老年胃食管反流病患者临床特征分析

Objective To analyze clinical characteristics of gastroesophageal reflux disease(GERD) in aged patients for improvement of diagnosis and treatemcnt. Methods The reflux disease questionnaire was performed in patients diagnosed as GERD based on Montreal definition and classification as well as Rome Ⅲ criteria.All patients were divided into elderly group (≥65 years) and control group(＜65 years). The incidence of hita[ hernia (HH), the frequencies of esophagitis (based on Los Angeles classification), clinical features, and quality of life were compared between two groups. Results There was no difference between two groups in male/female ratio and morbidity of HH(P＞0.05). In comparison with control group, the frequency of esophagitis graded as LC or LD increased and extra-esophageal symptoms were higher in elderly group (P＜ 0.05), but the lower typical symptoms (heartburn and regurgitation) were seen in the elderly group(P＜0.05). The scores of role physical, bodily pain and role emotional were higher in elderly group than those in control group (P＜0.05). There was no significant differences between two groups in physical function, vitality,social functioning, mental health, and general health. Conclusion The elderly GERD patients often have lower score of typical reflux symptoms (heartburn and regurgitation) and high incidence of severer esophagitis, but their quality of life is not significantly influenced.     

乙型肝炎肝硬化伴肝血吸虫病误诊原发性肝癌1例

一、病史摘要 患者,男性,60岁,江苏东台人,农民,因＂发现乙肝表面抗原阳性20余年,肝占位4d＂于2010年7月17日入院。患者于20余年前即发现乙型肝炎病毒表面抗原（HBsAg）阳性,长期未注意监测乙型肝炎病毒学指标及肝功能等的变化。近1年来轻度间断乏力,无畏寒、发热,无明显恶心、呕吐、厌油,     

干扰素联合利巴韦林治疗丙型肝炎出现横纹肌溶解症1例分析

干扰素（IFN）联合利巴韦林（RBV）是当前丙型病毒性肝炎的主要治疗方案,流感样症状、骨髓抑制、食欲减退、皮疹、诱发抑郁及自身免疫性疾病等是其主要不良反应。然而,IFN/RBV治疗诱发横纹肌溶解症（rhabdomyolysis,RM）的报道极为罕见。我科近年收治1例,现将其临床特点和处理结果报告如下,并对其发生机制进行简要探讨。     

老年胃食管反流病患者临床特征分析

Objective To analyze clinical characteristics of gastroesophageal reflux disease(GERD) in aged patients for improvement of diagnosis and treatemcnt. Methods The reflux disease questionnaire was performed in patients diagnosed as GERD based on Montreal definition and classification as well as Rome Ⅲ criteria.All patients were divided into elderly group (≥65 years) and control group(＜65 years). The incidence of hita[ hernia (HH), the frequencies of esophagitis (based on Los Angeles classification), clinical features, and quality of life were compared between two groups. Results There was no difference between two groups in male/female ratio and morbidity of HH(P＞0.05). In comparison with control group, the frequency of esophagitis graded as LC or LD increased and extra-esophageal symptoms were higher in elderly group (P＜ 0.05), but the lower typical symptoms (heartburn and regurgitation) were seen in the elderly group(P＜0.05). The scores of role physical, bodily pain and role emotional were higher in elderly group than those in control group (P＜0.05). There was no significant differences between two groups in physical function, vitality,social functioning, mental health, and general health. Conclusion The elderly GERD patients often have lower score of typical reflux symptoms (heartburn and regurgitation) and high incidence of severer esophagitis, but their quality of life is not significantly influenced.     

基于Roussel uclaf因果关系评估量表的药物性肝损伤140例诊治分析

目的 探讨药物性肝损伤(DILI)的病因构成及临床和预后特点. 方法 回顾性分析解放军第八一医院全军肝病中心2012年7月至2013年7月诊断为DILI的140例患者的临床资料,采用RUCAM量表评价药物应用史与肝损伤的相关性,并分析药物种类构成、DILI的临床类型及预后特点.结果 引起本组患者DILI的前3位药物为中药87例(62.1％)、解热镇痛药14例(10％)、抗生素7例(5％).男女性别比为1∶1.69.＞40 ～ ＜60岁患者71例(50.7％).患者RUCAM分值均≥3,临床表现无明显特异性,肝细胞损伤型DILI最多见,共72例(51.4％),胆汁淤积型43例(30.7％),混合型25例(17.9％);胆汁淤积型DILI患者的中位年龄(55.6岁)较肝细胞型(47.1岁)及混合型DILI (49.9岁)高.药物性急性肝衰竭患者占7.86％.结论 本研究患者中因中药引起的DILI所占比例最高,应引起高度重视;其次为解热镇痛药物和抗生素类药物.DILI的临床表现缺乏特异性,但老年患者相对易出现胆汁淤积.绝大多数DILI患者预后良好.     

