内科学：肝硬化和肝性脑病课件.ppt

ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE,Liver Cirrhosis,Natural History,Cirrhosis,End stage of any chronic liver diseaseCharacterized histologically by regenerative nodules surrounded by fibrous tissueClinically there are two types of cirrhosis:CompensatedDecompensated,DEFINITION OF CIRRHOSIS,Cirrhosis,Normal,Nodules,Irregular surface,GROSS IMAGE OF A NORMAL AND A CIRRHOTIC LIVER,Cirrhotic liver,Nodular,irregular surface,Nodules,GROSS IMAGE OF A CIRRHOTIC LIVER,Cirrhosis,Normal,Nodules surrounded by fibrous tissue,HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER,HISTOLOGICAL IMAGE OF CIRRHOSIS,Fibrosis,Regenerative nodule,PATHOGENESIS OF LIVER FIBROSIS,Hepatocytes,Space of Disse,Sinusoidal endothelial cell,Hepatic stellate cell,Fenestrae,Normal Hepatic SInusoid,Retinoid droplets,PATHOGENESIS OF LIVER FIBROSIS,Alterations in Microvasculature in Cirrhosis,Activation of stellate cellsCollagen deposition in space of DisseConstriction of sinusoidsDefenestration of sinusoids,Normal Liver,Hepatic vein,Sinusoid,Portal vein,Liver,Splenic vein,Coronary vein,THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW,Portal systemic collaterals,Distorted sinusoidal architectureleads to increased resistance,Portal vein,Cirrhotic Liver,Splenomegaly,ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE,AN INCREASE IN PORTAL VENOUS INFLOW SUSTAINS PORTAL HYPERTENSION,Mesenteric veins,Flow,Splanchnicvasodilatation,Distorted sinusoidal architechure,Portal vein,An Increase in Portal Venous Inflow Sustains Portal Hypertension,Mechanisms of Portal Hypertension,Pressure(P)results from the interaction of resistance(R)and flow(F):,Portal hypertension can result from:increase in resistance to portal flow and/or increase in portal venous inflow,MECHANISMS OF PORTAL HYPERTENSION,Compensatedcirrhosis,Decompensatedcirrhosis,Death,Chronic liver disease,Natural History of Chronic Liver Disease,NATURAL HISTORY OF CHRONIC LIVER DISEASE,Development of Complications in Compensated Cirrhosis,Ascites,Jaundice,Encephalopathy,GI hemorrhage,Probability of developing event,0,20,60,80,100,0,60,40,20,40,80,100,120,140,160,Months,Gines et.al.,Hepatology 1987;7:122,NATURAL HISTORY OF CIRRHOSIS,60,40,80,100,120,140,160,0,40,60,80,20,20,0,100,Months,Probability of survival,All patients with cirrhosis,Decompensated cirrhosis,180,Decompensation Shortens Survival,Gines et.al.,Hepatology 1987;7:122,Median survival 9 years,Median survival 1.6 years,SURVIVAL TIMES IN CIRRHOSIS,Liver insufficiency,Variceal hemorrhage,Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency,Cirrhosis,Ascites,Encephalopathy,Jaundice,Portal hypertension,Spontaneous bacterial peritonitis,Hepatorenal syndrome,COMPLICATIONS OF CIRRHOSIS,Cirrhosis-Diagnosis,Cirrhosis is a histological diagnosisHowever,in patients with chronic liver disease the presence of various clinical features suggests cirrhosisThe presence of these clinical features can be followed by non-invasive testing,prior to liver biopsy,DIAGNOSIS OF CIRRHOSIS,In Whom Should We Suspect Cirrhosis?,Any patient with chronic liver diseaseChronic abnormal aminotransferases and/or alkaline phosphatasePhysical exam findingsStigmata of chronic liver disease(muscle wasting,vascular spiders,palmar erythema)Palpable left lobe of the liverSmall liver spanSplenomegalySigns of decompensation(jaundice,ascites,asterixis),DIAGNOSIS OF CIRRHOSIS CLINICAL FINDINGS,LaboratoryLiver insufficiencyLow albumin(1.3)High bilirubin(1.5 mg/dL)Portal hypertensionLow platelet count(1,In Whom Should We Suspect Cirrhosis?,DIAGNOSIS OF CIRRHOSIS LABORATORY STUDIES,CT Scan in Cirrhosis,Liver with an irregular surface,Splenomegaly,Collaterals,DIAGNOSIS OF