医学精品课件肝性脑病的诊治.ppt

* * * 如图所示两组亚临床肝性脑病患者，一部分用乳果糖治疗8周，另一部分不用药，8周后乳果糖组亚临床肝性脑病的发生率明显下降。 * 显性HE诊治流程 肝硬化Child Pugh A.B或C级 临床有HE症状或体征 　　　　　查明诱因 了解生命体征及容量状况 有否出血与感染 有否低O2、低血糖、贫血、低钾 代谢性碱中毒及其它代谢异常 大脑MR或CT神经系统可能的异常 　　　　纠正诱因 去除镇静或安眠药 Iv补液，纠正电解质失衡 控制出血 治疗感染 　　　　　　　I-Ⅱ级HE 开始乳果糖治疗→2-3次大便/日 如乳果糖不耐受或无效→利福昔明或LOLA 如证实蛋白不耐受→植物饮食补ZN, BCAA 如持续或反复发作HE→肝移植 Ⅱ-Ⅳ级HE 收入院（ICU） 支持治疗，注意气道，抗菌素，TPN, 必要时人工呼吸 乳果糖（灌肠或肠内用药） 如乳果糖不耐受或无效→利福昔明（LOLA） 昏迷病人考虑用氟马西尼 肝移植 总 结 HE是急、慢性肝病严重的神经心理并发症 除了炎症、神经类固醇外，氨是HE产生的核心发病机制 OHE：具有神经系统异常的临床表现 MHE: 常规临床检查无异常、神经精神测试有改变 治疗原则： 查明及去除诱因 减少肠内氮质 长期治疗的评估 乳果糖和利福昔明是FDA批准用于HE治疗的一线药物 * Definition H 4 Hepatic encephalopathy is a syndrome belonging to the family of metabolic encephalopathies, like diabetic coma, carbon dioxide narcosis or hypoxia. It is characterized by an impairment of intellectual function ranging from sleep disorders to coma, occuring in patients with liver dysfunction. Hepatic encephalopathy can only be diagnosed after exclusion of other brain diseases, such as Wilsons disease, Korsakows syndrome or intracranial bleeding. * Definition H 4 Hepatic encephalopathy is a syndrome belonging to the family of metabolic encephalopathies, like diabetic coma, carbon dioxide narcosis or hypoxia. It is characterized by an impairment of intellectual function ranging from sleep disorders to coma, occuring in patients with liver dysfunction. Hepatic encephalopathy can only be diagnosed after exclusion of other brain diseases, such as Wilsons disease, Korsakows syndrome or intracranial bleeding. * * Precipitating factors H 7 Episodes of HE may be triggered by a number of factors. The most important are shown in Slide 7. Note that a number of medications, especially tranquilizers or sedatives, but also diuretics can trigger episodes of HE. * * * * * * * * Minimal HE H30 Minimal or subclinical hepatic encephalopathy often is missed on clinical examination, since standard investigations reveal no pathologic findings. Special neuropsychiatric and neurophysiologic tests have to be