介入性腹腔—腔静脉分流术治疗顽固性腹水

目的：评价介入性腹腔－腔静脉分流术对终末期肝功能失代偿患者并发顽固性腹水的治疗效果。材料与方法：７例转流患者年龄２２￣７０岁，平均４８．１岁。选择两端多侧孔分流导管，在腹腔与上腔静脉之间建立转流，术中测定腹腔内压和上腔静脉压，术后记录腹围改变，监测其肝肾功能指标。结果：腹腔－腔静脉压力差均值为１２２．９ｍｍＨ２Ｏ，腹围平均缩小１１．４ｃｍ（７￣１５ｃｍ）；术后肝肾功能指标得到改善，其中５例临床症状     

介入性腹腔—腔静脉分流术治疗顽固性腹水并发症的护理

顽固性腹水是临床肝功能失代偿期的重要并发症,常见于门脉性肝硬化晚期、肝硬化并肝癌及原发性肝癌合并门腔静脉主干瘤栓。由于治疗棘手,我院自1996年7月以来共进行了11例腹腔一腔静脉分流术(IPVS),下面就其术前后护理及术后并发症预防报告如下。     

肝硬化失代偿期患者钠代谢变化特点及其临床意义

目的：为观察失代偿期肝硬化患者钠代谢变化特点．为临床治疗提供帮助。方法：选取失代偿期肝硬化126例检测血电解质，比较有无腹水组、不同肝功能分级组低钠血症发生率，以及低钠血症与肝性脑病，肝肾综合征和死亡率之间的关系。结果：显示失代偿期肝硬化伴腹水时低钠血症发生率较无腹水时高，差异有显著性意义（P〈0．05）；肝功能越差，其低钠血症的发生率越高，差异有显著性意义（P〈0．05）；低钠血症组转正常血钠组肝性脑病，肝肾综合征，死亡的发生率为高，差异有显著意义。结论：失代偿期肝硬化患者低钠血症发生率与有无腹水、肝功能级别，以及肝性脑病、肝肾综合征和死亡率之间均有密切的关系。     

介入法腹水转流术治疗顽固性腹水

目的评价介入法腹水转流术(IPVS)对顽固性腹水(IA)的治疗价值。方法45例IA患者,在腹腔与上腔静脉之间建立通道,术中测定腹腔内压和上腔静脉压,术后记录腹围、尿量。结果手术成功率100%;手术时间20～40min;腹腔-上腔静脉压力差平均为129.3mm水柱;手术第2天腹围开始缩小,第3天则明显缩小,平均缩小7.8cm;术后尿量明显增多,较术前平均增加770ml/d。总有效率77.8%(35/45)。无严重并发症。结论IPVS对IA治疗具有操作简便、微创、患者在院外自我护理方便等优点,可明显提高其生活质量。     

顽固性腹水的介入治疗—经皮腹水—静脉转流术

肝硬化失代偿期及终末期肝癌患者其顽固性腹水的治疗 ,目前仍较为棘手 ,腹水消退困难 ,患者不但痛苦 ,且影响食欲及睡眠 ,大量引流将造成大量营养物质的丢失 ,引起电解质紊乱、肝肾综合症、肝性脑病及恶液质的发生 ,加重病情。 2年来我院对 4例顽固性腹水患者行ＰＶＳ术 ,疗效显著 ,但导管转位问题较为突出 ,现总结如下。材料与方法一、临床资料2例为乙肝后肝硬化失代偿期 ,1例为肝豆状核变性 ,肝硬化失代偿期 ,肝功能均为ＣｈｉｌｄＣ级 ,1例为卵巢癌腹腔广泛转移伴大量腹腔积液 ,4例患者出凝血时间均正常 ,无心脏疾病史。二、材料ＰＶＳ留…     

肝硬化难治性腹水治疗的几种方法

腹水是肝硬化由代偿转化为失代偿的一个重要标志,难治性腹水则是失代偿早中期转化为晚期的重要表现,可分别或同时出现上消化道大出血、自发性腹膜炎、肝肾综合征、稀释性低血钠等严重并发症,预后极差。约90％肝硬化腹水的患者对治疗有良好反应,但另有约10％的腹水患者,对利尿剂治疗无反应,需进行大量腹腔穿刺抽腹水及其它方法的治疗。     

