西咪替丁对预防肝硬化上消化道出血诱发腹水形成的作用

目的观察西咪替丁对肝硬变上消化道出血诱发腹水形成的预防作用．方法我们将本院1992／1997间肝硬变上消化道出血的住院病历，随机选其用西咪替丁和垂体后叶素联合治疗的患者52例分为治疗组和单用垂体后叶素治疗的患者用例作为对照组进行比较．两组间发病年龄、性别、入院时出血量估计，肝功能分级等情况均经统计学处理有可比性．治疗组以10％GS500mL加西咪替丁0．6～0．8静脉滴注，每12h一次，连用7d～14d，垂体后叶素（0．2～0．6）U／min、维持24h，出血停止后减半量维持12h～24h后停用．对照组单用垂体后叶素用量及用法与治疗组相同，其他治疗措施两组间无差异．结果治疗组52例，出现腹水5例，占9．6％．对照组60例，出现腹水16例，占26．7％，两组比较腹水的发生率有非常显著的差异（P＜0．01）．结论静脉滴注西咪替丁对肝硬变上消化道出血诱发腹水形成有良好的预防作用．     

幽门螺杆菌与肝硬变及肝癌关系的探讨

目的探讨幽门螺杆菌（Hp）与肝硬变及肝癌的关系．方法随机选择2例临床诊断为肝硬变（失代偿期）、原发性肝癌（晚期）的患者作为研究对象．1例为80岁，男，临床诊断为肝硬变（失代偿期），并发上消化道大出血，肝性脑病．B超示肝硬变并大量腹水、肝缩小．AFP20ng／mL．另1例69岁，男，临床诊断为原发性肝癌（晚期），B超为肝硬变癌变并腹水AFP593．4ng／mL.并发上消化道大出血、肝昏迷．用C14呼气试验来检查这两例患者的Hp并进行分析．结果以上2例患者经C14呼气试验检测Hp，其结果均为阳性，并且Hp阳性的肝硬变、肝癌患者易发生上消化道大出血、肝性脑病及肝昏迷．结论根据以上结果证明，Hp与肝癌、肝硬变的发生、发展关系密切．     

慢性肝病患者血浆内皮素、内毒素及肿瘤坏死因子水平的研究

目的探讨慢性肝炎、肝硬变患者血浆内皮素（ET），内毒素（ETM）及肿瘤坏死因子（TNF-α）的变化及致病机制，以及它们之间相互关系．方法正常人20例，慢性肝炎20例，肝硬变48例．采用特异性放免分析法测定血浆ET和TNF－α含量．用基质显色法鲎试验定量检测血浆ETM含量．结果①肝硬变组血浆ET，ETM，TNF－α水平明显高于正常人和慢性肝炎组（P＜0．01）．②肝硬变合并肝肾综合征和食管静脉曲张者血浆ET水平高于腹水和不伴腹水者（P＜0．01）．③ET水平的增高与ETM，TNF－α水平呈显著相关性（r=0．614，P＜0．01）．结论ET参与肝硬变发病，与门脉高压形成密切相关，ET的生物学效应与ETM，TNF－α密切相关．     

逐瘀疏肝丸治疗肝硬变42例

目的观察逐瘀疏肝丸治疗肝硬变的临床疗效．方法将各期乙肝后肝硬变42例，其中男34例，女8例，平均47．8岁；乙肝后肝硬变腹水者22例，腹水、乙肝后早期肝硬变28例，所有病例皆有不同程度的乏力．腹胀、纳差；可见肝掌、蜘蛛痣者39例．双下肢水肿、腹大、腹壁静脉曲张，脾脏肿大者16例，肝脏肿大者18例；肝功能检查中ALT升高者38例，TBil升高者18例，：TTT升高者34例，A／G倒置者28例；B超提示肝肿大者18例，大量腹水者6例，中度腹水者8例，少量腹水者8例，门脉高压者24例，肝体积缩小者8例．上述病例平分成两组，每组各21例．两组皆在西医常规综合治疗的基础上，治疗组加服逐瘀疏肝丸。逐瘀疏肝丸主要由柴胡、郁金、地鳖虫、灸鳖甲、炮山甲、全当归、益母草、太子参、炒白术、生黄芪、醋香附、紫丹参、生大黄、制厚朴、广三七等组成，所有病例一个疗程结束后采取全面检查，进行前后对比．结果治疗前后肝功能变化，治疗组肝功能的复常明显优于对照组，两组ALT，SB，TTT，A／G有效率，治疗组和对照组分别为89．5％，78％，88％，85．7％和47．4％，33．3％，53％，64％．两组复常有显著差异（P＜0．05）．两组主要临床症状的对比，治疗组症状的消失，好转总有效率100％，明显优于对照组总有效率的81％（P     

