肝硬化腹水及其相关并发症治疗新进展

<正>肝硬化是各种慢性肝病所导致的弥漫性肝纤维化和再生结节形成,在临床上主要表现为肝细胞功能障碍和门脉高压症。代偿期肝硬化可多年无症状,直至腹水、食管胃底静脉曲张破裂出血和肝性脑病等失代偿事件出现。肝硬化患者一旦进入失代偿期,则5 a生存率低于20%[1]。1腹水腹水是肝硬化最常见的并发症。在诊断为代偿期肝硬化后,约50%患者将在10年内出现腹水[2]。在因腹水住院的肝硬化病人中,1 a病死率增至15%,5 a     

肝硬化腹水及相关并发症的诊疗指南

<正>一、概述腹水(ascites)是失代偿期肝硬化患者常见且严重的并发症之一,也是肝硬化自然病程进展的重要标志,一旦出现腹水,1年病死率约15%,5年病死率约44%-85%~([1,2])。因此,腹水的防治一直是临床工作中常见的难点和研究的热点问题。2001年4月,世界胃肠病学组织(WGO)制定了《临床指南:成人肝硬化腹水的治疗(2001)》。2004年美国肝病学会(AASLD)制定了《成人肝硬化腹     

肝硬化腹水并发自发性腹膜炎50例临床分析

目的探讨肝硬化并发自发性细菌性腹膜炎（SBP）的特点,为科学治疗提供临床指导。方法回顾性分析50例肝硬化并发SBP患者的临床资料。结果50例患者中。发热37例（74．0％）,腹胀41例（82．0％）,腹痛30例（60．0％）,腹水多形核白细胞（PMN）比值〉0．50者43例（86．0％）,腹水细菌培养阳性27例（54．0％）。结论肝硬化并发SBP临床表现不典型．腹水PMN比值是诊断SBP的敏感指标之一。大肠杆菌为该疾病主要病原菌,对头孢噻肟和第三代喹诺酮类药敏感,可作为首选药物。     

肝硬化腹水合并自发性细菌性腹膜炎55例临床分析

自发性细菌性腹膜炎(spontaneoushacterialperitonitis,SBP)，是肝硬化合并腹水的患者常见与严重的并发症之一，这与肝硬化患者免疫功能明显降低，特别是肝内网状内皮系统严重受损，巨噬细胞吞噬功能以及白细胞黏附趋化与吞噬功能降低等原因有关，也是导致死亡的重要因素之一。本研究对大连市第八人民医院近2年来收治的55例肝硬化腹水合并自发性细菌性腹膜炎的临床资料进行分析，现将结果报道如下。     

肝硬化腹水的预后

腹水为肝硬化患者最常见的并发症之一,代偿期肝硬化患者大约60％于10年内出现腹水[1],出现腹水后,患者1年和5年内的死亡率分别为15％和44％[2].研究表明,年龄、并发症以及血清胆红素、白蛋白、肌酐等指标均影响腹水患者的预后,Child-Pugh分级、终末期肝病模型(MELD)评分、MELD-钠(MELD-Na)等模型可协助判断患者的预后.现对肝硬化腹水预后的研究进展做一综述.     

低蛋白腹水的肝硬化患者出现自发性细菌性腹膜炎的危险因素调查

我们采用多元回归分析对低蛋白腹水的肝硬化患者发生ＳＢＰ的高危因素进行了调查。 １．资料和方法：（１）病例为本院１９９８年４月至２０００年３月门诊及住院的肝硬化伴低蛋白腹水的患者９８例,男６９例,女２９例,平均年龄为（５６±６）岁。按ＣＡｉｌｄ－Ｐｕｇｈ评分,Ａ级４例,Ｂ级３９例,Ｃ级５５例。参加研究的患者均排除了重度肝肾功能不全和原发性肝癌并通过标准实验室技术对腹水和静脉血进行常规化验及肝、肾功能和电解质等生化检查。（２）方法：患者均在门诊进行定期随访,对腹水增长迅速或顽固性腹水者收入病房治疗。…     

ALBI评分联合PCT在肝硬化腹水患者自发性细菌性腹膜炎的预测作用

目的 探究白蛋白-胆红素(albumin-bilirubin, ALBI)评分联合降钙素原(procalcitonin, PCT)在肝硬化腹水患者自发性细菌性腹膜炎(spontaneous bacterial peritonitis, SBP)的预测价值。方法 回顾性纳入2017年6月至2021年7月我院住院治疗的376例肝硬化腹水患者,根据患者住院期间是否发生SBP,将其分为SBP组109例(28.99%)和非SBP组267例(71.01%)。通过电子病历系统收集患者入院时的临床资料,采用多因素Logistic回归分析肝硬化腹水患者住院期间发生SBP的独立危险因素。采用ROC曲线评定ALBI评分联合PCT预测SBP发生的性能。结果 单因素分析显示,SBP组肝性脑病比例、PCT、国际标准化比值、MELD、CTP、ALBI评分均高于非SBP组(P<0.05)。多因素Logistic回归分析结果显示,ALBI评分(OR=1.802,95%CI:1.153～2.818,P=0.009)、PCT(OR=1.374,95%CI:1.026～1.841,P=0.033)是发生肝硬化腹水患者住...     