CIRRHOSIS CAT SCAN,Diagnostic Algorithm,Patient with chronic liver disease and any of the following:Variceal hemorrhageAscitesHepatic encephalopathy,Liver biopsy not necessary for the diagnosis of cirrhosis,Physical findings:Enlarged left hepatic lobeSplenomegalyStigmata of chronic liver disease,Laboratory findings:ThrombocytopeniaImpaired hepatic synthetic function,Radiological findings:Small nodular liverIntra-abdominal collateralsAscitesSplenomegalyColloid shift to spleen and/or bone marrow,Yes,No,Yes,No,Liver biopsy,DIAGNOSTIC ALGORITHM,Liver insufficiency,Variceal hemorrhage,Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency,Cirrhosis,Ascites,Encephalopathy,Jaundice,Portal hypertension,Spontaneous bacterial peritonitis,Hepatorenal syndrome,COMPLICATIONS OF CIRRHOSIS,Cirrhosis is the most common cause of portal hypertensionThe site of increased resistance in cirrhosis is sinusoidalOther causes of portal hypertension are classified according to the site of increased resistance,Causes of Portal Hypertension,CAUSES OF PORTAL HYPERTENSION,Portal Hypertension Is Classified According to the Site of Increased Resistance,TypeExamplePre-hepaticPortal or splenic vein thrombosisPre-sinusoidalSchistosomiasisSinusoidalCirrhosisPost-sinusoidalVeno-occlusive diseasePost-hepaticBudd-Chiari syndrome,CLASSIFICATION OF PORTAL HYPERTENSION,Vasodilation and Hyperdynamic Circulation in Cirrhosis-Multiple Organ Involvement,Splanchnic vasodilation,Peripheral vasodilation,Pulmonary vasodilation,Cerebral vasodilation,VASODILATION AND HYPERDYNAMIC CIRCULATION IN CIRRHOSIS MULTIPLE ORGAN INVOLVEMENT,Splanchnic vasodilation,Varices and Variceal Hemorrhage,VARICES AND VARICEAL HEMORRHAGE,Portal Pressure Measurements,Definitive method to establish the diagnosis of portal hypertensionDirect methods(percutaneous,transjugular)are cumbersome and may be associated with complicationsThe safest and most reproducible method is measurement of the hepatic venous pressure gradient(HVPG),PORTAL PRESSURE MEASUREMENTS,Portal Pressure Measurements,The hepatic venous pressure gradient(HVPG)is obtained by subtracting the free hepatic venous pressure(FHVP)from the wedged hepatic venous pressure(WHVP):The FHVP acts as an internal zero to correct for extravascular,intraabdominal pressure increases(e.g.ascites),HVPG=WHVP-FHVP,PORTAL PRESSURE MEASUREMENTS,Small varices,Large varices,No varices,7-8%/year,7-8%/year,Varices Increase in Diameter Progressively,Merli et al.J Hepatol 2003;38:266,VARICES INCREASE IN DIAMETER PROGRESSIVELY,A Threshold Portal Pressure of 12 mmHg is Necessary for Varices to Form,P0.01,5,10,12,15,25,30,35,20,HepaticVenousPressureGradient(mmHg),Garcia-Tsao et.al.,Hepatology 1985;5:419,Varices Present(n=72),Varices Absent(n=15),A THRESHOLD PORTAL PRESSURE OF 12 mmHg IS NECESSARY FOR VARICES TO FORM,Variceal rupture,Cirrhosis,PROGRESSION OF PORTAL HYPERTENSION LEADS TO VARICEAL GROWTH AND VARICEAL RUPTURE,Predictors of hemorrhage:Variceal size Red signs Child B/C,NIEC.N Engl J Med 1988;319:983,Variceal hemorrhage,Varix with red signs,PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE,Prophylaxis of Variceal Hemorrhage,MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE-SUMMARY,Treatment of Acute Variceal Hemorrhage,General Management:IV access and fluid resuscitationDo not overtransfuse(hemoglobin 8 g/dL)Antibiotic prophylaxisSpecific therapy:Pharmacological therapy:terlipressin,somatostatin and analogues,vasopressin+nitroglycerinEndoscopic therapy:ligation,sclerotherapyShunt therapy:TIPS,surgical shunt,TREATMENT OF ACUTE VARICEAL HEMORRHAGE,Endoscopic Variceal Band Ligation,Bleeding controlled in 90%Rebleeding rate 30%Compared with sclerotherapy:Less rebleedingLower