肝炎后肝硬变与胆囊病变50例

目的本文旨在肝炎后肝硬变与胆囊病变之间从临床相关资料中探讨分析相互关系．以求了解其规律助于临床诊治．方法我院从1991／1996经确诊的肝炎后肝硬变患者50例，同时对胆囊进行以B超为主的检查．结果统计结果显示，胆囊大小均正常，而胆囊壁增厚改变的37例占74％，最厚达10mm，其余无明显改变．24例腹水患者均有明显的胆囊壁增厚表现，为双边征．厚度在7mm以上，合并结石6例占12％．因此，我们认为肝炎后肝硬变胆囊改变是以胆囊壁增厚为主的改变，并以肝功能减退而显著，可能是与免疫反应有关的非特异性改变？临床上诊断肝炎后肝硬变合并“胆囊炎”须慎重．结论关于肝硬变并发胆结石发病率较常人为高，是否与肝炎后肝硬变时胆囊本身改变有关，尚需进一步探讨．     

肝性脑病108例临床特点分析

目的我们回顾性的研究108例肝性脑病的临床特点并加以分析．方法本组108例均为临床确诊的肝性脑病患者．男83例，女25例，年龄分布16岁-81岁，肝硬变病程2a—11a，其中肝炎后肝硬变87例（80．6％）；酒精性肝硬变17例（15．7％）；瘀血性肝硬变4例（3．7％），并有16例作过脾切除．本组肝性脑病诱发因素居首位的是感染，占46．7％，其次为消化道出血，占24．1％，诱因还有氮质血症、高蛋白质饮食、放腹水等．结果本文资料告知肝炎后肝硬变的病死率为94．3％，而酒精性肝硬变病死率为35．3％，两组病死率进行比较，经统计学处理，差异有非常显著意义，P＜0．01说明肝硬变病因不同，肝性脑病预后不同，在治疗上要下功夫本组肝性脑病主要诱因为感染，而国内外报道资料，以上消化道出血为主要诱因．分析这种变化可能与近几年加强降低门脉压力的措施，注意胃粘膜的保护，早期补充维生素K及提高血浆清蛋白的浓度等有关．真实原因有待进一步探讨．结论通过本组资料说明，目前肝性脑病无特效疗法，是一种病死率很高病征，所以预防发生肝性脑病是重要的，要避免一切诱发因素，要进行严密的临床观察，争取早期诊断和及时的有效处置为上策．     

上消化道出血的发病特点及治疗体会

通过对560例上消化道出血住院患者的发病季节，出血病因，发患者群，诊断方法，治疗情况等进行分析认为引起上消化道出血的病因最多是溃疡病，具体为十二指肠球部溃疡（DU）＞胃溃疡（GU）＞胃炎及十二指肠球炎＞肝硬变食管静脉曲张＞胃癌等．本病有下列特点：①男性多于女性，男女之比为3．9：1；②DU出血多于GU出血，为1．8：1；③冬春季发病高于夏秋季；④各种职业均可发病，青少年学生发病应引起重视．治疗体会有：①绝对卧床休息，保持安静；②严密观察血压、尿量、血红蛋白等变化；③对溃疡病及胃、十二指肠炎症伴发的上消化道大出血，用质子泵抑制剂奥美拉唑有显著疗效；对肝硬变并发食管胃底静脉曲张破裂出血者用生长抑素施他宁等是目前最安全和有效的药物；④如经积极内科治疗仍不能控制出血者应及时转外科手术治疗．本组患者治愈率高达98．3％．死亡率为0．5％，明显低于新近文献报道．     