氧氟沙星预防肝硬化腹水并发自发性细菌性腹膜炎的临床观察

肝硬化腹水并发自发性细菌性腹膜炎(SBP),病情严重,预后极差,因此,预防肝硬化腹水患者并发SBP,能改善患者预后。关于口服抗生素,特别是喹诺酮类药物预防肝硬化腹水井发SBP,的国内报道较少,我们在2000年1月-2002年4月用随机对照研究的方法,对30例肝硬化腹水患者进行口服氧氟沙星预防SBP,并与不用氧氟沙星的30例肝硬化腹水患者作对照,发现口服氧氟沙星能有效预防肝硬化腹水患者并发SBP,而无明显不良反应,现报道如下。     

肝硬化腹水合并细菌性腹膜炎早期诊断与治疗的研究

为探讨肝硬化腹水合并细菌性腹膜炎(PBP)的早期诊断与治疗,我们测定腹水中乳酸值和同时进行动态观察,并应用腹腔灌洗治疗43例合并PBP,取得较满意效果。报告如下: 对象与方法一、对象:肝硬化腹水合并PBP组72例,非感染性肝硬化腹水组40例,结核性腹     

白蛋白防治肝硬化并发肾功能损害的临床研究

目的探讨白蛋白防治肝硬化患者发生肾功能损害的作用。方法 49例乙型肝炎肝硬化并发自发性细菌性腹膜炎患者接受头孢唑肟钠加白蛋白治疗14天,另49例只接受头孢唑肟钠治疗14天。结果联合治疗的患者在治疗结束时肾功能得到改善,低钠血症恢复;在联合治疗组中有4例(8.16%)患者出现肾功能损害,而在对照组中有15例(30.6%)患者出现肾功能损害(P0.05);联合组院内死亡5例(10.2%),而对照组院内死亡13例(26.5%,P0.05)。结论在合理应用抗生素的同时应用白蛋白可防治肝硬化自发性细菌性腹膜炎患者肾功能的进一步损害,从而降低病死率。     

肝硬化细菌移位及其后果

随着人们对细菌移位（bacterial translocation，BT）后果研究的不断深入，BT的概念已从传统的有活性的肠道菌群通过肠道屏障到达肠系膜淋巴结和肠腔外其他器官或部位，延伸到细菌释放产物（如内毒素和细菌DNA）的移位。现就细菌移位过程中的多种机制，特别是肠内菌群和黏膜屏障功能的改变及免疫防御机制综述如下。     

Multivariate predictive model for asymptomatic spontaneous bacterial peritonitis in patients with liver cirrhosis

BACKGROUND Spontaneous bacterial peritonitis(SBP) is a detrimental infection of the ascitic fluid in liver cirrhosis patients, with high mortality and morbidity. Early diagnosis and timely antibiotic administration have successfully decreased the mortality rate to 20%-25%. However, many patients cannot be diagnosed in the early stages due to the absence of classical SBP symptoms. Early diagnosis of asymptomatic SBP remains a great challenge in the clinic.AIM To establish a multivariate predictive model for early diagnosis of asymptomatic SBP using positive microbial cultures from liver cirrhosis patients with ascites.METHODS A total of 98 asymptomatic SBP patients and 98 ascites liver cirrhosis patients with negative microbial cultures were included in the case and control groups, respectively. Multiple linear stepwise regression analysis was performed to identify potential indicators for asymptomatic SBP diagnosis. The diagnostic performance of the model was estimated using the receiver operating characteristic curve.RESULTS Patients in the case group were more likely to have advanced disease stages, cirrhosis related-complications, worsened hematology and ascites, and higher mortality. Based on multivariate analysis, the predictive model was as follows: y(P) = 0.018 + 0.312 × MELD(model of end-stage liver disease) + 0.263 × PMN(ascites polymorphonuclear) + 0.184 × N(blood neutrophil percentage) + 0.233 × HCC(hepatocellular carcinoma) + 0.189 × renal dysfunction. The area under the curve value of the established model was 0.872, revealing its high diagnostic potential. The diagnostic sensitivity was 73.5%(72/98), the specificity was 86.7%(85/98), and the diagnostic efficacy was 80.1%.CONCLUSION Our predictive model is based on the MELD score, polymorphonuclear cells, blood N, hepatocellular carcinoma, and renal dysfunction. This model may improve the early diagnosis of asymptomatic SBP.     

Spontaneous bacterial peritonitis： A severe complication of liver cirrhosis

This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascitesspontaneous bacterial peritonitis. Epidemiology,aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.     

