参苓白术散加减结合利尿剂治疗肝硬化腹水32例

目前国内治疗肝硬化腹水的措施主要采用护肝利尿等常规治疗,但疗程较长疗效不够满意,笔者采用在常规治疗的基础上配以参苓白术散加减治疗肝硬化腹水取得较好的疗效,现报告如下。1 对象和方法1.1 对象 60例肝硬化腹水患者全部为2002年2月—2002年7月的住院病人,诊断标准符合中国中西医结合学会、消化专业委员会1993年11月制定的肝硬化诊断标准。60例病人随机分两组,即利尿剂治疗组28例,其中男25例,女3例;年龄18～70岁,平均40岁,病程4个月～28年,平均5     

利尿剂联合中药治疗肝硬化腹水15例

1 一般资料 15例患者,男14例,女1例。年龄30～65岁,平均年龄48岁。肝炎肝硬化腹水11例,血吸虫肝硬化腹水7例,酒精性肝硬化腹水2例(其中,具有相兼因素者53例)。所有病例均有中度以上腹水,部分合并黄疸,有近1/3病例为第2次或笫3次复发而就诊。     

建立肝硬变腹水的新方案

目的进一步评价补给足量电解质+高效利尿对肝硬变腹水治疗的作用.方法采用随机对照实验方法.治疗组饮食不限盐,氯化钾1g～2g,安体舒通100mg,速尿40mg～80mg,口服,均为3次/d;对照组低盐饮食,氯化钾0.5g～1g,安体舒通40mg,双氢克尿噻25mg～50mg或者速尿20mg,口服,均为3次/d.结果两组日尿量分别为2366mL±498mL与1308mL±208mL;腹水消退时间为14d±4d与27d±5d.两组对比有显著性差异(P均<0.01).结论补给足量电解质+高效利尿治疗肝硬变腹水安全、有效、快捷.     

利尿剂治疗肝硬化腹水并发高渗性非酮症性糖尿病昏迷二例

我们发现肝硬化腹水患者应用利尿剂并发高渗性非酮症性糖尿病昏迷（ＮＨＤＣ）并致死亡２例，现报告如下。［例１］患者女，３４岁。因黄疸５年，神志不清１２小时入院。曾确诊为：原发性硬化性胆管炎，胆汁性肝硬化。体检：意识模糊，皮肤巩膜明显黄染。腹膨隆软无压痛，...     

自体腹水回输治疗顽固性肝硬化腹水64例

顽固性肝硬化腹水患者,由于大量腹水压迫,影响呼吸及循环,特别是压迫肾脏影响肾功能,使尿量进一步减少,形成恶性循环;长期大量腹水的存在,容易并发自发性细菌性腹膜炎、肝性脑病、肝肾综合征及消化道出血等并发症,预后极差.     

腹水超滤回输和卡托普利联合治疗难治性肝硬化腹水89例

目的探讨腹水超滤回输和卡托普利联合治疗难治性肝硬化腹水的临床疗效。方法收集本院经排除自发性腹膜炎、结核性腹膜炎、腹腔肿瘤后的难治性肝硬化腹水病人185例,随机分成2组,对照组病人常规护肝和利尿,在此基础上进行腹水超滤回输,治疗组病人在常规护肝和腹水超滤回输基础上口服卡托普利,对2组病人的肾功能、腹水变化及腹水复发情况进行比较。结果治疗组病人肾功能恢复率较对照组高,腹水复发率较对照组明显降低,两组比较差异有显著性。结论腹水超滤回输联合卡托普利治疗难治性肝硬化腹水疗效好,复发率低,并发症少。     

开放饮食与限盐饮食对肝硬化腹水患者的影响

肝硬化腹水的治疗常规以限盐饮食加利尿剂，患者常出现低钠血症，发生率约50％。开放饮食在利尿剂治疗肝硬化腹水时对患者有何影响尚少见报道，我们观察了利尿剂治疗时，开放饮食与限盐饮食对98例肝硬化腹水患者的影响。     