上消化道出血并发急性脑梗死24例临床特点分析

上消化道出血并发急性脑梗死的病例鲜见报道，应总结其临床特点。目的：探讨上消化道出血并发急性脑梗死的临床特点。方法：分析24例上消化道出血并发急性脑梗死患者的临床特点。结果：本组24例患者的平均年龄63．0岁．9例（37．5％）上消化道出血病因为肝硬化，14例（58．3％）为大出血，14例（58．3％）使用抗纤溶药物，21例（87．5％）伴高血压、高血脂、冠心病、糖尿病等与动脉硬化有关的因素。发生脑梗死的平均时间为上消化道出血后3．6d，大面积梗死多见。结论：对上消化道出血伴有与动脉硬化有关的因素（高血压、高血脂、冠心病、糖尿病等）以及既往有肝硬化史的老年患者,尤其是大出血者。应认识到并发急性脑梗死的危险，出血后3d左右脑梗死的发生率最高。治疗应禁用或慎用抗纤溶药。     

胃角溃疡420例

目的探讨胃角溃疡的易发原因与临床特点．方法回顾总结本院1981－06／1997－06年间经内镜检查诊断胃角溃疡，并对其发病年龄、性别、部位、临床症状及并发症等进行统计、分析．结果诊断胃角溃疡420例，男性357例（85％），平均年龄51．8岁，50岁以上179例（42．6％），好发部位多在胃角中段276例（65．7％），单发居多338例（80％）．疼痛部位多在中上腹242例（57．7％），剧痛绞痛刺痛258例（61．4％），放射至背部250例（59．5％），并发出血145例（34．5％），合并胆汁反流161例（38．3％），合并浅表性胃炎242例（57.5％）．结论胃角溃疡占胃溃疡的首位（420／1206），其临床特点是：患者疼痛较剧．多位于中上腹，易向后背放射，易并发上消化道出血，50岁以上男性居多．究其原因主要是其特定的解剖位置──胃体与胃窦交界处，此处无盐酸形成，但易受到来自胃体壁细胞分泌的盐酸的侵害和十二指肠内容物反流的刺激，其粘膜屏障易受损伤，继而发生溃疡病的病理生理变化过程．幽门螺杆菌感染和老年人胃粘膜血流量减少也是原因之一．目前其发病机制仍公认塞氏所提出的攻击因子和防御因子失衡学说。     

生长抑素治疗肝硬变食管静脉曲张破裂大出血24例

1对象和方法1．1对象选择本院1994－03／1996－12应用生长抑素治疗的肝硬变食管静脉曲张破裂大出血患者24例，男20例，女4例，年龄42岁～65岁，平均56．3岁均表现大量呕血和便血，出血量在1000mL以上者20例，＞2000rnl，者4例，伴有失血性休克9例，肝昏迷者5例，患者基础病变为：肝炎后肝硬变20例（合并肝癌4例），酒精性肝硬变4例，肝功能Child分级：A级8例，B级9例，C级7例．回．2方法建立两条输液通路，一条输注生长抑素，首先以250ng冲击量静脉推注，继以250ng个速度连续滴注48h～72h（如输液中断超过3whn，重新注射25Ong冲击量）另…     

肝硬变腹水患者钾钠氯及酸碱失衡

目的研究肝硬变腹水患者的钾、钠、氯及酸碱失衡。方法肝硬变腹水患者１５４例，血Ｋ＋、Ｎａ＋、Ｃｌ－测定采用ＥＥＬ公司自动分析仪及火焰光度计。血气及酸碱度测定采用ＩＬ１３０２型自动微机分析仪。结果低血钾者５７例，高血钾者６例，低血钠者８１例，高血钠者１２例，低血氯者３４例，高血氯者８例。２４例血气及酸碱度测定结果显示，以碱中毒者为主。依次为呼碱、呼碱＋代酸、代酸、代碱、呼酸。本组高血钾、低血钠与Ｃｈｉｌｄ分级、ＢＵＮ、Ｃｒ值相关。从本组资料表明，重症肝硬变腹水患者水盐代谢失衡多为医源性所致，且加重原有失衡。高钾血症、急性低钠血症及高钠血症大多如此，多为住院后发生，常可危及生命。结论肝硬变腹水患者的高钾血症、低钠血症和高钠血症大多在肝肾功能低下，不适当的治疗所致，是影响预后的重要因素     

Bacterial translocation in cirrhotic rats. Its role in the development of spontaneous bacterial peritonitis.

