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1、CIRRHOSIS of LIVERXiaohongTaoTheFirstAffiliatedHospitalChongqingUniversityofMedicalSciencesIntroduction 一种或几种病因长期或反复作用引起的慢性进行性肝一种或几种病因长期或反复作用引起的慢性进行性肝病的后期阶段。病的后期阶段。(Its the end result of hepatocellular injury resulted from different causes, ERLD) 病理病理有广泛肝细胞变性坏死、肝细胞结节性再生、有广泛肝细胞变性坏死、肝细胞结节性再生、结缔组织增生及纤维
2、化，正常肝小叶结构破坏和假小结缔组织增生及纤维化，正常肝小叶结构破坏和假小叶形成、肝逐渐变形、变硬。叶形成、肝逐渐变形、变硬。The histologic feature is degeneration, regeneration(nodular) and fibrosis.Accordingtothefollowingsequence:INJURYDEGENERATIONandnecrosisregenerationFIBROSISFORMATIONOFFIBRO-VASCULARMEMBRANESPARENCHYMALDISSECTIONINTONODULESREARRANGEMENTOF
3、BLOODCIRCULATIONCIRRHOSISREARRANGEMENTOFBLOODCIRCULATIONCIRRHOSISIntroduction临床临床肝功能损害和门脉高压为主肝功能损害和门脉高压为主、晚期常出现、晚期常出现消化道出血、肝性脑病等并发症。消化道出血、肝性脑病等并发症。(Theclinicalmanifestationscanbebroadlyclassifiedintothoseresultingfromhepatocellulardysfunction,suchasjaundiceandcoagulopathyandportalhypertension.Thecom
4、plicationoftenappearinlatephase,suchashemmorrage,hepaticencephalopathy. 世界性疾病，所有种族、不论国籍、年龄或性别、均世界性疾病，所有种族、不论国籍、年龄或性别、均可罹患。可罹患。 年龄年龄3548岁最多，男：女为岁最多，男：女为368：1。Cirrhosisisthethirdmostcommoncauseofdeath,afterheartdiseaseandcancer.killingabout25,000peopleeachyear.IntroductionHISTORY In1761,Thispeculiartr
5、ansformationoftheliverwasidentifiedbythefirstanatomicpathologist,GianbattistaMorgagniinhis500autopsies.HISTORYIn1826(65yearslatter),thenameofcirrhosiswasgivenbyLaennecbecauseoftheyellowish-tancolorofthecirrhoticliver.cirrhosis(greek=orangecolor).HISTORYOnlyin1930,onehundredyearslater,thefirsttheorya
6、stothepathogenesisofthisdisorderwasadvancedbyRoessle:parenchymaldegeneration,regenerationandscarringwhichisnowunderstoodaccordingtothefollowingsequence:HISTORYINJURYDEGENERATIONFIBROSISFORMATIONOFFIBRO-VASCULARMEMBRANESPARENCHYMAL DISSECTION INTO NODULESREARRANGEMENT OF BLOOD CIRCULATIONCIRRHOSISREA
7、RRANGEMENTOFBLOODCIRCULATIONCIRRHOSIS其他病因其他病因 寄生虫感染寄生虫感染 血吸虫、华枝睾血吸虫、华枝睾吸虫吸虫 胆汁淤积胆汁淤积 肝内淤胆或肝外胆肝内淤胆或肝外胆管梗阻管梗阻 循环障碍循环障碍 慢性充血性心力衰慢性充血性心力衰竭、缩窄性心包炎竭、缩窄性心包炎 肝静脉和（或）下腔静脉梗阻肝静脉和（或）下腔静脉梗阻 工业毒物工业毒物 四氰化碳、磷、砷、四氰化碳、磷、砷、双醋酚丁、四环素双醋酚丁、四环素 代谢障碍代谢障碍 血色病（铁质沉积）血色病（铁质沉积）、肝豆状核变性（铜沉积）、肝豆状核变性（铜沉积） 营养障碍营养障碍 慢性炎症性肠病、慢性炎症性肠病、食物
8、中缺乏蛋白质、维生素、抗食物中缺乏蛋白质、维生素、抗脂肝物质脂肝物质 原因不明原因不明病因病因ETIOLOGY (CAUSES)ETIOLOGY2.Alcoholabuse143.Bileductobstruction(PBC,PSC)4.ExposuretocertainchemicalsUseofcertaindrugs(CCI4)135.Persistentobstructiontooutflowofbloodfromtheliver(suchasoccursintheBudd-Chiarisyndrome)HeartandbloodvesseldisturbancesETIOLOGY6
9、.Hereditarydisease,Highbloodtyrosinelevelsatbirth(congenitaltyrosinosis)Glycogenstoragedisease,Alpha1-antitrypsindeficiencyHereditaryaccumulationoftoomuchcopper(Wilsonsdisease)7.Autoimmunediseases(includingautoimmunechronichepatitis)128.Schistosoma hematobiumSchistosoma hematobiumCAUSESIronoverload(
