Karkmann Kathrin, Piecha Felix, Rünzi Anna Caterina, Schulz Lisa, von Wulffen Moritz, Benten Daniel, Kluwe Johannes, Wege Henning
Medizinische Klinik und Poliklinik, Gastroenterologie und Hepatologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg.
III. Medizinische Klinik, Gastroenterologie, Hepatologie, Endoskopie, Helios Klinikum Duisburg, Duisburg.
Z Gastroenterol. 2018 Jan;56(1):55-69. doi: 10.1055/s-0043-124000. Epub 2018 Jan 9.
In 2015, more than 13 000 people died due to the consequences of liver cirrhosis in Germany. Frequently, relevant liver fibrosis is diagnosed by non-invasive methods (e. g., ultrasound-based measurement of liver stiffness) already in the compensated stage. Following diagnosis of liver fibrosis, a thorough investigation of the underlying chronic liver disease and effective treatment are important to prevent progression to decompensated cirrhosis. Since morbidity and mortality dramatically increase in the decompensated stage (patients may present with jaundice, ascites, hepatic encephalopathy, gastrointestinal bleeding) with an upsurge in 1-year-mortality from 1 - 3.4 % to 20 - 57 %, prophylactic measures to prevent decompensation are indicated. Based on a risk stratification, these measures include propranolol or carvedilol as non-selective betablockers, as well as endoscopic band ligations as primary prophylaxis to prevent variceal bleeding. Because of the high risk for malignant transformation (2 - 8 % per year depending on the underlying etiology), surveillance by liver ultrasound every six months is essential to detect liver cancer in an early stage and to facilitate curative therapy. Currently under debate is the administration of antibiotics to prevent bacterial infections, which commonly trigger acute decompensation. To this regard, studies are not convincing and the risk to induce drug resistance has to be observed. However, health care providers should check the vaccination status and recommend missing vaccinations. The management of compensated liver cirrhosis also includes counseling and potentially also a drug therapy to prevent osteoporosis and muscle wasting. In this review, we will discuss specific prophylactic measures in the management of compensated liver cirrhosis based on the pathophysiological background and central clinical studies. If a patient decompensates despite these prophylactic measures (approximately 15 % of patients with liver cirrhosis per year), liver transplantation has to be discussed as definitive therapy (especially in patients with MELD > 15).
2015年，德国有超过13000人死于肝硬化并发症。通常，在代偿期即可通过非侵入性方法（如基于超声测量肝脏硬度）诊断出相关肝纤维化。肝纤维化确诊后，全面调查潜在的慢性肝病并进行有效治疗对于预防进展至失代偿期肝硬化至关重要。由于失代偿期（患者可能出现黄疸、腹水、肝性脑病、胃肠道出血）的发病率和死亡率显著增加，1年死亡率从1%-3.4%飙升至20%-57%，因此需要采取预防失代偿的措施。基于风险分层，这些措施包括使用普萘洛尔或卡维地洛作为非选择性β受体阻滞剂，以及内镜下套扎术作为预防静脉曲张出血的一级预防措施。由于恶性转化风险高（每年2%-8%，取决于潜在病因），每六个月进行一次肝脏超声监测对于早期发现肝癌并促进根治性治疗至关重要。目前正在讨论使用抗生素预防细菌感染，细菌感染通常会引发急性失代偿。在这方面，研究结果并不令人信服，必须注意诱导耐药性的风险。然而，医护人员应检查疫苗接种情况并推荐补种缺失的疫苗。代偿期肝硬化的管理还包括咨询，可能还包括药物治疗以预防骨质疏松和肌肉萎缩。在本综述中，我们将基于病理生理背景和核心临床研究讨论代偿期肝硬化管理中的具体预防措施。如果患者尽管采取了这些预防措施仍出现失代偿（每年约15%的肝硬化患者）,则必须讨论将肝移植作为最终治疗方法（尤其是终末期肝病模型评分＞15的患者）。
