肝性脑病诊断治疗新认识

王宇明; 晏泽辉

肝性脑病诊断治疗新认识

第三军医大学西南医院全军感染病研究所

详细信息

中图分类号: R747.9
计量
- 文章访问数: 4767
- HTML全文浏览量: 6
- PDF下载量: 1065
- 被引次数: 0
出版历程
- 出版日期: 2010-06-20

The new concepts on hepatic encephalopathy

摘要

摘要: 新近我国出台了《肝性脑病（HE）诊断治疗专家共识》,成为国际上两个指南的重要补充。按照第11届消化病学大会（WCOG）工作小组的标准,我国的HE以C型为主。同时,HBV携带者首次发病出现重症化时实际系因大块或亚大块肝坏死所致急性肝衰竭（ALF）,其HE的机制与C型不同,处理也不同。因此,我国的HE患者除C型外,A型也不少见。磁共振波谱学（MRS）、脑部单光子发射断层扫描（SPECT）和正电子发射断层扫描（PET）是近年来发展较快的HE无创性检查手段。脑水肿发生机制的研究新进展有星形胶质细胞肿胀、细胞外谷氨酸盐变化、脑循环障碍等,而相应对策有NAC、镇静剂、脱水及低温疗法等。关于BCAA疗法,经证实BCAA代谢在ALF是降低的,而在CLF则是增高的,提示前者不宜补充BCAA制剂,后者则可补充BCAA制剂。目前用于HE治疗的药物主要有鸟氨酸-门冬氨酸（OA）、不吸收抗生素和不吸收双糖,而L-鸟氨酸-乙酸苯酯（OP）作为清除血氨的一种新的治疗药物,具有重要的潜在应用价值。
- 肝性脑病 /
- 诊疗准则
Abstract: The consensus of hepatic encephalopathy (HE) has been newly published in China to be the supplement to the two national guidelines.According to 11th World Congresses of Gastroenterology (WCOG) proposed classification, type C encephalopathy is mostly seen in China.Moreover, a big portion of ALF is actually happened in HBV carriers for the large and sub-bulk hepatic necrosis.However, type A associated with acute liver failure (ALF) , is not rare, Brain MRI, CT, MRS, SPE-CT and PET-CT may provide useful information in diagnosis.Brain edema has been found to play an important role in the pathogenesis of HE, especially in patients with ALF.The new progress of pathogenetic mechanisms in brain edema include astrocyte swelling, extracellula glutamine change and disturbance of cerebral circulation, and the corresponding management are NAC treatment, tranquilizer, dehydration and hypothermia therapy.Intake of BCAA and protein should mainly depend on the types of HE.It has been proved BCAA reduce in ALF but increase in CLF, which implicate it's not suitable to supplement BCAA to the former but the latter.L-Ornithine-L-aspartate (OA) and nonabsorbable antibiotics and disaccharides are currently extensively used in HE, and L-Ornithine phenylacetate (OP) has potential value of application in HE.
- hepatic encephalopathy /
- practice guideline

HTML全文

参考文献(34)

[1]Blei AT, Cordoba J.Hepatic Encephalopathy[J].Am J Gastroenterol, 2001, 96 (7) ∶1968-1976.

[2]Ferenci P, Lockwood A, Mullen K, et al.Hepatic encephalopathy-definition, nomenclature, diagnosis, and quantification:final report of the working party at the11th World Congresses of Gastroenterology, Vienna, 1998[J].Hepatology, 2002, 35 (3) ∶716721.

[3]肝性脑病诊断治疗专家委员会.肝性脑病诊断治疗专家共识[J].中华实验和临床感染病杂志 (电子版) , 2009, 3 (4) ∶449-473.

[4]涂传涛.肝性脑病的诊断方法及其研究进展[J].实用肝脏病杂志, 2009, 12 (2) ∶158-160.

[5]颜迎春, 张明香.肝性脑病的现代治疗[J].中国现代医生, 2008, 46 (10) ∶22-23.

[6]白启轩, 贾继东.肝性脑病的研究进展[J].现代消化及介入诊疗, 2009, 14 (1) ∶29-32.

[7]Cordoba J, Raguer N, Flavia M, et al.T2hyperintensity along the cortico-spinal tract in cirrhosis relates to functional abnormalities[J].Hepatology, 2003, 38 (4) ∶1026-1033.

[8]Clemmesen JO, Larsen FS, Kondrup J, et al.Cerebral herniation in patients with acute liver failure is correlated with arterial ammonia concentration[J].Hepatology, 1999, 29 (3) ∶648-653.

[9]Blei AT.The pathophysiology of brain edema in acute liver failure[J].Neurochem Int, 2005, 47 (1-2) :71-77.

[10]王秋实, 刘辉, 梁长虹.33例活体肝脏磁共振氢质子波谱分析[J].山东医药, 2007, 47 (23) ∶67-68.

[11]Huda A, Guze BH, Thomas A, et al.Clinical correlation of neuropsychological tests with1H magnetic resonance spectroscopy in hepatic encephalopathy[J].Psychosom Med, 1998, 60 (5) ∶550556.