10、hemochromatosis)9.Unknown(NASH,Cryptogenic)发病机制发病机制Stellate cell, extracellular matrixPATHOLOGY Classification of cirrhosis According to World HealthOrganization(Anthony P.P. et al. J.Clin.Pathol. 31:395,1978)MORPHOLOGIC:MacronodularMicronodularMixeHISTOLOGIC:Portal,Post-necrotic,PostHepatitic,Bilia
11、ry,CongestiveETIOLOGICAGENTS:Genetic,Toxic,Infectious,Biliary,Vascular,CryptogenicMACRONODULAR CIRRHOSIS: Larger nodules separated by wider scars and irregularly distributed throughout the liver usually due to an infectious agent such as viral hepatitis which does not diffuse uniformly throughout th
12、e liver. DISSECTIONNODULES:contain remnants of portal tracts an central veins. are separated by wide scars but contain thin fibrous septa. contain dilated sinusoids especially at their periphery looking like multiple central veins obviously produced by the inflow of arterial blood coming from the su
13、rrounding wide scars. the portal tracts within large nodules may be hypoplastic containing portal venule and arteriole but no bile ducts giving the impression of a disappearing bile duct disorder. within wide scars regenerative nodules may develop. REGENERATIVENODULES:these occur in micro and macro
14、nodular cirrhosis. they arise in the midst of scars favored by the rich arterial blood of scar tissue. they are round nodules with a fibrous pseudo capsule with bile ductules due to obstruction of bile flow. they have embryonal type of cell plates.they often show focal cholestasis. they may undergo
15、dysplastic and malignant changes. they compress the vessels of the capsule contributing to the perpetuation of the cirrhosis. 大体形态 肝逐渐变形、变硬变小、包膜增厚、结节出现而致肝硬化。病理组织学改变假小叶形成1小结节性小结节性 结节结节的直径的直径3-5mm,3-5mm, 1cm，大小均匀，纤，大小均匀，纤维间隔较窄，结节维间隔较窄，结节中可有门脉管道。中可有门脉管道。常见于酒精性肝硬常见于酒精性肝硬化。化。病理分型病理分型2 2大结节性大结节性 结结节直径大小不等
16、节直径大小不等1-3cm1-3cm，大者直径，大者直径可达可达5cm，结节由，结节由纤维隔分开，其纤维隔分开，其中可含正常肝小中可含正常肝小叶。多见于肝炎叶。多见于肝炎后肝硬化。后肝硬化。 病理病理3 3混合性混合性混合性混合性 大小结节大小结节大小结节大小结节均有，兼有大、小结均有，兼有大、小结均有，兼有大、小结均有，兼有大、小结节两型的病理特点，节两型的病理特点，节两型的病理特点，节两型的病理特点，临床上绝大多数肝硬临床上绝大多数肝硬临床上绝大多数肝硬临床上绝大多数肝硬化均为此型。化均为此型。化均为此型。化均为此型。病理病理4 4不完全分隔型不完全分隔型不完全分隔型不完全分隔型 肝小肝小肝
17、小肝小叶由纤维围成结节，纤叶由纤维围成结节，纤叶由纤维围成结节，纤叶由纤维围成结节，纤维间隔可向小叶延伸，维间隔可向小叶延伸，维间隔可向小叶延伸，维间隔可向小叶延伸，但分隔小叶不完全，再但分隔小叶不完全，再但分隔小叶不完全，再但分隔小叶不完全，再生结节不明显生结节不明显生结节不明显生结节不明显。Schistosoma Schistosoma Schistosoma Schistosoma JaponicaJaponicaJaponicaJaponica Schistosomiasis: egg implanted Schistosomiasis: egg implanted in portal
