Munoz S J, Maddrey W C
Division of Gastroenterology and Hepatology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.
Gastroenterol Clin North Am. 1988 Jun;17(2):265-87.
Many advances have been made in the understanding, diagnosis, and management of severe complications of liver disease. The pathogenesis of hepatic encephalopathy remains a challenge. Several toxins including ammonia, mercaptans, short-chain fatty acids, benzodiazepine-like substances, GABA-like substances, and impaired glutamatergic neurotransmission are at the top of the list of candidates. Use of the benzodiazepine antagonists is an experimental but promising new therapy in patients with hepatic encephalopathy. In patients with cirrhosis, spontaneous bacterial peritonitis (SBP) remains a common and highly lethal complication. The diagnosis of SBP is based on the polymorphonuclear cell count in the ascites and confirmed by culture of ascitic fluid. Early diagnosis and aggressive treatment has reduced mortality of SBP from greater than 90 per cent to 30 to 50 per cent. The appearance of cerebral edema in severe acute hepatocellular failure is associated with high mortality and conventional neurologic signs may be unreliable indicators of brain swelling. Current management of cerebral edema in fulminant hepatocellular failure may include early placement of an extradural sensor for continuous monitoring of intracranial pressure, so that short-term measures can be instituted making later liver transplantation safer. Coagulopathy remains a serious problem in patients with liver disease. Exchange plasmapheresis is a promising short-term adjuvant therapy. However, liver transplantation should be considered the definitive treatment for fulminant hepatocellular failure. The gastroenterologist often encounters multiorgan failure in patients with severe liver disease. Liver transplantation is now an important therapeutic consideration in almost every patient with severe, irreversible liver disease. Efforts should be targeted to early diagnosis of irreversible disease and coordination of patient care with a liver transplant center.
在肝病严重并发症的认识、诊断和管理方面已经取得了许多进展。肝性脑病的发病机制仍然是一个挑战。包括氨、硫醇、短链脂肪酸、苯二氮䓬类物质、γ-氨基丁酸（GABA）类物质以及谷氨酸能神经传递受损在内的几种毒素是主要的候选因素。使用苯二氮䓬拮抗剂对肝性脑病患者来说是一种试验性但有前景的新疗法。在肝硬化患者中，自发性细菌性腹膜炎（SBP）仍然是一种常见且致死率很高的并发症。SBP的诊断基于腹水中多形核细胞计数，并通过腹水培养得以证实。早期诊断和积极治疗已将SBP的死亡率从超过90%降低至30%至50%。严重急性肝衰竭中脑水肿的出现与高死亡率相关，而传统的神经系统体征可能并不是脑肿胀的可靠指标。暴发性肝衰竭中脑水肿的当前管理措施可能包括早期放置硬膜外传感器以持续监测颅内压，以便能够采取短期措施，使后期肝移植更安全。凝血障碍在肝病患者中仍然是一个严重问题。置换血浆疗法是一种有前景的短期辅助治疗方法。然而，肝移植应被视为暴发性肝衰竭的确定性治疗方法。胃肠病学家在严重肝病患者中经常会遇到多器官功能衰竭。现在，对于几乎每一位患有严重、不可逆肝病的患者，肝移植都是一个重要的治疗考量。应致力于早期诊断不可逆疾病，并与肝移植中心协调患者护理。