肝衰竭患者肾功能评估策略的优化分析

目的通过比较急性/亚急性肝衰竭和慢加急性/亚急性肝衰竭患者血清肌酐(serum creatinine, Scr)、胱抑素C(cystatin C, Cyc)及基于多种公式计算的估算肾小球滤过率(estimated glomerularfiltration rate, eGFR),优化筛选适合此类患者的肾功能评估指标。方法回顾性分析2011年1月-2018年5月符合急性/亚急性肝衰竭(Ⅰ组)或慢加急性/亚急性肝衰竭(Ⅱ组,又分ⅡA、ⅡB、ⅡC组)诊断标准的210例肝衰竭患者的临床资料,以213例健康体检者为对照组,比较各组Scr、Cyc及9种eGFR计算公式在肝衰竭患者及对照组的组间和组内差异。结果Ⅱ组Scr和Cyc水平显著高于对照组(P均<0.05);Ⅰ组Cyc水平显著高于对照组(P <0.05),而2组间Scr水平比较,差异无统计学意义(P> 0.05)。Ⅰ、Ⅱ组内eGFR4、eGFR5、eGFR10及eGFR7的异常率最低值分别为100%、80.00%、96.44%及60.00%,对照组内的异常率最低值分别为100%、25.82%、70.89%及10.33%。与eGFR1和eGFR2相比,eGFR3的假正常率最高,最高达48.81%。血清Cyc及Scr均正常时,eGFR6假降低率较其他eGFR均高,最高达65.24%。结论对于肝衰竭患者的肾功能评估,血清Cyc较Scr更为可靠。各种eGFR公式中,以基于Scr联合Cyc的公式eGFR11和基于Scr的eGFR2及eGFR1较为合适,尤其是eGFR11。     

肝脏多发性占位伴血清AFP显著升高1例

患者,男性,54岁,因上腹部持续隐痛不适2月余于2012年5月9日入院。病程中患者偶有上腹部饱胀不适,食欲较前稍减退,无发热,无恶心、呕吐,无腹泻、便血。外院腹部B超提示肝内多发占位,我院门诊查血清AFP1306.69μg/L(正常参考值0～20μg/L)。上腹部CT平扫+增强(见图1):肝内多发低密度影,部分边缘欠清;肝胃间隙内类圆形软组织密度影,内似有钙化样密度,与胰体及胃分界欠清,考虑占位性病变;右侧     

两种常用抗肝纤维化中成药临床疗效的比较

目的：比较扶正化瘀胶囊和安络化纤丸临床抗肝纤维化作用。方法选择99例肝纤维化患者,随机分为两组,分别采用扶正化瘀胶囊治疗51例和安络化纤丸治疗48例,疗程为12个月,观察两组治疗前后 Fibroscan 值、肝纤维化四项、肝脏彩色超声以及肝脏病理学等的变化。结果经治疗后,扶正化瘀胶囊组 Fibroscan 值为8．25 KPa、HA 为143．4 ng/mL、LN 为95．9 ng/mL、PC-III 为109．3 ng/mL、Ⅳ-C 为72．1 ng/mL、门静脉内径为10．13 mm、脾脏厚度为38．40 mm。安络化纤丸组 Fibroscan 值为13．04 kPa、HA 为208．7 ng/mL、LN 为155．5 ng/mL、PC-III 为110．0 ng/mL、Ⅳ-C 为117．5 ng/mL、门静脉内径为12．61 mm、脾脏厚度为45．01 mm。两组相比差异有统计学意义（P ＜0．05）,此外扶正化瘀胶囊改善纤维化分级具有显著的效果（P ＜0．05）。结论与安络化纤丸相比,扶正化瘀胶囊具有更好的临床疗效。     

肝病时肾损伤和肾功能不全评估的若干问题

病毒性肝炎和肝硬化等肝病患者的肾损伤和肾功能不全总体上可分为急性肾损伤(AKI)、慢性肾病和慢加急性肾病。AKI又分为1期(风险期)、2期(损伤期)和3期(衰竭期)。肝肾综合征传统上分为Ⅰ和Ⅱ型,近年提出还存在伴有肾器质性损伤的Ⅲ型。肝病伴肾病一词被用来描述肝硬化背景下任何类型的肾疾病。目前临床上判断肝病时肾功能状态相对敏感和准确的生化指标包括估算的肾小球滤过率、单位时间内血清肌酐的升幅、血清胱抑素C水平等,尿微量白蛋白水平等对早期发现肾病也有重要价值。肝病病因、严重程度、感染等并发症、营养状态、治疗药物以及基础肾病等均可能与肝病状态下的肾损伤和肾功能不全相关,应注意辨别。     

中草药肝损伤的临床诊断

目的 为中草药肝损伤（HILI）的临床诊断提供基于模块化证据链的路线图。方法 分析中草药应用与肝损伤发生的时序关系、中草药自身相关肝毒性信息、合并用药情况的评估及非药物性肝损伤因素的排查等4大模块信息,并进行证据链的逻辑组合。结果及结论 HILI的临床诊断原则与现代药（化学药和生物医药）相似,但具有自身的特点和难点。在阐述中草药与肝损伤时序关系多样性的基础上,对中草药相关肝毒性、合并用药肝毒性及其他肝损伤病因的存在情况进行了多维评估,构建了基于完整证据链的HILI临床诊断路线图。罗素优克福因果关系评估法（RUCAM）量表对HILI的诊断有参考价值,改良电子化因果关系评估法（RECAM）量表对HILI的诊断价值有待在真实世界临床进一步论证,必要时可借助结构化专家观点程序（SEOP）确认诊断;肝活检病理组织学的某些病变特点有助于明确HILI的诊断;HILI相关生物标志物有待深入探索。