18、 venules lead to in portal venules lead to periportal fibrosis and periportal fibrosis and granuloma, not cirrhosisgranuloma, not cirrhosis病理病理全身改变脾胃肺临床表现临床表现clinical presentation 代偿期代偿期 症状较轻，缺乏特异性。可症状较轻，缺乏特异性。可有乏力、纳差、恶心、上腹不适、有乏力、纳差、恶心、上腹不适、腹胀、腹泻等，查体见一般情况较腹胀、腹泻等，查体见一般情况较好，肝脏轻度肿大，质地结实或偏好，肝脏轻度肿大，质地结实或
19、偏硬。脾脏轻度或中度肿大。肝功能硬。脾脏轻度或中度肿大。肝功能正常或轻度异常。正常或轻度异常。SYMPTOMS Aboutonethirdofcirrhosisarecompensatedand,donotproduceanyclinicalsignandsymptomsandareaccidentallydiscoveredduringamedicalexaminationoranoperationoratautopsy(Asymptomatic).Therestaredecompensatedandproducecomplicationsmainlyduetoliverfailureand
20、portalhypertension.Thetwomajorproblemsthateventuallycausesymptomsarelossoffunctioninglivercellsanddistortionofthelivercausedbyscarring.GeneralFatigue,MalaiseWeaknessWeightlossPoorappetite,anorexiaNauseaFever临床表现失代偿期decompensated一、肝功能损害表现： lossoffunctioninglivercells1.全身症状：消瘦、乏力及低热等。2.消化道症状：纳差、恶心、腹胀A
21、bdominal fullness, gaseous及腹泻。 Jaundice 3.出血倾向Atendencytobleed(coagulopathy)及贫血：鼻、牙龈、皮肤、胃肠出血等，不同程度的贫血。 Nosebleed,bleedinggums,Decreasednumberofredbloodcells(anemia),Gastrointestinalbleedingfromvarices4.内分泌系统失调： 蜘蛛痣、肝掌、皮肤颜面色素沉着、男性乳房发育、睾丸萎缩及女性月经失调。SkinSpiderlikebloodvessels(Spiderangioma)Redpalms(palm
22、arerythema)FloridcomplexionItchingOtherUrineoutput,decreasedSwelling,overallHormonesHighlevelsofinsulinbutpoorresponsetoitCessationofmenstrualperiodsanddecreasedfertility(inwomen)Impotenceandfeminization(inmen)This very large spider nevus with its central arteriole developed in a patient with hepati
23、c cirrhosis. Spider nevi develop through deficient estrogen metabolism, and a few can be seen in pregnancy or in patients taking the oral contraceptive. They occur in the distribution of the drainage of the superior vena cava and are therefore seen on the face, arms and upper trunk. Spider nevi will
24、 disappear following hepatic function improving.Here multiple vascular spiders have coalesced to form a network on the anterior chest wall. This appearance has been termed paper money skin. Vascular spiders and palmar erythema are traditionally attributed to estrogen excess. It is not clear why thes
25、e tend to occur in the upper half of the body (the distribution of the superior vena cava). Gynaecomastiainalcoholicliverdisease.Thismalepatientwithalcoholicliverdiseasehasgynaecomastia.Maleswithliverdysfunctionhavefeaturesoffeminizationwithraisedserumestrogenlevelsandreductionsintestosteronelevels,
26、whileestrogenreceptorsintissueincreaseinnumber.Gynaecomastiaisespeciallycommoninalcoholicliverdisease,probablybecausealcoholincreasesthehepaticmetabolismoftestosterone.Spironolactone(analdosteroneantagonist)isalsoassociatedwithgynaecomastia,especiallyinpatientswithchronicliverdisease.临床表现失代偿期临床表现失代偿