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自发性细菌性腹膜炎(spontaneous bacterial peritonitis,SBP)的发生率很高,在肝硬化腹水患者中达10%~30%。SBP使肝脏功能受损加重,并使肝移植患者围手术期病死率增加,最严重的并发症是肝肾综合征,发生率约30%。SBP的病死率很高,一次发生SBP的病死率约20%,SBP发生后1年的病死率     

肝硬化腹水的治疗进展

腹水是肝硬化最常见的并发症之一,腹水的出现不仅影响生活质量,而且影响存活时间。近年来,肝硬化腹水治疗研究已取得较大成绩,本文重点介绍水钠限制、放腹水与白蛋白输注、利尿剂与利水剂的使用、抗菌药物的使用、肝移植等方面的进展。     

肝硬化腹水的治疗

目的探讨腹水的治疗方法。方法通过收治的28例肝硬化腹水患者通过改善肾血流量,在此基础上应用利尿剂,以促进腹水的消退,经过一疗程的治疗,彩超对比治疗前后肾血流量以及肾功能即BUNn、Cr的变化。并与23例对照者。结果发现治疗组利尿剂应用相对较少,腹水消退较快,一疗程即住院治疗一个月后,复查彩超、肾血流量有不同程度的增加,BUNn、Cr均未上升。对照组只有在大量应用利尿剂的基础上,腹水才能消退,经一疗程即住院治疗1个月后复查彩超,肾血流量有不同程度的减少,BUN、Cr有轻度升高。结论肝硬化腹水患者通过在改善肾血流量的基础上,应用利尿剂促进腹水的消退,印在保肾的基础上,适当利尿,为临床上治疗肝硬化腹水提供了客观依据。     

American College of Cardiology/American Heart Association Chronic Heart Failure Evaluation and Management guidelines: relevance to the geriatric practice

BACKGROUND: Heart failure (HF) is the only cardiovascular disease with increasing incidence and prevalence. Most HF patients are older adults. With the aging of the population and effective treatment of hypertension and coronary artery disease, the two major underlying causes of HF, the number of older Americans with HF is expected to rise significantly in the coming decades. HF is the number one hospital discharge diagnosis for older adults. It is one of the causes of frequent hospital readmissions, reflecting acute decompensation and compromised quality of life for patients and increased cost and resource use for the healthcare system. It is also associated with approximately 300,000 deaths annually, most in older adults. Advances in the management of HF in the past several decades have significantly decreased the mortality and morbidity associated with this condition. Randomized controlled trials have demonstrated the beneficial effects of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta-blockers, and spironolactone on survival and quality of life of HF patients, but there is evidence of underuse of evidence-based care for HF. Several national guidelines have been published since 1994 that recommended evidence-based evaluation and management of HF. In 1995, the American College of Cardiologists (ACC) and the American Heart Association (AHA) published their first HF guidelines that recommended left ventricular (LV) function evaluation for all patients presenting with HF and use of ACE inhibitors for all patients with LV systolic dysfunction (LVSD) unless contraindicated. The guidelines recommended the use of hydralazine and isosorbide dinitrate in patients who could not use ACE inhibitors. In addition, digoxin was recommended in patients with HF due to LVSD but not adequately responsive to ACE inhibitors and diuretics and in those with atrial fibrillation and rapid ventricular rates. Diuretic use was recommended for symptomatic patients with evidence of fluid overload. Use of anticoagulation was restricted to patients with atrial fibrillation or to those with a history of systemic or pulmonary embolism. Beta-blockers were reserved for HF patients after acute myocardial infarctions. Recent advances in the management of HF called for a revision of the guidelines. PURPOSE: The purpose of revising the 1995 ACC/AHA guidelines was to incorporate recent advances in pharmacological and nonpharmacological approaches to HF treatment and to assist physicians in clinical decision-making in the management of HF. METHODS: The ACC/AHA invited representatives from the American College of Chest Physicians, the Heart Failure Society of America, the International Society for Heart and Lung Transplantation, the American Academy of Family Physicians, and the American College of Physicians-American Society of Internal Medicine to participate in the preparation of the guidelines. The writing committee searched pertinent medical literature in English using computerized databases such as MEDLINE and EMBASE and manually searching the bibliographies of the selected articles. The writing committee classified HF into four stages, including patients who are at high risk for developing HF. According to this new classification, Stage A and B represent asymptomatic patients, the former at high risk for developing HF but no structural disorder, the latter with structural disorders of the heart. Stage C encompasses patients with underlying structural heart disorders who are symptomatic, either currently or in the past. Stage D includes end-stage HF patients. This new classification is intended to complement the New York Heart Association (NYHA) functional classification of HF into Class I (asymptomatic), Class II (symptomatic on less than ordinary exertion), Class III (symptomatic on ordinary exertion), and Class IV (symptomatic at rest). RESULTS: The recommendations are categorized into those for evaluation and management.     

