102例肝硬化合并食管静脉曲张出血二级预防硬化治疗分析

目的 评价硬化治疗预防食管静脉曲张再出血的疗效。方法 回顾性分析我院2010年3月—2012年2月行食管静脉曲张硬化治疗(esophageal varices sclerotherapy,EVS)二级预防的肝硬化合并食管静脉曲张出血患者102例的临床资料。102例共行EVS328例次,其中择期309例次,追加治疗19例次,首次治疗(3.0±0.8)次。对其中88例进行1～20(10.2±2.5)个月随访。结果 随访88例中,食管静脉曲张消失和基本消失率为79.5%,远期再出血率为12.5%。主要并发症为术后发热、食管注射点溃疡或糜烂出血。结论 EVS治疗食管静脉曲张出血,可明显降低再出血率。     

Motor vehicle accidents: How should cirrhotic patients be managed?

Motor vehicle accidents (MVAs) are serious social issues worldwide and driver illness is an important cause of MVAs. Minimal hepatic encephalopathy (MHE) is a complex cognitive dysfunction with attention deficit, which frequently occurs in cirrhotic patients independent of severity of liver disease. Although MHE is known as a risk factor for MVAs, the impact of diagnosis and treatment of MHE on MVA-related societal costs is largely unknown. Recently, Bajaj et al demonstrated valuable findings that the diagnosis of MHE by rapid screening using the inhibitory control test (ICT), and subsequent treatment with lactulose could substantially reduce the societal costs by preventing MVAs. Besides the ICT and lactulose, there are various diagnostic tools and therapeutic strategies for MHE. In this commentary, we discussed a current issue of diagnostic tools for MHE, including neuropsychological tests. We also discussed the advantages of the other therapeutic strategies for MHE, such as intake of a regular breakfast and coffee, and supplementation with zinc and branched chain amino acids, on the MVA-related societal costs.     

A Macaca mulatta model of fulminant hepatic failure

AIM: To establish an appropriate primate model of fulminant hepatic failure (FHF).METHODS: We have, for the first time, established a large animal model of FHF in Macaca mulatta by intraperitoneal infusion of amatoxin and endotoxin. Clinical features, biochemical indexes, histopathology and iconography were examined to dynamically investigate the progress and outcome of the animal model.RESULTS: Our results showed that the enzymes and serum bilirubin were markedly increased and the enzyme-bilirubin segregation emerged 36 h after toxin administration. Coagulation activity was significantly decreased. Gradually deteriorated parenchymal abnormality was detected by magnetic resonance imaging (MRI) and ultrasonography at 48 h. The liver biopsy showed marked hepatocyte steatosis and massive parenchymal necrosis at 36 h and 49 h, respectively. The autopsy showed typical yellow atrophy of the liver. Hepatic encephalopathy of the models was also confirmed by hepatic coma, MRI and pathological changes of cerebral edema. The lethal effects of the extrahepatic organ dysfunction were ruled out by their biochemical indices, imaging and histopathology.CONCLUSION: We have established an appropriate large primate model of FHF, which is closely similar to clinic cases, and can be used for investigation of the mechanism of FHF and for evaluation of potential medical therapies.     

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM:To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. METHODS:Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n= 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were:technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney Utest and the χ 2 test as appropriate. RESULTS:No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P= 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. CONCLUSION:RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.     

肝断面血流阻断器在肝癌切除术中的应用

目的:比较不同的肝血流阻断方法在肝切除术中应用的有效性及安全性.方法:回顾性分析我院2004-2009年117例行肝切除术的肝癌患者的相关资料.A组:自制肝断面血流阻断器局部血流控制(n=42);B组:解剖性半肝血流阻断(n=35);C组:第一肝门阻断(Pringle法,n=40).比较3组患者术中出血量和手术时间、术后肝功能的恢复以及术后并发症的发生率.结果:术中出血量和手术时间A组均明显少于B(P=0.026,P<0.001)、C(P<0.001,P<0.001)组.A组术后第3、7天肝功能(TB、ALT)的明显好于C组(TB:P=0.014,=0.009;ALT:P<0.001,P<0.001).C组术后有29例出现不同程度的腹水,术后腹水发生率显著高于A组(P<0.001);2例发生肝功能衰竭,1例出现胃肠道出血,死亡1例.结论:肝切除术中采用肝断面血流阻断器能有效控制出血、缩短手术时间,对肝功能影响小,是一种简便、安全有效的方法.     