27、期 二、门脉高压二、门脉高压 （Portal HypertensionPortal Hypertension）portal hypertensionNormally,bloodfromtheintestinesandspleeniscarriedtotheliverthroughtheportalvein.Butcirrhosisslowsthenormalflowofbloodthroughtheportalvein,whichincreasesthepressureinsideit.Thisconditioniscalledportalhypertension.1. Splenomegal
28、yThissplenomegalyiscongestive One of the most common findings with portal hypertension is splenomegaly, as seen here. The spleen is enlarged from the normal 300 grams or less to between 500 and 1000 gm.1. Splenomegaly HypersplenismBloodDecreasednumberofredbloodcells(anemia)Decreasednumberofwhitebloo
29、dcells(leukopenia)Decreasednumberofplatelets(thrombocytopenia)Atendencytobleed(coagulopathy)食管静脉曲张食管静脉曲张（Oesophageal Varices ） 腹壁静脉曲张腹壁静脉曲张痔静脉曲张痔静脉曲张rectal hemorroid临床表现临床表现失代偿期失代偿期二、门脉高压二、门脉高压2.侧枝循环建立侧枝循环建立CollateralshuntingCollateralshuntingTheenlargedbloodvessels,calledvarices,havethinwallsandcar
30、ryhighpressure,andthusaremorelikelytoburst.Iftheydoburst,theresultisaseriousbleedingproblemintheupperstomachoresophagusthatrequiresimmediatemedicalattention.Oesophageal varices. Normal oesophageal mucosa shows long, thin, evenly spaced lines. Varices show as filling defects in the regular contour of
31、 the oesophagus, with the corkscrew sign (arrow), most often in the lower third but the entire oesophagus may be involved. Hepatic cirrhosis is the commonest cause of portal hypertension. Blood from gastro-oesophageal collaterals reaches the superior vena cava system. Hypertension in the gastro-oeso
32、phageal venous vessels lead to gastro-oesophageal varices. Haemorrhages following varices rupture may be a slow ooze with melena or a sudden haematemesis. The mortality of bleeding varices is about 40% with each episode. Portal hypertension results from the abnormal blood flow pattern in liver creat
33、ed by cirrhosis. The increased pressure is transmitted to collateral venous channels. Sometimes these venous collaterals are dilated. Seen here is caput medusae which consists of dilated veins seen on the abdomen of a patient with cirrhosis of the liver.B. Distention of Abdominal wall veinC. Rectal
34、hemorrhiod二、门脉高压3.腹水(Ascitis)形成原因：A.门脉压力高10mmHgB.低蛋白血症plasmacolloidosmoticpressuredecreaseC.肝淋巴循环障碍Increasedhepaticlymph(5more)D.Arteriolarvisodilatation:ThisstimulatereninangiotetionandantidureitchormoneAscites and umbilical hernia.This patient with alcoholic cirrhosis presented with massive abdomi
35、nal distension due to ascites. Other noteworthy features here include the umbilical hernia with a bluish tinge (almost certainly due to porto-systemic collateral circulation) and profound muscle-wasting.二、门脉高压二、门脉高压4.门脉高压胃肠病门脉高压胃肠病5.胸水胸水hepatichydrothorax6.肝肺综合征：肝肺综合征：hepatopulmonarysyndrome无肺部疾病、肺内