Management of primary biliary cirrhosis. The American Association for the Study of Liver Diseases practice guidelines

Primary biliary cirrhosis (PBC) is a presumed autoimmune disease of the liver, which predominantly affects women once over the age of 20 years. Most cases are diagnosed when asymptomatic (60%). The antimitochondrial antibody is present in serum in most, but not in all, patients with PBC. The disease generally progresses slowly but survival is less than an age- and gender-matched general population. The symptomatic patient may have fatigue, generalized pruritus, portal hypertension, osteoporosis, skin xanthomata, fat soluble vitamin deficiencies, and/or recurrent asymptomatic urinary tract infections. Many nonhepatic autoimmune diseases are found in association with PBC and may prompt initial presentation. To date, immunosuppressive therapy has not been shown to prolong survival in PBC. The hydrophilic bile acid, ursodeoxycholic acid (UDCA), has been shown when given in a dose of 13 to 15 mg/kg daily for up to 4 years to delay the time to liver transplantation or death. This therapy also causes a significant improvement of all the biochemical markers of cholestasis but has no beneficial effects on any of the symptoms or associated disorders. Treatment with UDCA does not obviate the need for liver transplantation. Therapies to prevent complications arising from malabsorption, portal hypertension, and/or osteoporosis are required as well. Good control of pruritus can be achieved in most patients. PBC is diagnosed with increasing frequency, but the agent(s) responsible for this slowly progressive destruction of the interlobular bile ducts remains elusive and hence a specific therapy remains unavailable.     

Management of digestive bleeding related to portal hypertension in cirrhotic patients： A French multicenter cross-sectional practice survey

INTRODUCTION Gastrointestinal hemorrhage is a major complication of cirrhosis, and several consensus conferences[1,2] have attempted to standardize its management. All the recommendations are based on results of meta analysis of randomized trials, which a…     

Clinical practice guidelines for the management of cirrhotic patients with ascites. Committee on Ascites of the Italian Association for the Study of the Liver

An ad hoc Committee appointed by the Italian Association for the Study of the Liver prepared these Clinical Practice Guidelines for the Management of Cirrhotic Patients with Ascites. The initial evaluation of a patient with ascites should include a history, physical evaluation, paracentesis with ascitic fluid analysis, abdominal ultrasonography and biochemistry to assess the severity of liver disease and renal functionality. To improve the efficiency of the choice between the different opportunities available in the treatment of ascites, patients can be classified into two subgroups: patients with uncomplicated ascites and patients with complicated ascites, including refractory ascites, bacterial peritonitis, hyponatraemia and renal failure. Based upon evidence emerging from controlled clinical trials or case-control studies, satisfactory treatment for uncomplicated ascites is represented by paracentesis, sodium-restricted diet and diuretics, whereas the treatment of patients with complicated ascites requires other specific approaches. As the prognosis for most patients with ascites is poor, the last part of the paper offers simple criteria in the selection of patients candidates for liver transplantation. The aim of these guidelines is to reduce inappropriate practice and to improve efficiency in the management of patients with ascites. The Committee holds that a periodic update will be necessary to conform to future scientific developments.     