mortalityFewer complicationsFewer treatment sessions,ENDOSCOPIC VARICEAL BAND LIGATION,Transjugular Intrahepatic Portosystemic Shunt,Hepatic vein,Portal vein,Splenic vein,Superior mesenteric vein,TIPS,THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT,Evolution of Varices,Level of Intervention,Management Recommendations,Cirrhosis with no varices,Small varicesNo hemorrhage,Medium/large varicesNo hemorrhage,Variceal hemorrhage,Recurrent variceal hemorrhage,Pre-primary prophylaxis,Primary prophylaxis,Secondary prophylaxis,Repeat endoscopy in 2-3 yearsNo specific therapy,Small varicesRepeat endoscopy in 1-2 yearsNo specific therapy?beta-blocker to prevent enlargementMedium/Large varicesNon-selective beta-blockersEVL in those intolerant to drugs,Endoscopic/pharmacologic therapyAntibiotics in all patientsTIPS or shunt surgery as rescue therapy,Beta-blockers+nitrates or EVLBeta-blockers+EVL?TIPS or shunt surgery as rescue therapy,SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE,Liver insufficiency,Variceal hemorrhage,Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency,Cirrhosis,Ascites,Encephalopathy,Jaundice,Portal hypertension,Spontaneous bacterial peritonitis,Hepatorenal syndrome,COMPLICATIONS OF CIRRHOSIS,Cirrhosis,Ascites,PATHOGENESIS OF ASCITES,Ultrasound is the Most Sensitive Method to Detect Ascites,Liver,ULTRASOUND IS THE MOST SENSITIVE METHOD TO DETECT ASCITES,Diagnostic Paracentesis,Indications,Contraindications,New-onset ascitesAdmission to hospitalSymptoms/signs of SBPRenal dysfunctionUnexplained encephalopathy,None,DIAGNOSTIC PARACENTESIS,Cirrhotic ascites,Cardiac ascites,Peritoneal malignancy,1.1,4.0,3.0,2.0,1.0,0,Serum ascites albumin gradient(g/dL),Serum-Ascites Albumin Gradient is High in Portal Hypertensive Causes of Ascites,Runyon,Ann Intern Med 1992;117:215,SERUM-ASCITES ALBUMIN GRADIENT(SAAG)IS HIGH IN PORTAL HYPERTENSIVE CAUSES OF ASCITES,Activation of neurohumoral systems,Site of Action of Different Therapies for Ascites,Cirrhosis,Intrahepatic resistance,Arteriolar resistance(vasodilation),Sinusoidal pressure,Ascites,Sodium and water retention,Diuretics,Effective arterial blood volume,MECHANISM OF ACTION OF THE DIFFERENT THERAPIES FOR ASCITES,Management of Uncomplicated Ascites,Definition:Ascites responsive to diuretics in the absence of infection and renal dysfunction,Sodium restrictionEffective in 10-20%of casesPredictors of response:mild or moderate ascites,Urine Na excretion 50 mEq/dayDiureticsShould be spironolactone-basedA progressive schedule(spironolactone furosemide)requires fewer dose adjustments than a combined therapy(spironolactone+furosemide),MANAGEMENT OF UNCOMPLICATED ASCITES,Definition and Types of Refractory Ascites,Occurs in 10%of cirrhotic patients,Diuretic-intractable ascitesTherapeutic doses of diuretics cannot be achieved because of diuretic-induced complicationsDiuretic-resistant ascitesNo response to maximal diuretic therapy(400 mg spironolactone+160 mg furosemide/day),Arroyo et al.Hepatology 1996;23:164,DEFINITION AND TYPES OF REFRACTORY ASCITES,Spontaneous Bacterial Peritonitis(SBP)Complicates Ascites and Can Lead to Renal Dysfunction,SPONTANEOUS BACTERIAL PERITONITIS(SBP)COMPLICATES ASCITES AND CAN LEAD TO RENAL DYSFUNCTION,Early Diagnosis of SBP,Diagnostic paracentesis:If symptoms/signs of SBP occurUnexplained encephalopathy and/or renal dysfunctionAt any hospital admissionDiagnosis based on ascitic fluidPMN count 250/mm3,Rimola et al.,J Hepatol 2000;32:142,EARLY DIAGNOSIS OF SPONTANEOUS BACTERIAL PERITONITIS(SBP),TREATMENTINDICATED,Diagnosis and Management of Spontaneous Bacterial Peritonitis,Diagnostic Paracentesis,PMN250?,Culture Positive?,TREATMENT NOT INDICATED,NO,Repeat