Diagnosis and therapy of ascites in liver cirrhosis

Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, ...     

腹水超滤浓缩-细菌过滤回输腹腔治疗肝炎肝硬化合并自发性细菌性腹膜炎的临床疗效分析

目的 评估腹水超滤浓缩-细菌过滤回输腹腔技术治疗肝炎肝硬化合并自发性细菌性腹膜炎患者的临床疗效.方法 110例肝炎肝硬化合并自发性细菌性腹膜炎患者随机分为研究组和对照组,两组患者均采用保肝、利尿、对症、支持及静脉滴注抗生素等常规治疗,疗程2周.研究组在常规治疗基础上,采用腹水超滤浓缩-细菌过滤回输腹腔治疗;对照组在常规治疗基础上,采用腹腔穿刺放液治疗.结果 治疗后研究组腹水蛋白及补体C3水平明显高于对照组(P＜0.01),研究组血清白蛋白水平明显高于对照组(P＜0.01),研究组临床疗效明显好于对照组(P＜0.01).结论 腹水超滤浓缩-细菌过滤回输腹腔技术治疗肝炎肝硬化合并自发性细菌性腹膜炎患者的临床疗效明显好于腹腔穿刺放液治疗.     

Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review

Spontaneous bacterial(SBP) and spontaneous fungal peritonitis(SFP) can be a life-threatening infection in patients with liver cirrhosis(LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant(MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.     

肝硬化并发自发性细菌性腹膜炎临床研究进展*

目的 自发性细菌性腹膜炎(SBP)为目前肝硬化患者最常见的并发症之一,具有发病率高,疾病发展快,病死率高等特征。该病临床表现常不典型,腹腔感染的诊断主要基于腹腔积液白细胞计数。治疗则以经验性抗生素使用为主,联合调节肠道菌群、补充白蛋白等。有条件者可考虑肝移植。早期发现并积极实施干预对改善本病预后、降低病死率都有着重要的意义,但在有关SBP诊断、治疗和预防方面,仍面临巨大的挑战,需要深入研究进一步解决相关问题的策略,从而更好地指导临床实践,改善患者预后。     

终末期肝病模型对肝硬化腹水患者并发自发性腹膜炎的预测价值

MELD≤19分组、20～29分组和≥30分组分别为12.50%,52.38%和66.67%.MELD≤30分组与≤19分组的肝硬化腹水患者并发SBP比较,OR值为14(95%CI 5.41～36.20);20～29分组与≤19分组比较,OR值为7.7(95%CI 4.17～14.20).ROC曲线下面积(AUC)为0.774(95%CI 0.689～0.855).结论 MELD分值和肝硬化腹水患者SBP发病率线性正相关,高MELD分值提示发生SBP风险增加.     

肝硬化发生自发性细菌性腹膜炎的危险因素分析

目的探讨肝硬化自发性细菌性腹膜炎（SBP）发生的危险因素。方法 398例肝硬化患者被分为SBP组（135例）和无SBP组（263例）,比较两组年龄、性别、病程、既往SBP史、腹水时间、糖尿病史、腹水总蛋白、消化道出血、肝功能Child-Pugh分级、抗生素预防、重要生化及凝血指标等因素。结果两组患者在既往SBP史、腹水时间、糖尿病史、腹水总蛋白、消化道出血、Child-Pugh分级、抗生素预防、血Na＋、TBil、ALB、PT等方面差异有非常显著性意义（P〈0.01）。结论肝硬化SBP发生与一些因素高度相关,应予以及时有效的防治,以减少SBP的发生。     

肝硬化并发自发性细菌性腹膜炎的临床特征及病原菌耐药分析

目的探讨肝硬化合并自发性细菌性腹膜炎(SBP)的临床特征及病原菌耐药情况。方法分析135例肝硬化合并SBP患者在抗感染治疗前后体温、腹部症状和体征、血常规、腹水白细胞及多核细胞数变化、腹水培养及药物敏感试验。结果 82.2%患者有发热,90.4%有腹部症状,88.9%有中等以上腹水7,0.4%有顽固性腹水;21.5%外周血白细胞数≥10.0×109/L,63.7%中性粒细胞0.7;45.2%腹水白细胞数0.5×109/L,57.8%多核细胞0.5;25.4%(30/118)细菌培养阳性,其中革兰氏阴性菌25例(83.3%),革兰氏阳性菌5例(16.7%),检测出的革兰氏阴性菌对大部分常用的抗菌药物耐药;治愈40例(29.63%),好转48例(35.56%),无效、恶化或自动出院47例(34.81%),其中死亡15例。结论肝硬化合并SBP的临床症状不典型,腹水培养阳性率低,以革兰阴性菌为主。除应尽早行腹水培养外,需根据临床症状、体征、血常规、腹水常规检查等综合分析,及时应用有效抗生素治疗,以提高患者的生存率。