36、血管短路、无肺部疾病、肺内血管短路、肺肺内血管扩张内血管扩张,低氧血症低氧血症/肺泡肺泡-动动脉氧梯度增加脉氧梯度增加三联症三联症.Sumarry for portal hypertetionPortalhypertention:sacCollateralshuntingorcollateralcirculation:earComplications Bleedingesophagealvarices(Varicealbleeding)HepaticencephalopathyAbdominalfluidretention(ascites)andinfectionofthefluid(bact
37、erialperitonitis)Livercancer(hepatocellularcarcinoma)Kidneyfailure(hepatorenalsyndrome)Dilutionalhyponatremiavariceshavethinwallsandcarryhighpressure,andthusaremorelikelytoburst.Iftheydoburst,theresultisaseriousbleedingproblemintheupperstomachoresophagusthatrequiresimmediatemedicalattention.Symptoms
38、 vomitingvomitingbloodblack,tarrystoolsdecreasedurineoutputsymptomsofcirrhosispalenesslightheadedness肝性脑病肝性脑病HepaticencephalopathyTheliverofapersonwithcirrhosisalsohastroubleremovingtoxins,whichmaybuildupintheblood.ThesetoxinscandullmentalfunctionandleadtopersonalitychangesandevencomaEarlysignsoftox
39、inaccumulationinthebrainmayincludeneglect of personal appearance,unresponsiveness,forgetfulness,trouble concentrating,orchanges in sleeping habits.Hepatorenalsyndromeoccurswhenthereisadecreaseinkidneyfunctioninapersonwithaliverdisorder.Thisisoftenexhibitedby:Absentorlowurineproduction,lessthan400cc/
40、dayVerylowurinesodiumconcentrationLowserumsodiumFluidretentionintheabdomenorextremitiesIncreasedBUN(Azotemia)andcreatininelevels实验室及特殊检查实验室及特殊检查一、一、实验室检查实验室检查(Lab Test) 1血常规血常规 贫血、脾亢时白细胞和血小板减少。贫血、脾亢时白细胞和血小板减少。 2尿常现尿常现 胆红素、蛋白、管型。胆红素、蛋白、管型。 3肝功能肝功能 失代偿期失代偿期 liver function test 血清胆红素血清胆红素 凝血酶原时间、凝血酶原时间
41、、 thetimeneededforbloodtoclot. 白蛋白及白球比例白蛋白及白球比例 转氨酶转氨酶 染料排泄功能染料排泄功能 如靛青绿（如靛青绿（ICG）滞留。）滞留。 前胶原前胶原III肽（肽（ PIIIP ）TestWhatIsMeasuredWhattheTestMayIndicateAlkalinephosphataseAnenzymeproducedintheliver,bone,andplacentathatisreleasedintothebloodduringinjuryBileductobstruction,liverinjury,andsomecancersAla
42、ninetransaminase(ALT)AnenzymeproducedintheliverthatisreleasedintothebloodduringinjuryLivercellinjury(asinhepatitis)Aspartatetransaminase(AST)Anenzymereleasedintothebloodwhentheliver,heart,muscle,orbrainisinjuredInjurytoliver,heart,muscles,orbrainBilirubinAcomponentofthedigestivejuice(bile)producedby
43、theliverObstruction,liverdamage,excessivebreakdownofredbloodcellsGamma-glutamyltranspeptidaseproducedbytheliver,pancreas,andkidneysandreleasedintothebloodwhentheseorgansareinjuredOrgandamage,drugtoxicity,alcoholabuse,diseaseofthepancreasLacticdehydrogenaseAnenzymereleasedintothebloodwhencertainorgan
44、sareinjuredDamagetotheliver,heart,lung,orbrainandexcessivebreakdownofRBCAlbuminproducedbytheliverandnormallyreleasedintotheblood;oneofitsfunctionsistoholdfluidinsidethebloodvesselsLiverdamageAlpha-fetoproteinAproteinproducedbythefetalliverandtestesSeverehepatitisorcanceroftheliverortestesMitochondri