Paracentesis,YES,PMN250?,Culture Positive?,NO,NO,YES,YES,YES,NO,MANAGEMENT ALGORITHM IN SPONTANEOUS BACTERIAL PERITONITIS(SBP),Treatment of Spontaneous Bacterial Peritonitis,Recommended antibiotics for initial empiric therapyi.v.cefotaxime,amoxicillin-clavulanic acidoral nofloxacin(uncomplicated SBP)avoid aminoglycosidesMinimum duration:5 daysRe-evaluation if ascitic fluid PMN count has not decreased by at least 25%after 2 days of treatment,Rimola et al.,J Hepatol 2000;32:142,TREATMENT OF SPONTANEOUS BACTERIAL PERITONITIS(SBP),All SBPs,SBP caused by gram-negative bacteria,Probability of SBP recurrence,Months,Months,Norfloxacin Reduces Recurrence of Spontaneous Bacterial Peritonitis,Gines et al.,Hepatology 1990;12:716,NORFLOXACIN REDUCES RECURRENCE OF SPONTANEOUS BACTERIAL PERITONITIS(SBP),Indications for Prophylactic Antibiotics to Prevent Spontaneous Bacterial Peritonitis,Cirrhotic patients hospitalized with GI hemorrhage(short-term)Norfloxacin 400 mg p.o.BID x 7 daysPatients who have recovered from SBP(long-term)Norfloxacin 400 mg p.o.daily,indefinitelyWeekly quinolones not recommended(lower efficacy,development of quinolone-resistance),INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS TO PREVENT SPONTANEOUS BACTERIAL PERITONITIS(SBP),Hepatorenal Syndrome,ASCITES AND HEPATORENAL SYNDROME,Characteristics of Hepatorenal Syndrome,Renal failure in patients with cirrhosis,advanced liver failure and severe sinusoidal portal hypertensionAbsence of significant histological changes in the kidney(“functional”renal failure)Marked arteriolar vasodilation in the extra-renal circulationMarked renal vasoconstriction leading to reduced glomerular filtration rate,CHARACTERISTICS OF HEPATORENAL SYNDROME(HRS),Two Types of Hepatorenal Syndrome,Type 1Rapidly progressive renal failure(2 weeks)Doubling of creatinine to 2.5 or halving of creatinine clearance(CrCl)to 1.5 mg/dL or CrCl 40 ml/minAssociated with refractory ascites,Arroyo et al.,Hepatology 1996;23:164,TYPES OF HEPATORENAL SYNDROME(HRS),SURVIVAL IN THE DIFFERENT TYPES OF HEPATORENAL SYNDROME(HRS),0,2,4,6,8,12,10,Months,1,0.2,0.4,0.6,0.8,Survival probability,0,Type 2,p=0.001,Survival in Different Types of Hepatorenal Syndrome(HRS),Gines et al.,Lancet 2003;362:1819,Type 1,Cirrhosis,Arteriolar resistance(vasodilation),Effective arterial blood volume,Ascites,Sodium and water retention,Activation of neurohumoral systems,NSAIDs,DiureticsDiarrheaHemorrhage,VasodilatorsLVP w/o albuminInfection,THERE ARE MANY CONDITIONS OTHER THAN HEPATORENAL SYNDROME THAT CAN LEAD TO RENAL FAILURE IN PATIENTS WITH CIRRHOSIS,Cirrhosis,Arteriolar resistance(vasodilation),Effective arterial blood volume,Ascites,Sodium and water retention,Activation of neurohumoral systems,NSAIDs,DiureticsDiarrheaHemorrhage,VasodilatorsLVP w/o albuminInfection,HEPATORENAL SYNDROME(HRS)IS A DIAGNOSIS OF EXCLUSION,Advanced hepatic failure and portal hypertensionCreatinine 1.5 mg/dL or creatinine clearance 40 ml/minAbsence of shock,bacterial infection,or nephrotoxic drugsAbsence of excessive gastrointestinal or renal fluid lossNo improvement in renal function after plasma volume expansion with 1.5 L of isotonic salineUrinary protein 500 mg/dL and normal renal ultrasound,Major Criteria in the Diagnosis of Hepatorenal Syndrome,Arroyo et al.,Hepatology 1996;23:164,MAJOR CRITERIA IN DIAGNOSING HEPATORENAL SYNDROME,Urine Sodium and Urine Volume are Minor Criteria in the Diagnosis of HRS,Minor criteriaUrine sodium plasma osmolalitySerum sodium 130 mEq/LUrine volume 500 ml/dayUrine RBCs 50/HPF,Arroyo et al.,Hepatology 1996;23:164,URINE SODIUM AND URINE VOLUME ARE MINOR CRITERIA IN THE DIAGNOSIS OF HEPATORENAL SYNDROME(HRS),Activation of neurohumoral systems,Site of Action