浓缩腹水经静脉回输法消除肝硬化腹水7例

1996～ 1 999年 ,我院采用浓缩腹水经静脉回输法为 7例肝硬化失代偿期患者消除大量顽固性腹水 ,取得良好效果 ,现报告如下。1　临床资料1 1　一般情况　本组 7例患者均为男性 ,年龄 41～ 5 9岁 ,其中肝炎后肝硬化 1例 ,血吸虫病性肝硬化 3例 ,混合性肝硬化 3例。腹水持续时间 4～ 1 5个月 ,平均 6 5个月 ,经限制水钠摄入、利尿、排放腹水、补充血浆、白蛋白等治疗 3个月以上无好转 ,或腹疗短期内反复增长 ,腹围 81～93ｃｍ。患者压迫症状严重 ,不能平卧 ,2例伴脐疝 ,1例伴鞘膜积液 ,1例尿少且利尿效果差。腹水检查提示为漏出液 ,脱落细…     

肝硬化难治性腹水的治疗现状

腹水是肝硬化三大并发症（腹水，肝性脑病和静脉曲张出血）中最常见者，一旦发生腹水，2年生存率约是50％。腹水是肝硬化由代偿转化为失代偿的一个重要标志，难治性腹水则是失代偿早、中期转化为晚期的重要表现，可分别或同时出现严重的并发症如上消化道大出血、自发性腹膜炎、肝肾综合征等，预后极差。90％的腹水患者对治疗有良好反应，另约10％的腹水患者，对利尿剂治疗无反应，需进行大量腹腔穿刺抽腹水及肝移植等处理。近年国外对难治性腹水作了一些规范性处理的意见，现综述如下。     

经皮经肝门腔静脉分流术

目的 评价经皮经肝途径建立门腔静脉分流术的可行性及探讨其临床意义。方法 19例门静脉高压患者行经皮经肝途径门腔静脉分流术(PTPS)。静脉曲张出血16例，难治性腹水2例，肝肺综合征1例；Child’S B级4例、C级15例。经皮经肝穿刺门静脉左支再穿刺肝段下腔静脉，经肝植入PTFE覆膜支架于门静脉左支与腔静脉之间。结果 19例经肝段下腔静脉TIPS分流术均获成功，技术成功率100％，未出现术中与操作技术相关并发症，术后门腔压力梯度平均下降13cmH2O，平均随访216d，所有患者未发生再出血，难治性腹水得到有效地控制。一年内初步开通率94．8％，明显高于传统TIPS。结论经皮经肝途径建立门腔静脉分流是安全可行的，结果 提示由于PTPS肝内具有顺直的分流道的优势，一年内支架初步开通率明显高于传统TIPS。     

奥曲肽联合腹水超滤浓缩回输治疗肝炎肝硬化晚期顽固性腹水的临床应用研究

目的：评价奥曲肽联合腹水浓缩回输治疗肝炎肝硬化晚期难治性腹水的疗效。方法：将84例肝硬化晚期顽固性腹水患者随机分为两组,研究组42例,常规治疗基础上加用奥曲肽联合腹水超滤浓缩回输腹腔治疗;对照42例,常规治疗基础上,采用治疗性腹腔穿刺放腹水治疗。疗程均为4用。结果：研究组治疗后体重、腹围、24h尿量、血浆及腹水中蛋白量及肌酐改善情况明显好于对照组（P〈0．05）。研究组临床疗效显著好于对照组（P〈0．05）。结论：奥曲肽联合腹水超滤浓缩回输腹腔技术是治疗肝炎肝硬化终末期顽固性腹水的一种较理想的治疗方法,因其价廉、易操作、疗效好特点值得临床应用推广。     

Congenital intrahepatic portosystemic venous shunt: sonographic and magnetic resonance imaging

We report an intraheptic portosystemic venous shunt (IPVS) detected by ultrasound in an asymptomatic newborn. The lesion, which was further documented using color Doppler ultrasound and magnetic resonance imaging (MRI), had almost totally disappeared 6 months later without any treatment. Intraheptic portosystemic venous shunts (IPVS) are uncommon and their etiology is controversial. Some cases of IPVS have been reported in the literature, most of them in adult patients with portal hypertension and cirrhosis of the liver [1–3]. However, only scattered reports describe IPVS in the absence of liver pathology [4–8]. A revision of the proposed etiologies of IPVS is made and the usefulness of gray-scale and color Doppler sonography and MRI in diagnosing IPVS is discussed.     

