检测对良恶性腹水具有鉴别价值,CEA+CA199+Ch联合检测对鉴别良恶性胸腹水具有十分重要的意义。     

人血白蛋白治疗肝硬化腹水疗效与安全性的Meta分析

目的 评价人血白蛋白治疗肝硬化腹水的疗效与安全性. 方法 以“cirrhosis”、“ascites”、“albumin”、“randomized controlled trials”和“肝硬化”、“腹水”、“人血白蛋白”、“随机对照试验”为检索词,检索Cochrane图书馆、PubMed、EMBase、Web of Science、中国生物医学文献数据库、中国知网、维普数据库和万方数据库,收集用人血白蛋白治疗肝硬化腹水的随机对照试验并全文发表的论文.根据纳入标准对文献进行筛选和评估,采用RevMan 5.2软件进行统计分析,计算相对危险度（RR）和95％置信区间（CI）.试验组静脉滴注人血白蛋白,对照组静脉滴注等容积0.9％氯化钠注射液或人工胶体液（如羟乙基淀粉、葡聚糖、聚明胶肽等）或不用药.比较试验组与对照组的疗效与安全性. 结果 共检索到相关文献688篇,筛选后最终纳入13篇,英文11篇,中文2篇,共1 152例患者.Meta分析结果显示,试验组低钠血症发生率（7.67％）低于对照组（14.66％）,差异有统计学意义（RR =0.60,95％CI：0.41 ～0.88,P=0.008）;试验组和对照组腹水消退率（91.67％比88.44％）、肾损伤发生率（5.12％比6.93％）、感染发生率（5.04％比4.93％）、肝性脑病发生率（5.90％比5.00％）、消化道出血发生率（2.57％比2.73％）、高钾血症发生率（1.09％比6.45％）、再住院率（52.15％比61.82％）、因腹水再住院率（38.68％比41.85％）、住院病死率（3.80％比4.54％）、总病死率（21.40％比24.83％）差异均无统计学意义（均P＞0.05）.试验组与对照组不良反应发生率（3.13％比3.05％）差异无统计学意义（P=0.97）. 结论 目前的研究未证明使用人血白蛋白与人工胶体液或晶体液治疗肝硬化腹水的疗效及安全性有明显差异.     

Portal hypertension and ascites

Portal pressure is the product of portal blood flow and resistance; an increase in either leads to increased portal pressure. Cirrhosis is the underlying cause in most cases, but portal hypertension can develop due to prehepatic, intrahepatic and posthepatic obstruction to the flow, secondary to variety of causes. Diagnosis can be established by a combination of non-invasive imaging or portal vasculature and clinical or serological markers for the cause underlying cirrhosis. Development of gastro-oesophageal varices and ascites are the most important clinical manifestation of portal hypertension. Non-selective beta-blockers and endoscopic band ligation are effective in primary and secondary prevention of variceal bleeding. Active variceal haemorrhage is managed using a combination of vasoactive drug (e.g. terlipressin) and endoscopic band ligation. If these measures fail, transjugular intrahepatic portosystemic shunt (TIPS) insertion achieves haemostasis. Diuretic therapy with spironolactone and furosemide are the mainstays of management of ascites. If ascites becomes refractory, repeat large volume paracentesis and TIPS in selected cases help to control symptoms. Development of ascites is an important landmark in the natural history of cirrhosis and liver transplantation should be considered definitive treatment.