Bacterial translocation occurs in ascitic cirrhotic rats, but its association with ascites infection is unknown. The aim of this study was to assess the relation between bacterial translocation and ascites infection in cirrhotic rats. Male Sprague-Dawley rats were induced to cirrhosis with intragastric CCl4. Ascitic fluid, portal and peripheral blood, mesenteric lymph nodes, liver and spleen samples were cultured before death in those cirrhotic rats with less (group A) or more (group B) than 250 polymorphonuclear neutrophils/mm3 in ascitic fluid, as well as in healthy control rats. Histological examination of jejunum, ileum, and caecum was also performed. Bacterial translocation occurred in 45% of ascitic rats (without differences between groups A and B), but in 0% controls (p = 0.01). Bacterial translocation was associated with positive ascitic fluid culture in 60% of the cases. In all of them the same bacterial species was isolated in both mesenteric lymph node and ascitic fluid. Submucosal caecal oedema (100%), ileal lymphangiectasia (41%), and caecal inflammatory infiltrate (41%) occurred in ascitic rats, the last being associated with ascitic fluid positive culture (p = 0.04). These results suggests that bacterial translocation occurs frequently in ascitic cirrhotic rats, and may play a permissive, but not unique, part in a number of ascites infections. Whether histological changes seen in cirrhotic ascitic rats favour bacterial translocation remains to be elucidated.     

Nitric oxide and renal functions in liver cirrhosis.

BACKGROUND/AIMS: Nitric oxide, a potent vasodilating agent, has been proposed to play a role in pathogenesis of ascites and hepatorenal syndrome. The aim of this study was to evaluate the interaction between the plasma nitric oxide, nitric oxide synthetase levels and renal functions in patients with different degrees of chronic liver disease. METHODS: The study population included 38 subjects: 14 patients with chronic hepatitis, 11 with preascitic cirrhosis and 13 with ascitic cirrhosis. Nitric oxide and nitric oxide synthetase were determined by colorometric assay. We calculated glomerular filtration rate and fractional sodium excretion. RESULTS: Nitric oxide levels in groups were as follows: 79.28+/-24.86, 99.03+/-21.31, 197.05+/-49.61 microm, respectively. Nitric oxide synthetase levels were 2.64+/-0.56, 3.64+/-0.89, 7.75+/-2.46 micromol/L/sec, respectively. Nitric oxide and nitric oxide synthetase levels in the ascitic cirrhotic group were significantly higher than in the others (p<0.05). When glomerular filtration rates were compared, the only significant difference was determined between the groups with chronic hepatitis and ascitic cirrhosis (92.31+/-25.21, 48.46+/-16.45, p<0.05). Fractional sodium excretion was significantly increased in the ascitic cirrhotic group (4.42+/-2.76, p<0.05). CONCLUSIONS: Nitric oxide and nitric oxide synthetase increased with progression of liver disease, especially in ascitic cirrhosis. We also showed that this increase negatively affects the renal tubular and glomerular functions.     

Zinc and liver cirrhosis

We have measured zinc levels in serum and urine of healthy controls, patients with liver cirrhosis and patients with cirrhosis and hepatic cancer. In patients with ascitic fluid, we also measured zinc, total protein, albumin and alpha 2-globulin. Basal measurements were performed in blood drawn at 8.00, before the intravenous administration of 8 mg zinc in the form of zinc sulphate. Serum levels were measured at various intervals to a total time of 24 h after overload, and total urine was collected for zinc determinations 24 h before and 24 h after overload. Under basal conditions, cirrhotic patients had lower serum levels and higher rates of urinary excretion of zinc than controls. After overload, blood levels of zinc fell more rapidly in cirrhotic patients than in controls, the former group showing no concomitant rise in urinary zinc excretion, thus suggesting an organic deficit in this trace element. In ascitic fluid, the concentration of zinc was positively correlated with protein content.     