不同肝功能分级肝硬化患者的食管压力测定

为了解不同肝功能分级肝硬化患者食管蠕动功能和食管压力变化的特点，选择肝硬化患者（肝硬化组）94例，均经临床或病理确诊为肝硬化且有食管静脉曲张，肝功能Child分级；A组38例，有8例伴发腹水，B级37例，有20例伴发腹水；C级19例，有18例伴发腹水，另选择无肝硬化的正常对照（正常对照组）72例，均无消化系统疾病及胃肠道症状，无腹部手术，外伤史。检查前7天停用所有影响胃肠动力的药物。采用美国Sandhill公司Biolab食管动力检测系统及配套分析软件。结果显示，肝硬化肝功能A－C级各组食管下段括约肌静息压依次降低，松弛压力增大，松弛率变小；肝硬化组食管上段蠕动波起始点速度变慢，蠕动性收缩减少，异常收缩增加；肝硬化肝功能A－C级各组食管体部下段蠕动压力幅值依次降低，蠕动波起始点速度变慢，蠕动性收缩减少，异常收缩增加。以上结果表明，肝硬化患者肝功能损害越重，对食管正常动力影响越大，同时肝硬化患者食管静脉曲张与腹水形成亦有协同作用。     

Primary biliary cirrhosis: clinical, pathologic, and helical CT findings in 53 patients

PURPOSE: To evaluate and compare clinical, pathologic, and helical computed tomographic (CT) findings of primary biliary cirrhosis (PBC). MATERIALS AND METHODS: The authors reviewed the medical records and CT scans of 53 patients who underwent evaluation, treatment, and orthotopic liver transplantation (OLT) at their institution. All patients underwent helical multiphase CT (total, 98 abdominal CT scans; range, one to five scans per patient). Multiple epidemiologic, clinical, and morphologic criteria were evaluated. Advanced disease was defined as hepatic insufficiency leading to OLT within the subsequent 2 years. Clinical and morphologic features were evaluated and compared in the advanced and less advanced cases of PBC. RESULTS: Common and characteristic findings included the following: 45 (85%) of the 53 patients were women with the onset of disease (diagnosis) in middle age (mean, 50.7 years; range, 26-71 years). The average time from diagnosis to OLT was 6.1 years (range, 1.5-20.0 years). CT findings in advanced PBC often resembled those seen in other forms of cirrhosis, with a small heterogeneously attenuating liver, varices, and splenomegaly. The liver in less advanced disease was usually enlarged or normal in size, with a smooth contour, little atrophy, and lacelike fibrosis and regenerative nodules in nearly one-third of the livers. Patients with less advanced disease frequently had varices (n = 33 [62%]) and ascites (n = 13 [24%]). Lymphadenopathy was seen in 47 (88%) patients. Hepatocellular carcinoma was found in four (8%) patients, two of whom also had chronic hepatitis C. During a follow-up period of 5-72 months (median, 46 months; mean, 42 months) after OLT, only two patients experienced recurrence of PBC. CONCLUSION: PBC is an important cause of liver failure, with distinctive clinical and CT findings that may assist diagnosis and allow adequate treatment. CT can demonstrate varices and ascites before frank cirrhosis is evident and can help evaluate the progression of the disease.     

An unexpected death due to massive ascites and a giant mucinous ovarian cystadenoma

A female in her thirties fell face down in her room. She was motionless when her sister found her. She was transported to the hospital by ambulance and was in a state of cardiopulmonary arrest on admission. She did not respond to resuscitation. Her abdomen had started to swell 3 years before her death. An autopsy was performed to clarify the decedent’s cause of death. She was 172 cm tall and weighed 146 kg. Her maximum abdominal girth was 172.1 cm. A subcutaneous hemorrhage measuring 4.5 cm in diameter was observed in the epigastric region. The abdominal cavity contained brownish ascites (54.1 L). The left ovary was markedly swollen, and the combined weight of the uterus and right ovary was more than 13.0 kg. A left ovarian tumor consisting of serous and mucinous cysts was detected. There were no metastatic lesions in the peritoneum or other organs. She might have suffered circulatory disturbance caused by the ascites and ovarian tumor. Moreover, being in a prone position would have resulted in an increase in intra-abdominal pressure, further exacerbating her circulatory problems. Therefore, her cause of death was considered to be circulatory failure caused by significant ascites and a large ovarian tumor.     

