Diagnostik und Therapie des Aszites bei Leberzirrhose

Zum Thema Man kann davon ausgehen, da? bei ca. 80% der Patienten mit Aszites eine parenchymat?se Lebererkrankung in fortgeschrittenem Stadium vorliegt. Im Vordergrund der Diagnostik stehen Anamnese, klinischer Befund und Ultraschalluntersuchung, mittels derer in der geeigneten Rechts-Seiten-Lage Aszitesmengen ab 300 ml dargestellt werden k?nnen. Zur weiteren differentialdiagnostischen Abgrenzung von malignem bzw. entzündlichem und nicht malignem bzw. nicht entzündlichem Aszites ist eine Parazentese notwendig. Untersucht werden sollten: Zellzahl und Differenzierung, zytologische Untersuchung, Gesamteiwei?, Cholesterin und bateriologische Untersuchungen unter Einschlu? von aeroben und anaeroben Blutkulturen. Die diagnostischen Kriterien zur Untersuchung des Aszites und die daraus abgeleiteten therapeutischen Konsequenzen werden in der vorliegenden Arbeit eingehend und mit praxisnahen Algorithmen, Tabellen und Abbildungen erl?utert. Klinik und Laboruntersuchungen der spontanen bakteriellen Peritonitis k?nnen im Rahmen dieser übersicht nur marginal behandelt werden. Dazu wird ausdrücklich auf die Arbeit von J. Sch?lmerich et al. in diesem Heft des INTERNIST verwiesen.     

Pathogenese und Progression der Leberzirrhose: aktuelle Perspektiven

Die Gastroenterologie - Die Leberzirrhose wurde traditionell lange als irreversibles Endstadium verschiedener chronischer Lebererkrankungen betrachtet, das über die Entwicklung...     

Leberzirrhose

The early detection of liver cirrhosis is essential for the treatment and monitoring of chronic liver disease. Because of their high accuracy, increasing availability and possibility of assessment of the course by repeat testing, non-invasive methods for assessment of liver fibrosis are increasingly being used as standard in the diagnostics and the importance of liver biopsies is therefore decreasing. The most relevant methods are non-invasive measurement of liver stiffness by transient or shear wave elastography and serum biomarkers. In addition to the measurement of fibrosis, which has different threshold values depending on the procedure and liver disease, more and more studies have evaluated the usefulness of non-invasive techniques for assessment of the prognosis and complications of liver cirrhosis. This article gives an overview on the current state of research on non-invasive procedures in liver cirrhosis.     

Volumenüberladung bei Herzinsuffizienz, nephrotischem Syndrom und Leberzirrhose

Volume retention in heart failure, nephrotic syndrome, and liver cirrhosis reflects pathological changes in homeostatic mechanisms that regulate the extracellular volume (sympathetic activity, renin-angiotensin-aldosterone system [RAAS], natriuretic peptides) and plasma osmolality (antidiuretic hormone [ADH]). In heart failure and liver cirrhosis, these changes are induced by a reduction of the effective circulating volume, which is the part of the extracellular fluid that is within the arterial system and effectively perfusing the tissues. This reduction in the effective circulating volume is caused by reduced cardiac output (heart failure), or by splanchnic vasodilatation with arterial underfilling (liver cirrhosis). In both cases, baroreceptors in both the carotid sinuses and in the glomerular afferent arterioles upregulate RAAS- and sympathetic activity, resulting in systemic vasoconstriction and renal sodium (and volume) retention. More severe reductions in the effective circulating volume may additionally stimulate ADH release, thus increasing the reabsorption of free water with subsequent hyponatriemia. In nephrotic syndrome, volume retention results either directly from the primary renal disease, which induces renal sodium and volume retention (“overfilling”), or indirectly from the reduced plasma oncotic pressure due to hypoalbuminemia, which induces a fluid shift from the intravascular to the interstitial space (“underfilling”) with subsequent acitivation of baroreceptors and secondary sodium and volume retention.     

Komplikationen der Leberzirrhose

Massive ascites and hepatorenal syndrome (HRS) are frequent complications of liver cirrhosis; therefore, effective therapy is of great clinical importance. This review provides an update on recent advances and new developments. Therapeutic paracentesis can be safely performed even in patients with severe coagulopathy. Selected patients with refractory or recurrent ascites are good candidates for transjugular intrahepatic portosystemic shunts (TIPS) which may provide a survival benefit and improvement in quality of life. Spontaneous bacterial peritonitis is typically treated with third generation cephalosporins. Prophylaxis of hepatorenal syndrome in patients with spontaneous bacterial peritonitis using albumin infusion is recommended. After resolution, secondary prophylaxis should be discussed and primary prophylaxis can be considered in patients with low ascitic protein and poor liver or kidney function. Liver transplantation is the best therapeutic option with long-term survival benefits for patients with HRS. To bridge the time until transplantation TIPS or terlipressin and albumin are good options.     