Bacterial infection in cirrhotic patient

BACKGROUND: Bacterial infections at admission or during hospitalization are frequent complication of cirrhosis that occurs in about 30% of the cases. Furthermore they are responsible for 25% of deaths in this population. AIM: Evaluate the prevalence of bacterial infections in cirrhotic patients at a general hospital and determine its correlation with alcoholic etiology of liver disease; degree of hepatic dysfunction and upper gastrointestinal bleeding. PATIENTS/METHODS: Five hundred and forty one admissions were retrospectively evaluated in 426 cirrhotic patients at years 1992 to 2000. The mean age was 50.5 years (15-95), being 71.2% male. The alcoholic etiology of cirrhosis was 35.4%. The main outcome considered was discharge or death during admission. RESULTS: One hundred and thirty five episodes of bacterial infections (25%) were diagnosed. The most frequent are urinary tract infection (31.1%), spontaneous bacterial peritonitis (25.9%) and pneumonia (25.2%). The association between urinary tract infection and pneumonia occurred in 3.7% and erysipelas or cellulites in 11.1%. Bacteremia occurred in 2.9%. There was a correlation between bacterial infection and alcoholic etiology of liver disease, hepatic dysfunction and upper gastrointestinal bleeding. The mortality was higher in the infected patients (8.9%) and in those with a poor hepatic function. CONCLUSIONS: Bacterial infections are common complications in cirrhotic patients and are correlated with alcoholic etiology, Child Pugh classification and upper gastrointestinal bleeding. Furthermore, bacterial infections are correlated with poor prognosis.     

肝硬化并发上消化道出血的危险因素分析

目的了解肝硬化并发上消化道出血的相关危险因素,为预防和控制疾病提供可靠依据.方法将130例肝硬化患者分为出血组64例,非出血组66例.采用单、多因素分析法对肝硬化上消化道出血的相关因素进行分析并进行病例对照研究.结果肝硬化并发上消化道出血与食管静脉曲张（OR=3942,P=0.001）、肝功能分极（OR=1.028,P＜0.05）、门脉高压性胃病（OR=3.862,P＜0.05）显著相关.结论肝硬化并发上消化道出血的危险因素是食管静脉曲张、肝功能分极、门静脉内径、门脉高压性胃病.     

Anticoagulation Therapy in Patients with Liver Cirrhosis is Associated With an Increased Risk of Variceal Hemorrhage

ObjectiveThe belief that cirrhotic patients are “auto-anticoagulated” often results in anticoagulation therapy being withheld in these patients. We aimed to understand patterns of use of anticoagulation and to determine the risk of bleeding complications in cirrhotic patients.MethodsWe retrospectively analyzed 320 cirrhotic patients treated with anticoagulation therapy from July 15, 2014 to January 30, 2018. We performed bivariate and multivariate analyses to identify risk factors for clinically relevant bleeding. We conducted a separate analysis using propensity score matching to compare bleeding rates of a noncirrhotic cohort group on anticoagulation to anticoagulated patients with cirrhosis.ResultsNonalcoholic steatohepatitis (47%) was the most common cause of cirrhosis, and 49% were classified as Child-Pugh class B, a mean model for end-stage liver disease score of 14 and Charlson comorbidity index of 7. Anticoagulation was initiated for atrial fibrillation/atrial flutter in 56% of patients; warfarin was used in 57% of patients and concomitant use of antiplatelet therapy in 25%. Bleeding occurred in 18%, with upper gastrointestinal bleeding (53%) being the most common source. In the propensity-matched cohort, bleeding rates were higher in cirrhotics than in control patients who were matched for baseline characteristics. In multivariate analysis of the cirrhotic patients, the presence of esophageal varices was associated with higher odds of clinically relevant bleeding.ConclusionAnticoagulated cirrhotic patients who have esophageal varices are at an increased risk of bleeding. We recommend that patients with cirrhosis and esophageal varices who require anticoagulation have their varices managed carefully prior to initiation of anticoagulation.     