Value of computed tomography and magnetic resonance imaging for assessing severity of liver cirrhosis secondary to viral hepatitis

PURPOSE: The aim of this study was to assess the value of abdominal CT and MRI in determining the severity of cirrhosis secondary to hepatitis compared to Child-Pugh classification. MATERIALS AND METHODS: The study included 23 patients who were clinically and histologically diagnosed with chronic liver disease secondary to viral hepatitis. Each patient underwent dynamic abdominal CT imaging and MRI within the same week. CT and MRI findings were retrospectively reviewed. The same parameters were used from the CT and the MR images for each patient. The parameters included liver volume index (posterior segment of the right lobe, medial and lateral segments of the left lobe), spleen volume index, ascites, portosystemic collaterals, contour irregularities of the liver and confluent fibrosis within the liver. The findings were compared with the patients' Child-Pugh grades. Multiple regression analysis was used for statistical analysis. RESULTS: On MRI, liver volume index (P = 0.0001), and ascites (P = 0.009) were strongly correlated with Child-Pugh grades. With CT, only ascites was correlated with Child-Pugh grades (P = 0.002). CONCLUSION: This study indicates that liver volume index on MRI, and ascites on CT and MRI are good indicators of clinical severity of cirrhosis secondary to hepatitis. To show the effect of the other parameters, more research is needed with larger patient groups.     

Value of acoustic radiation force impulse elastography for the assessment of ascites syndrome

AIM:To assess the feasibility of performing acoustic radiation force impulse(ARFI) elastography in patients with ascites and its predictive value for the cirrhotic or non-cirrhotic etiology of ascites.METHODS:Our study included 153 patients with ascites,mean age 58.8 ± 13.1 years.One hundred and fifteen(75.2%) patients had ascites in the context of cirrhosis,29(18.9%) had non-cirrhotic ascites(diagnosed by clinical,ultrasound,endoscopic and/or laparoscopic criteria) and in 9(5.9%) cases we could not establish the etiology of ascites.We performed 10 ARFI measurements and the median value was calculated and expressed in meters/second(m/s).Among the 29 patients with non-cirrhotic ascites were included:20 laparoscopically demonstrated peritoneal carcinomatosis with histological confirmation,7 acute pancreatitis with ascites which later resolved,and one case each of lymphatic ascites and ascites in the context of a liver abscess.In 11 of the 20 patients with peritoneal carcinomatosis,the liver structure was homogenous in the ultrasound examination and in 9 patients the ultrasound exam revealed liver metastases.RESULTS:We could not obtain valid ARFI measurements in 5 patients(3.2%).The mean liver stiffness measurements by means of ARFI were statistically significantly higher in patients with cirrhotic ascites than in those with non-cirrhotic ascites:3.04 ± 0.70 vs 1.45 ± 0.59 m/s(P < 0.001).For a cut-off value of 1.8 m/s for predicting cirrhosis(and ascites in the context of cirrhosis),as obtained in a previous study,ARFI had 98.1% sensitivity,86.2% specificity,96.4% positive predictive value,92.5% negative predictive value and 95.6% accuracy for predicting cirrhotic ascites.For a cut-off value of 1.9 m/s the accuracy was 94.9% and for a 2 m/s cut-off value it was 92.8%.CONCLUSION:ARFI elastography is feasible in most patients with ascites and has a very good predictive value for the cirrhotic or non-cirrhotic etiology of ascites.     

Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.     

TIPS bei Patienten mit therapierefraktärem Aszites und Nierenfunktionsstörungen

Background. A transjugular intrahepatic portosystemic shunt (TIPS) is increasingly being used for treatment of patients with refractory ascites and renal failure. The aim of this study was to investigate the effects of TIPS in patients with refractory ascites and organic or functional renal impairment. Methods. A TIPS was placed for refractory or intractable ascites in 10 consecutive patients with liver cirrhosis and impaired renal function (serum creatinine >1.5 mg/100 ml). Four of them had organic kidney disorders. The other six patients had functional renal impairment due to the underlying liver disease. Results. TIPS was effective in reducing ascites in 8 of 10 patients, including all patients with organic renal disease. Furthermore, after TIPS the renal function improved in all patients. Serum creatinine and serum urea levels decreased significantly from 1.8 to 1.5 mg/100 ml (p <0.05) and from 107 to 78 mg/100 ml respectively. Conclusion. TIPS may be useful in patients with functional and in patients with organic renal disease, resulting in improvement of ascites and renal function.