45、alantibodiesCirculatingantibodiesagainstmitochondria,aninnercomponentofcellsPrimarybiliarycirrhosisandcertainautoimmunediseasesProthrombintimeTimeneededforbloodtoclot(clottingrequiresvitaminKandsubstancesmadebytheliver)LiverdamageorpoorabsorptionofvitaminKcausedbyalackofbile一、一、实验室检查实验室检查4免疫功能检查免疫功能
46、检查（l）细胞免疫）细胞免疫 半数以上半数以上T淋巴细胞低于正常，淋巴细胞低于正常，CD3、CD4和和CD8细胞均有降低。细胞均有降低。（2）体液免疫）体液免疫 免疫球蛋白免疫球蛋白 IgG、IgA、IgM 增增高。高。（3）非特异性自身抗体）非特异性自身抗体 如抗核抗体、抗平滑肌如抗核抗体、抗平滑肌抗体、抗线粒伴抗体等出现。抗体、抗线粒伴抗体等出现。（4）病因为病毒性肝炎者，乙型、丙型或乙型加）病因为病毒性肝炎者，乙型、丙型或乙型加丁型肝炎病毒标记呈阳性反应。丁型肝炎病毒标记呈阳性反应。一、实验室检查一、实验室检查5腹水检查腹水检查Theserumascitesalbumingradient
47、(SAAG),calculatedbysubtractingtheascitesalbuminconcentrationfromtheserumvalue,isthemostaccuratemethodofclassifyingascites.AnSAAGvalueofgreaterthan1.1g/dLpredictsaportalhypertensivecausewithmorethan95%accuracy.Valueslessthan1.1g/dLareassociatedwithneoplasms,tuberculosis,pancreatitis,orbileleak;theasc
48、iticfluidshouldbetested,asindicated,foramylase,cytology,andmycobacterialculture.腹水检查腹水检查Iftheabsolutepolymorphonuclear(PMN)countisgreaterthan250/mm3(percentPMNtimestotalwhitebloodcountWBC),apresumptiveSBPdiagnosisshouldbemade,andempiricalantibiotictherapy(e.g.,cefotaxime,1to2gintravenouslyevery6to8h
49、ours,orceftriaxone,500to1000mgintravenouslyevery12hours)shouldbegivenfor5to7days.二、特殊检查二、特殊检查(Special test)US钡餐钡餐CTCryptogeniccirrhosis.Spiral CT in an elderly male patient with progressive abdominal distension. The liver is small and a large volume of ascites is present. However, contact is maintai
50、ned between the posterior surface of the liver and the diaphragm (arrows), the bare area since this region is not peritonealized. A CT scan of the upper abdomen showing an widespread (disseminated) carcinoma of the liver (hepatocellular carcinoma). The liver is the large organ on the left side of th
51、e picture. Note the moth-eaten appearance. 胃静脉曲张内镜内镜食管静脉曲张食管静脉曲张 a b 食管静脉曲张红色征（CR） a ：食管曲张静脉表面CR+: 表现为樱桃红点b：食管曲张静脉表面CR+：表现为蚯蚓状扩张的红色血管。 门脉高压胃病门脉高压胃病门脉高压胃病门脉高压胃病(gastripathyinportalhypertension)(gastripathyinportalhypertension)内镜内镜 a b门脉高压性大肠病门脉高压性大肠病内镜内镜超声内镜(Endoscopic ultrasound)超声内镜腹腔镜腹腔镜(celioscop
52、e)肝穿刺诊断病史病史肝功能损害肝功能损害门脉高压门脉高压肝脏改变肝脏改变化验或特殊检查化验或特殊检查病理特点病理特点鉴别诊断伴肝大的其他疾病伴肝大的其他疾病伴脾大的其他疾病伴脾大的其他疾病伴腹水的其他疾病伴腹水的其他疾病与肝硬化并发症相似的其他疾病与肝硬化并发症相似的其他疾病Child-pugh分级分级 项目项目 1 2 3肝性脑病（期）肝性脑病（期） 无无 1-2 3-4腹水腹水 无无 易消退易消退 难消退难消退 胆红素（胆红素（mol/L） 51白蛋白（白蛋白（gL） 3535 28-35 2828凝血酶原时间（秒凝血酶原时间（秒) 1414 15-17 1818注：根据注：根据5项的总
53、分判断分级，项的总分判断分级，A级级 6 分，分，B级级7-9分，分，C级级10分。分。Child Pugh Classification治疗治疗MANAGEMENTTreatment Liverdamagefromcirrhosiscannotbereversed,buttreatmentcanstopordelayfurtherprogressionandreducecomplications.Treatmentdependsonthecauseofcirrhosisandanycomplicationsapersonisexperiencing.Cirrhosiscausedbyalco