Nitric oxide and renal function in cirrhotic patients with ascites: from physiopathology to practice

Patients with cirrhosis and ascites show systemic and splanchnic arterial vasodilation, which causes a reduction in effective arterial blood volume and the activation of hormonal anti-natriuretic systems. Renal impairment is the most important predictor of hospital mortality in cirrhotic patients with SBP. In patients with SBP, the inflammatory response to the infection (TNF-alpha, IL-6) may be an important mechanism of renal dysfunction. Ascitic-fluid NO metabolites are related independently to the development of renal impairment. Treatment of SBP with intravenous albumin in addition to cefotaxime prevents renal impairment and reduces mortality in comparison with treatment with cefotaxime alone. As soon as ascites develops, liver transplantation should be considered in eligible patients, especially when local mean waiting times exceed life expectancy. Nitric oxide (NO), tumour necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6) have been implicated in the pathogenesis of circulatory alterations observed in cirrhotic patients with ascites. Kidney failure is one of the main factors associated with mortality in patients with end-stage liver disease developing complications, particularly severe infections and variceal haemorrhage. Renal impairment occurs in patients with the highest concentration of cytokines in plasma and ascitic fluid and is associated with marked activation of the renin-angiotensin system. In patients with spontaneous bacterial peritonitis (SBP), serum and ascitic fluid levels of NO metabolites (nitrites and nitrates) were higher than those of patients with sterile ascites, and renal impairment is considered to be caused by a decrease in effective arterial blood volume as a result of the infection. The administration of albumin prevents deterioration of renal function and reduces mortality in these patients. However, SBP and renal dysfunction are late complications in the course of liver cirrhosis. As soon as ascites develops, liver transplantation should be considered in eligible patients, especially when local mean waiting times exceed life expectancy. A better knowledge of metabolic disorders associated with the early stage of cirrhosis is essential for the development of optimal therapeutic strategies for the prophylaxis and treatment of portal hypertension and its complications.     

Coincidence of liver cirrhosis and gallstones

In the years 1957-1975 we found out of 13336 autopsies in a medium-sized urban general hospital 912 cases of cirrhosis of the liver. In comparison these persons with sections of non-cirrhotic controls the frequency of gallstones was neither for the total group (33.9%) nor for the males (27.1%) significantly raised. Only in the female subgroup of cirrhotic patients we could demonstrate a significantly increased frequency of gallstones (43.5%) in comparison to the female control group (38.3%). With regards to all kinds of predominantly lithogenous alterations of the gallbladder (concrements, chronic cholecystitis, cholecystectomy) we found for the cirrhotic group and its subgroups a significant positive coincidence of both diseases. The female to male ratio for the frequency of cholelithiasis and for all kinds of lithogenous alterations of the gallbladder was 1.6:1 for the cirrhotic group and the controls.     

Spontaneous peritonitis in cirrhotic ascites

In a ten-year retrospective study 15 cases of spontaneous bacterial peritonitis were identified. All patients had cirrhosis and ascites. Abdominal pain was present in all and abdominal tenderness in 11. Diagnosis was established by paracentesis with the finding of either an elevated ascitic fluid cell count (>300 WBC/mm³) in 13 cases or organisms and numerous neutrophiles on gram stain in 6 cases. On ascitic fluid cultureE coli was the most common organism isolated in 6 cases, klebsiella was isolated in 3 cases, andDiplococcus pneumoniae (D. pneumoniae) in 2 cases. Positive blood cultures were obtained in 60% of the cases. Three patients responded to therapy, including antibiotics, and survived to leave the hospital. No features unequivocally differentiated the survivors. The nonsurvivors died from complications of advanced liver disease including hepatic coma, hepatorenal syndrome, and esophageal variceal hemorrhage. Spontaneous bacterial peritonitis is a potentially treatable cause of deterioration in the patient with cirrhotic ascites. Because of its varied presentation it may escape recognition despite ease of diagnosis. Prompt recognition requires awareness of this entity.