2004 American College of Cardiology/American Heart Association guidelines for the management of patients with ST-elevation myocardial infarction: implications for emergency department practice

The American College of Cardiology and the American Heart Association last published evidence-based guidelines for the management of ST-segment elevation myocardial infarction (STEMI) in 1999. In mid-2004, in recognition of the evolution and improvement of many of the most basic tenets of clinical management of STEMI since that time, an updated edition of the STEMI guidelines has been published. These guidelines offer many evidence-based recommendations that are pertinent to the out-of-hospital and emergency department care of STEMI patients, including initial evaluation, risk stratification, stabilizing management, and the choice between pharmacologic and mechanical revascularization. These are presented and discussed here.     

A critical review of the American College of Cardiology/American Heart Association practice guidelines on bicuspid aortic valve with dilated ascending aorta

The 2006 practice guidelines from the American College of Cardiology and the American Heart Association recommend prophylactic aortic replacement for even an asymptomatic patient with a bicuspid aortic valve (BAV) when the aortic dimensions exceed arbitrary ranges based on Marfan syndrome, without comparing risk estimates of aortic dissection with operative risks. In the International Registry of Acute Aortic Dissection, which includes >1,000 autopsied subjects, the average age is 63 years; BAVs are found in only 3%, compared with histories of hypertension in 72%. The risk for valve-sparing aortic replacement is 4% and that for late mortality is 10%, on the basis of 5 publications. The aortic dimensions are from guidelines for Marfan syndrome, with a proved genetic weakness of connective tissue, whereas no culprit genes have been demonstrated in BAV. Although cystic medial necrosis is seen in dilated aortas associated with Marfan syndrome and BAV, it is also seen in dilated aortas with other causes. There is no convincing proof that cystic medial necrosis causes dissection or is simply an effect of dilatation. BAV is not associated with dilatation of the pulmonary arteries, in contrast to Marfan syndrome. Hemodynamic explanations for dilatation of the ascending aorta have been largely ignored because of a belief that it requires severe aortic stenosis or regurgitation. In conclusion, vascular dilatation without a genetic weakness is caused by coarse periodic vibrations from even trivial valve disorders, demonstrated experimentally. There is a natural history of progressive deterioration of the BAV, including the valve left in a valve-sparing aortic replacement, that makes the operation ill advised, as opposed to valve replacement with aortic reinforcement.     

Management of critically-ill cirrhotic patients

Cirrhotic patients are prone to develop life-threatening complications that require emergency care and ICU admission. They can present specific decompensations related to cirrhosis such as variceal bleeding and hepatorenal syndrome (HRS) or other critical events also observed in the general population such as severe sepsis or septic shock. Clinical management of all these entities requires a specific approach in cirrhosis. Cirrhotic patients have a hyperdynamic circulation with high cardiac output and low systemic vascular resistance in the absence of infection. Circulatory dysfunction increases the susceptibility of critically-ill cirrhotic patients to develop multiple organ failure and attenuates vascular reactivity to vasopressor drugs. HRS, a severe functional renal failure occurring in patients with advanced cirrhosis and ascites, is also secondary to this circulatory dysfunction that leads to an extreme renal vasoconstriction. Moreover, hypotensive cirrhotic patients require a carefully balanced replacement of volemia, since overtransfusion increases portal hypertension and the risk of variceal bleeding and undertransfusion causes tissue hypoperfusion which increases the risk of multiple organ failure. Cirrhotic patients are also at a high risk for development of other bleeding complications and are more susceptible to nosocomial infections. This extreme complexity of critically-ill cirrhotic patients requires a specific medical approach that should be known by general intensivists since it has a negative impact on patient prognosis. This review will focus on the diagnostic approach and treatment strategies currently recommended in the critical care management of patients with cirrhosis.