隐匿性肝性脑病的诊疗进展

隐匿性肝性脑病(minimal hepatic encephalopa-thy,MHE)又称亚临床肝性脑病(subclinicalhepatic encephalopathy,SHE),是慢性肝病和肝硬化最常见的严重并发症,是一种具有渐进性、可逆性的神经精神病学异常和运动功能失调特点的疾病.尽管其发病机制仍未明确,血清和中枢神经系统(central nervoussystem,CNS)血氨升高仍被认为是肝性脑病(hepatic encephalopathy,HE)的致病机制和治疗核心,并受血脑屏障改变、神经递质紊乱、氨基丁酸和苯二氮异常等因素影响.因此明确其诱发因素是HE治疗的关键.治疗药物包括抗生素、二糖类、益生菌、门冬氨酸鸟氨酸(L-ornithine-L-aspartate,LOLA)、苯甲/苯乙酸盐等.因此,对MHE的发病机制、临床诊断和治疗研究进展进行归纳,为临床诊疗提供前沿性、系统性信息,具有重要意义.     

蓝莓对免疫性肝纤维化大鼠肝组织TLR4,TLR9表达的影响

目的:探讨蓝莓抗氧化作用对猪血清免疫性肝纤维化大鼠肝组织Toll样受体4(toll-like receptor 4,TLR4)和Toll样受体9(TLR9)蛋白表达的影响.方法:60只♂Wistar大鼠随机分为正常对照组(A组)、模型组(B组)、蓝莓低、中、高剂量防治组(C、D、E组)、复方鳖甲软肝片防治组(F组).除A组外,其余各组均腹腔注射猪血清制备大鼠肝纤维化模型.C、D、E、F组在造模同时分别给予蓝莓原浆或复方鳖甲软肝片灌胃,1次/d,共12wk.第12周末处死大鼠,计算大鼠肝脏指数,行肝脏病理组织学检查,测定各组大鼠血清ALT和AST水平、肝组织匀浆超氧化物歧化酶(superoxide dismutase,SOD)、丙二醛(malondialdehyde,MDA)及羟脯氨酸(hydroxyproline,Hyp)含量,免疫印迹法(western blot,WB)和免疫组织化学法检测TLR4和TLR9蛋白质在肝脏组织中的表达.结果:各组大鼠血清ALT、AST水平无明显差异(F=4.274,0.917,P>0.05);与B组比较,D,E组肝组织匀浆SOD活性、GSH含量明显升高(F=6.662,61.472,P<0.05);肝脏指数、MDA及Hyp含量明显降低(F=3.972,42.755和41.265,P<0.05);肝纤维化程度明显减轻(F=63.339,P<0.05),胶原表达减少;E组大鼠肝组织TLR4和TLR9蛋白质表达明显减少(F=6.932和7.534,P<0.05).结论:TLR4和TLR9蛋白质表达增加可能与免疫性肝纤维化的发生发展有关.蓝莓对大鼠免疫性肝纤维化有一定的预防作用.     

血清腹水白蛋白梯度与肝硬化食管静脉曲张程度的相关性

目的:探讨血清腹水白蛋白梯度(serum-ascites albumin gradient,SAAG)与肝硬化食管静脉曲张程度之间的相关性.方法:收集诊断明确的肝硬化合并腹水患者,根据食管静脉曲张程度分为无或轻度组、中度组和重度组,采用单因素方差分析、相关分析、构建受试者工作特征曲线(receiver operating characteristic,ROC)曲线等方法进行统计学分析.结果:共纳入43例患者,单因素方差分析显示3组之间存在显著差异(F=26.317,P<0.001),Spearman相关系数r=0.759,P<0.001,提示SAAG与食管静脉曲张具有正向相关性.构建ROC曲线得到曲线下面积为0.926,当SAAG取值为20.5g/L时是诊断中重度食管静脉曲张的最佳界值,此时敏感度为87.1%,特异度为83.3%.结论:SAAG与食管静脉曲张具有较好的相关关系,该指标对于中重度食管静脉曲张具有诊断价值.     

Hepatic Encephalopathy

Chronic liver disease and cirrhosis affect hundreds of millions of patients all over the world. The majority of patients with cirrhosis will eventually develop complications related to portal hypertension. One of these recurrent and difficult to treat complications is hepatic encephalopathy. Studies have indicated that overt hepatic encephalopathy affects 30 to 45% of patients with cirrhosis and a higher percentage may be affected by minimal degree of encephalopathy. All of these factors add to the impact of hepatic encephalopathy on the healthcare system and presents a major challenge to the gastroenterologist, hospitalist and primary care physician.     

Neuropsychological tools in hepatology: a survival guide for the clinician

Neuropsychological assessment has three main applications in clinical hepatology: (i) to detect, grade and monitor liver failure-related cognitive alterations in end-stage liver disease (hepatic encephalopathy), (ii) to substantiate complaints of attention or concentration difficulties in patients with non-cirrhotic chronic hepatitis C viral infection, and (iii) to screen patients who are being considered for liver transplantation for early signs of dementia. However, there is limited agreement on how cognitive assessment should be conducted in these patients, and how results should be interpreted and used to implement clinical decisions. In this review, we summarize the available literature on neuropsychological dysfunction in patients with cirrhosis and with chronic hepatitis C viral infection and provide some guidance on how to utilize neuropsychological assessment in practice.