null肝硬化腹水的治疗
【 The Guidelines of 2006 】肝硬化腹水的治疗
【 The Guidelines of 2006 】06级全科住院医师 韩静
流行病学调查
No1. About cirrhosis流行病学调查
No1. About cirrhosis
4% general population abnormal liver function or liver disease
(non-alcoholic fatty liver disease, alcoholic liver disease, and chronic hepatitis)
10–20% develop cirrhosis over a period of 10–20 years null我国肝硬化患者占内科总住院人数的4.3%~14.2%
发病高峰年龄 35~48岁
男女比例 3.6~8:1流行病学调查
No2. About ascites流行病学调查
No2. About ascitesThe majority (75%) of patients with ascites have underlying cirrhosis,the remainder being due to malignancy(10%), heart failure (3%), tuberculosis(2%), Pancreatitis(1%), and other rare causes
50% of cirrhosis patients over 10 years of follow up
50% mortality over two years-the need to consider liver transplantation as a therapeutic null机制:门脉高压、低蛋白血症、淋巴液生成过多,、继醛、抗利尿激素等
诊断:病史,查体,X线,B超,CT。
关于腹水的检查:蛋白定量、中性粒细胞计数、腹水培养、SAAG;淀粉酶;细胞学血清腹水白蛋白浓度梯度(SAAG)血清腹水白蛋白浓度梯度(SAAG) nullThe initial ascitic fluid analysis should include serum ascites-albumin gradient in preference to ascitic protein.
(Level of evidence: 2b; recommendation: B.)
nullAscitic amylase should be measured when there is clinical suspicion of pancreatic disease. (Level of evidence: 4; recommendation: C.)
nullAscitic fluid should be inoculated into blood culture bottles at the bedside and examined by microscopy for a neutrophil count.
(Level of evidence: 2a; recommendation:B.)
肝硬化腹水的治疗肝硬化腹水的治疗1. Bed rest 卧床休息
2. Dietary salt restriction 限盐
3. Role of water restriction 限水
4. Management of hyponatraemia
治疗低钠血症
5. Therapeutic paracentesis治疗性穿刺
6. TIPS 经颈静脉肝内门体分流术
7. SBP 自发性细菌性腹膜炎nullThere have been no clinical studies to demonstrate increased efficacy of diuresis with bed rest or decreased duration of hospitalisation ! VS
Traditional recommendation:
patients should be
treated with diuretics while on bed rest null
Bed rest is NOT recommended for the treatment of ascites.
(Level of evidence: 5;
recommendation: D. )
Back Dietary salt restriction限盐 Dietary salt restriction限盐 90 mmol/day (5.2 g)
no-added salt diet
Certain drugs eg: 泡腾片,静脉用抗生素(2.1–3.6 mmol /g ),环丙沙星(30 mmol /200ml)
hepatorenal syndrome or renal impairment with severe hyponatraemia
( International Ascites Club recommend infusion of normal saline) nullDietary salt should be restricted to a no-added salt diet of 90 mmol salt/day (5.2 g salt/day). (Level of evidence: 2b; recommendation: B.)
BackRole of water restriction限水 Role of water restriction限水 There have been no studies on the benefits or harm of water restriction on the resolution of ascites. Backnull Management of hyponatraemia in
patients on diuretic therapy (Level ofevidence:5; recommendation: D.)
Diuretics 利尿剂 Diuretics 利尿剂 spironolactone螺内酯
frusemide呋赛米
amiloride阿米诺利 15–30 mg/day
bumetanide布美他尼(丁尿胺) similar to frusemidenull
Firstline treatment of ascites should be spironolactone alone, increasing from 100 mg/day to a dose of 400 mg/day.
If this fails to resolve ascites, frusemide should be added in a dose of up to 160mg/day, but this should be done with careful biochemical
and clinical monitoring.
(Level of evidence: 1a;
recommendation:A.)Backnull Therapeutic paracentesis
治疗性穿刺large or refractory ascites
need for colloid replacement therapy. nullpost-paracentesis circulatory dysfunction ---Failure to give volume expansion
ascites recurs (93%) --- if diuretic therapy is not reinstituted ;only 18% of patients treated with spironolactone ; Reintroduction of diuretics after paracentesis (usually within 1–2 days) does not appear to increase the risk of post-paracentesis circulatory dysfunctionnull Therapeutic paracentesis is the firstline treatment for patients with large or refractory ascites(Level of evidence: 1a; recommendation: A.)
Paracentesis of <5 litre of uncomplicated ascites should be followed by plasma expansion with a synthetic plasma expander and does not require
volume expansion with albumin (Level of evidence:2b; recommendation: B.)nullLarge volume paracentesis should be performed in a single session with volume expansion being given once paracentesis is complete, preferably using 8 g albumin/litre of ascites removed (that is, 100 ml of 20%albumin/ 3l ascites). (Level of evidence: 1b; recommendation:A.)
BacknullTIPS can be used for the treatment of refractory ascites requiring frequent therapeutic paracentesis or hepatic hydrothorax with appropriate assessment of risk
benefit ratio. (Level of evidence: 1b; recommendation:B.)
BackSpontaneous bacterial peritonitis (SBP)
自发性细菌性腹膜炎 Spontaneous bacterial peritonitis (SBP)
自发性细菌性腹膜炎 neutrophil count ≧250 cells/mm3
in the absence of an intra-abdominal and surgically treatable source of sepsis
In patients with an ascitic fluid neutrophil count of 250 cells/mm3, empiric antibiotic therapy should be started. (Level of evidence:1b; recommendation: A.)
nullThird generation cephalosporins such as cefotaxime(头孢噻肟 ) have been most extensively studied in the treatment of SBP and have been shown to be effective. (Level of evidence: 1a; recommendation: A.)
Patients with SBP and signs of developing renal impairment should be given albumin at 1.5 g albumin/kg in the first six hours followed by 1 g/kg on day 3. (Level of evidence: 2b; recommendation: B.)nullPatients recovering from one episode of SBP should receive prophylaxis with continuous oral norfloxacin 400 mg/day (or ciprofloxacin at 500 mg once daily).(Level of evidence: 1b; recommendation: B.)
All patients with SBP should be considered for referral for liver transplantation. (Level of evidence: 1c; recommendation: B.)
null Thanks !