1肝硬化胸腹水要点.ppt

Hepatic hydrothorax is a recurrent pleural eff usion that occurs in patients with end-stage liver disease and portal hypertension. Compared with the other complications of cirrhosis such as ascites and variceal bleed, hydrothorax is relativelyless common with a reported incidence of 5– 12% . The pleural eff usion associated with cirrhosis is usually right sided (85 % ), though it may be left sided (13 % ) or bilateral (2 % ) at times . The precise pathogenic mechanism underlying the formation of pleural fluid in patients with cirrhosis has notbeen elucidated. A few commonly proposed mechanisms include passage of transudative fl uid from the peritoneal cavity to the pleural space through diaphragmatic defects, hypoalbuminemia leading to decreased oncotic pressure, and leakage of the thoracic duct (6,7) . Th e medical management of hydrothorax is similar to that of ascites. Sodium restriction and diuretics form the fi rst line of therapy. When patients fail to respond to maximal tolerateddoses of above measures the hydrothorax is called refractory, and its management is challenging and usually unsuccessful. Repeated thoracocentesis and chest tube drainage have been associated with decreased quality of life, and have resulted in hyponatremia and hypoalbuminemia because of excessive volume loss (7) . Pleurodesis and peritoneovenous shunts are surgical options that are usually associated with rapid fluid reaccumulation (8) and also with procedure-related complications. Liver transplantation has been considered the only curative treatment for hepatic ydrothorax. 难治性肝性胸腔积液(refractory hepatic hydrothorax) 采用物理的、化学的或生物的方法使胸膜产生无菌性炎症而发生脏层和壁层胸膜相互粘连，以达到消除胸膜腔、减少气体和液体渗出的治疗方法称为胸膜粘连术（pleu-rodesis），亦称为胸膜腔闭锁术。 （1）粘连方法：治疗胸腔积液和气胸的胸膜粘连方法基本相同，有以下几种方法：①经胸腔穿刺注射法，即在进行胸腔穿刺抽液或抽气后，将粘连剂注入胸腔内。因该法疗效较差，现已较少应用。②经胸腔引流管注入法，在插管胸腔引流肺完全复张后，经胸腔引流管注入粘连剂，该法相对简便，疗效肯定，为目前最常用的方法。③经胸腔镜注药法，在胸腔镜检查时将粘连剂均匀地涂布于胸膜表面。④胸腔内滑石粉喷入法，使用一喷粉装置将滑石粉喷入胸腔内。⑤剖胸术中应用粘连剂。 肠腔静脉分流术是将肠系膜上静脉与下腔静脉行吻合分流，以减轻门静脉高压，常用肠腔h型加桥术、肠腔侧侧吻合术等。h型架桥