[12]Yazgan Y, Narin Y, Demirturk L, et al.Value of regional cerebral blood flow in the evaluation of chronic liver disease and subclinical hepatic encephalopathy[J].J Gastroenterol Hepatol, 2003, 18 (10) ∶1162-1167.

[13]Rovira A, Alonso J, Cordoba J.MR imaging findings in hepatic encephalopathy[J].AJNR Am J Neuroradiol, 2008, 29 (9) ∶16121621.

[14]Haussinger D, Schliess F.Pathogenetic mechanisms of hepatic encephalopathy[J].Gut, 2008, 57 (8) ∶1156-1165.

[15]Bjerring PN, Eefsen M, Hansen BA, et al.The brain in acute liver failure.A tortuous path from hyperammonemia to cerebral edema[J].Metab Brain Dis, 2009, 24 (1) ∶5-14.

[16]Manley GT, Fujimura M, Ma T, et al.Aquaporin-4deletion in mice reduces brain edema after acute water intoxication and ischemic stroke[J].Nat Med, 2000, 6 (2) ∶159-163.

[17]Papadopoulos MC, Verkman AS.Aquaporin-4and brain edema[J].Pediatr Nephrol, 2007, 22 (6) ∶778-784.

[18]Ellis AJ, Wendon JA, Williams R.Subclinical seizure activity and prophylactic phenytoin infusion in acute liver failure:a controlled clinical trial[J].Hepatology, 2000, 32 (3) ∶536-541.

[19]Bhatia V, Batra Y, Acharya SK.Prophylactic phenytoin does not improve cerebral edema or survival in acute liver failure-a controlled clinical trial[J].J Hepatol, 2004, 41 (1) ∶89-96.

[20]Walsh TS, Hopton P, Philips BJ, et al.The effect of N-acetylcysteine on oxygen transport and uptake in patients with fulminant hepatic failure[J].Hepatology, 1998, 27 (5) ∶1332-1340.

[21]Strauss G, Hansen BA, Knudsen GM, et al.Hyperventilation restores cerebral blood flow autoregulation in patients with acute liver failure[J].J Hepatol, 1998, 28 (2) ∶199-203.

[22]Shimomura Y, Honda T, Goto H, et al.Effects of liver failure on the enzymes in the branched-chain amino acid catabolic pathway[J].Biochem Biophys Res Commun, 2004, 313 (2) ∶381-385.

[23]Honda T, Fukuda Y, Nakano I, et al.Effects of liver failure on branched-chain alpha-keto acid dehydrogenase complex in rat liver and muscle:comparison between acute and chronic liver failure[J].J Hepatol, 2004, 40 (3) ∶439-445.

[24]Cordoba J, Lucke R.Driving under the influence of minimal hepatic encephalopathy[J].Hepatology, 2004, 39 (3) ∶599-601.

[25]Cordoba J, Lopez-Hellin J, Planas M, et al.Normal protein diet for episodic hepatic encephalopathy:results of a randomized study[J].J Hepatol, 2004, 41 (1) ∶38-43.

[26]Merli M, Riggio O.Dietary and nutritional indications in hepatic encephalopathy[J].Metab Brain Dis, 2009, 24 (1) ∶211-221.

[27]Ahmad I, Khan AA, Alam A, et al.L-ornithine-L-aspartate infusion efficacy in hepatic encephalopathy[J].J Coll Physicians Surg Pak, 2008, 18 (11) ∶684-687.

[28]Poo JL, Gongora J, Sanchez-Avila F, et al.Efficacy of oral L-ornithine-L-aspartate in cirrhotic patients with hyperammonemic hepatic encephalopathy.Results of a randomized, lactulose-controlled study[J].Ann Hepatol, 2006, 5 (4) ∶281-288.

[29]Acharya SK, Bhatia V, Sreenivas V, et al.Efficacy of L-ornithine L-aspartate in acute liver failure:a double-blind, randomized, placebo-controlled study[J].Gastroenterology, 2009, 136 (7) ∶2159-2168.

[30]Soarez PC, Oliveira AC, Padovan J, et al.A critical analysis of studies assessing L-ornithine-L-aspartate (LOLA) in hepatic encephalopathy treatment[J].Arq Gastroenterol, 2009, 46 (3) ∶241-247.

[31]Jiang Q, Jiang XH, Zheng MH, et al.L-Ornithine-l-aspartate in the management of hepatic encephalopathy:a meta analysis[J].J Gastroenterol Hepatol, 2009, 24 (1) ∶9-14.

[32]Jalan R, Wright G, Davies NA, et al.L-Ornithine phenylacetate (OP) :a novel treatment for hyperammonemia and hepatic encephalopathy[J].Med Hypotheses, 2007, 69 (5) ∶1064-1069.

[33]Davies NA, Wright G, Ytrebo LM, et al.L-ornithine and phenylacetate synergistically produce sustained reduction in ammonia and brain water in cirrhotic rats[J].Hepatology, 2009, 50 (1) ∶155164.

[34]Ytrebo LM, Kristiansen RG, Maehre H, et al.L-ornithine phenylacetate attenuates increased arterial and extracellular brain ammonia and prevents intracranial hypertension in pigs with acute liver failure[J].Hepatology, 2009, 50 (1) ∶165-174.

施引文献

资源附件(0)

访问统计