54、holabuseistreatedbyabstainingfromalcohol.Treatmentforhepatitis-relatedcirrhosisinvolvesmedicationsusedtotreatthedifferenttypesofhepatitis,suchasinterferonforviralhepatitiscorticosteroidsforautoimmunehepatitis.Inallcases,regardlessofthecause,followingahealthydietandavoidingalcoholareessentialbecauset
55、hebodyneedsallthenutrientsitcanget,andalcoholwillonlyleadtomoreliverdamage.Dietarychangesthatmaybehelpful:peoplewithlivercirrhosismaybeunabletotoleratenormalamountsofdietaryproteinbecausethecirrhoticliverislessabletodetoxifyammonia,amajorproductofproteindigestion.Lifestylechangesthatmaybehelpful:Avo
56、idanceofalcoholisstronglyrecommendedforpeoplewithlivercirrhosis.Alcoholisdirectlytoxictotheliver.Inpeoplewithalcohol-inducedlivercirrhosis,evenmoderatealcoholconsumptionincreasestheriskofportalhypertension,adangerousbloodpressureabnormalityintheliverscirculation.一、一、一般治疗一般治疗（1）卧床休息）卧床休息bedrest 肝功能损害
57、、黄疽、肝功能损害、黄疽、腹水、出血者。腹水、出血者。 （2）饮食）饮食 (DIAT)保证各种营养、进食易保证各种营养、进食易消化、富含蛋白质、维生素及足够热量消化、富含蛋白质、维生素及足够热量和适量脂肪的食物。戒酒！和适量脂肪的食物。戒酒！ regardlessofthecause,ahealthydietandavoidingalcohol （3）静脉输液）静脉输液 摄入不足者，补充热量及摄入不足者，补充热量及营养。营养。二、二、药物治疗药物治疗（1）维生素）维生素（2）护肝药物：）护肝药物： 肝泰乐肝泰乐 水飞蓟素水飞蓟素 肌苷肌苷 易善复易善复三、脾功能亢进的治疗三、脾功能亢进的治疗1
58、脾切除术脾切除术 2脾动脉栓塞术脾动脉栓塞术四、腹水的治疗四、腹水的治疗1限制钠、水的摄入限制钠、水的摄入salt-restricteddiet ： 每日摄入钠每日摄入钠盐盐500800mg（氯化钠（氯化钠1220g）；进水量）；进水量1000ml左右，左右， 2 利尿剂利尿剂 ： 螺内酯、呋塞米螺内酯、呋塞米usuallycombinedwithdrugscalleddiuretics,whichmakethekidneysexcretemorefluidintheurine.3 放腹水加输注白蛋白放腹水加输注白蛋白Iftheascitesmakesbreathingoreatingdiff
59、icult,thefluidmayberemovedthroughaneedle-aprocedurecalledtherapeuticparacentesis.Often,largeamountsofalbuminarelostfromthebloodintotheabdominalfluid,soalbuminmaybeadministeredintravenously. 4 提高血浆胶体渗透压提高血浆胶体渗透压 5 腹水浓缩回输腹水浓缩回输 6 腹腔腹腔-颈静脉引流颈静脉引流 （Le Veen引流法）引流法）7 经颈静脉肝内门体分流术经颈静脉肝内门体分流术（trans jugular i
60、ntrahepatic portosystemic shunt，TIPS）五、食管、胃静脉曲张破裂出血的治疗五、食管、胃静脉曲张破裂出血的治疗1一般性治疗 2生长抑素及其类似物：生长抑素奥曲肽3加压素： 垂体后叶素、三甘氨酸赖氨酸加压素4硝酸甘油：与血管加压素共同使用。5立止血、凝血酶类制6气囊压迫止血Balloon-tubetamponade 7.内镜治疗食管静脉曲张出血内镜硬化治疗内镜装有气囊用以阻断血液回流，保障硬化剂停留在曲张静脉内。 曲张静脉 静脉内注射 静脉旁注 射部位 内镜硬化治疗，曲张静脉内+曲张静脉旁。内镜硬化治疗 a b c组织黏合剂治疗胃底静脉曲张clotting age
61、nt a：胃底静脉曲张b：注射组织黏合剂 c：治疗6个月后复查内镜硬化治疗套扎治疗rubber-bandligation a b c食管静脉曲张套扎治疗。A，b为皮圈套扎，c为尼龙圈套扎。8TIPS9外科治疗断流术分流术六、预防出血及预防再出血的治疗六、预防出血及预防再出血的治疗Toreducetheriskofbleedingfromesophagealvarices,wemaytrytoreducethepressureintheportalvein.Onewayistogivepropranolol,adrugusedtotreathighbloodpressure. 1 1受体阻滞剂受体阻滞剂 普奈洛尔（心得安）普奈洛尔（心得安） 2硝酸酯制剂硝酸酯制剂 硝酸异山梨酯、单硝酸异山硝酸异山梨酯、单硝酸异山梨酯梨酯3钙通道拮抗剂钙通道拮抗剂 硝苯吡啶硝苯吡啶 七、其他并发症的治疗七、其他并发症的治疗 原发性腹膜炎原发性腹膜炎肝性脑病肝性脑病肝肾综合征肝肾综合征八、八、肝移植肝移植.