Komplikationen bei Leberzirrhose

Die Gastroenterologie -     

Komplikationen der Leberzirrhose

The occurrence of complications increases the mortality in patients with cirrhosis of the liver. Therefore, early detection and treatment of complications of cirrhosis is of major importance. Following diagnosis of cirrhosis, a screening gastroscopy detects esophageal varices. Primary prevention of variceal bleeding can be initiated with ??-receptor antagonists or variceal band ligation. With the first episode of ascites or the manifestation of other complications of cirrhosis such as hepatic encephalopathy and hepatorenal syndrome, a paracentesis excludes spontaneous bacterial peritonitis. Hepatorenal syndrome can be treated with a combination of vasopressors and albumine. Furthermore, occurrence of complications in patients with cirrhosis of the liver should prompt the evaluation of an indication for liver transplantation.     

Pulmonale Komplikationen der Leberzirrhose

Hepatopulmonary syndrome, portopulmonary hypertension and hepatic hydrothorax are typical pulmonary complications in patients with liver cirrhosis. Whereas hepatopulmonary syndrome and portopulmonary hypertension represent pulmonary vascular diseases, the development of hepatic hydrothorax is associated with the presence of ascites and phrenic lesions. For severe hepatopulmonary syndrome and refractory hepatic hydrothorax, liver transplantation is the treatment of choice. In severe portopulmonary hypertension specific medical treatment is indicated. In selected patients, beside intravenous prostanoids, oral endothelin receptor antagonists and phosphodiesterase type-5 inhibitors are possible treatment options.     

Diabetes und Schwangerschaft

In Bavaria a decline in perinatal mortality from 2.1 to 0.8% was registered from 1987 to 2007 in 7,800 pregnancies with known preconception diabetes. The evaluation of the new Institute of Medicine (IOM) guidelines in 680,000 obese pregnant women from Bavaria has been demonstrated to be suboptimal. Bariatric surgery, especially a Roux-en-y gastric bypass, leads to reduced adverse pregnancy outcomes, such as preeclampsia and gestational diabetes in extremely adipose women. Breastfeeding shows persistent benefits on cardiovascular health in reducing the incidence of metabolic syndrome. The amount of insulin in pregnant women with optimal preconception preparation changes in three typical directions. Progression of retinopathy during pregnancy has been documented in type 1 and also in type 2 diabetes. Results from secondary Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study data show increasing risk for preeclampsia and neonatal obesity with rising blood glucose and body-mass index (BMI) of the mother. Blood glucose lowering therapy and specialized obstetrical care both reduce the risk of adverse pregnancy outcome in gestational diabetes mellitus (GDM). Adolescents carry an increased risk of overweight at 16 years of age when the mothers had been obese or have had GDM during pregnancy.     

Diabetes und Demenz

Diabetes mellitus is a known risk factor for cognitive dysfunction and dementia. Chronic hyperglycemia, genetic predisposition, arterial hypertension, hyperlipoproteinemia, micro- and macrovascular diseases, and depression play a major role in the development of cognitive dysfunction. Both pathophysiology of diabetes and dementia and the specifics of diabetes therapy in patients with dementia are presented in this review.     

Leber und Diabetes

Non-alcoholic fatty liver disease (NAFLD) affects about 30?% of the general population and 70?% of patients with type 2 diabetes. The disease manifests as steatosis of the liver on the basis of a genetic predisposition through environmental factors, such as obesity, nutrition and lack of physical activity. Although NAFLD has a relatively benign prognosis, the hepatic metabolic disturbance causes insulin resistance and is strongly associated with the development of diabetes and cardiovascular diseases. It is important to distinguish NAFLD from non-alcoholic steatohepatitis (NASH) which can lead to cirrhosis and hepatocellular carcinoma (HCC). The diagnosis can be made by exclusion of other hepatic diseases and by liver biopsy. Future efforts will focus on substituting the need for a biopsy by the use of non-invasive serum markers and measurement of liver stiffness. Therapeutic options for patients with NASH are currently limited to lifestyle intervention and administration of pioglitazone and vitamin E; however, it is probable that further therapeutic options will be available in the future, some of which are currently being tested in clinical trials.     

Glukokortikoide und Diabetes

Glucocorticoid-induced hyperglycemia is of clinical importance for patients with diabetes and for patients with unknown diabetes mellitus. The influence of glucocorticoids on glucose metabolism is multifactorial. The different types of glucocorticoids and their difference in pharmacodynamics make therapy approaches difficult. Furthermore, studies comparing antidiabetic therapy for glucorticoid-induced hyperglycemia are lacking. For the majority of patients, insulin therapy is the best option to prevent short, medium, and long term health issues.