重庆医科大学：《内科学》课程教学资源（教案讲稿）cirrhosis of liver讲稿.doc_大学文库

重庆医科大学临床学院教案讲稿制表时间：2004 年 8 月 2 教学内容辅助手段时间分配结核性腹膜炎 [概述]：It’s the end result of hepatocellular injury resulted from different causes• The histologic feature is degeneration, regeneration(nodular) and fibrosis. According to the following sequence: INJURY DEGENERATION FIBROSIS FORMATION OF FIBRO-VASCULAR MEMBRANES PARENCHYMAL DISSECTION INTO NODULES REARRANGEMENT OF BLOOD CIRCULATION CIRRHOSISREARRANGEMENT OF BLOOD CIRCULATION CIRRHOSIS The clinical feature of cirrhosis result from hepatic cell dysfunction, portasystemic shunting or portal hypertension. The complication often appear in late phase, such as hemmorrage, hepatic encephalopathy [病因和发病机理] 1.Hepatitis virus (HBV,HCV) 2.Alcohol abuse 3. Bile duct obstruction 4. Persistent obstruction to outflow of blood from the liver (such as occurs in the Budd-Chiari syndrome) Heart and blood vessel disturbances 5.Exposure to certain chemicals Use of certain drugs 6.Hereditary disease, High blood tyrosine levels at birth (congenital tyrosinosis) Glycogen storage disease , Alpha1-antitrypsin deficiency Hereditary accumulation of too much copper (Wilson's disease) 7. Malnutrition 8.Autoimmune diseases (including autoimmune chronic hepatitis) Malnutrition 9. Iron overload (hemochromatosis) 10. Unknown (Cryptogenic) [病理] MORPHOLOGIC: Macronodular Micronodular Mixe HISTOLOGIC: Portal, Post-necrotic, Post Hepatitic, Biliary, Congestive ETIOLOGIC AGENTS: Genetic, Toxic, Infectious, Biliary, Vascular, Cryptogenic [临床表现] About one third of cirrhosis are compensated and, do not produce any clinical symptoms and are accidentally discovered during a medical examination or an operation or at autopsy. The rest are decompensated and produce complications mainly due to liver failure and portal hypertension. The two major problems that eventually cause symptoms are loss of functioning liver cells and distortion of the liver caused by scarring. decompensated 一、loss of functioning liver cells 1. General：Fatigue,Weakness, Weight loss, , Fever, 2.Gastroenterology： Poor appetite、Nausea、Abdominal fullness, gaseous,diarrha Jaundice 3.Hematology: A tendency to bleed (coagulopathy),animia,nose bleeding, Nosebleed, bleeding gums , Decreased number of red blood cells (anemia) ,Gastrointestinal bleeding from varices 4. Hormones: A. High levels of insulin but poor response to it B. Cessation of menstrual periods and decreased fertility (in women) C. Impotence and feminization (in men)Skin Spiderlike blood vessels

重庆医科大学临床学院教案讲稿制表时间：2004 年 8 月 3 Red palms (palmar erythema ) Florid complexion Itching Other Urine output, decreased Swelling, overall Blood Decreased number of red blood cells (anemia) Decreased number of white blood cells (leukopenia) Decreased number of platelets (thrombocytopenia) A tendency to bleed (coagulopathy) Portal Hypertension1.脾大 splenomegaly One of the most common findings with portal hypertension is splenomegaly, as seen here. The spleen is enlarged from the normal 300 grams or less to between 500 and 1000 gm. Varices. When blood flow through the portal vein slows, blood from the intestines and spleen backs up into blood vessels in the stomach and esophagus. These blood vessels may become enlarged because they are not meant to carry this much blood. The enlarged blood vessels, called varices, have thin walls and carry high pressure, and thus are more likely to burst. If they do burst, the result is a serious bleeding problem in the upper stomach or esophagus that requires immediate medical attention. 3. Ascitis 三．并发症 Complications 1. Bleeding esophageal varices(Variceal bleeding) Bleeding varices are a life-threatening complication of portal hypertension (increased blood pressure in the portal vein caused by liver disease. Increased pressure causes the veins to balloon outward). The vessels may rupture, causing vomiting of blood and tarry black stools. If a large volume of blood is lost, signs of shock will develop. vomitingvomiting bloodblack, tarry stoolsdecreased urine outputsymptoms of cirrhosis palenesslightheadednessHepatic encephalopathy This topic will be discussed later 3. Abdominal fluid retention (ascites) and infection of the fluid (bacterial peritonitis) 4. Liver cancer (hepatocellular carcinoma) This topic will be discussed later 5. Kidney failure (hepatorenal syndrome) Hepatorenal syndrome occurs when there is a decrease in kidney function in a person with a liver disorder. This is often exhibited by: Absent or low urine production, less than 400 cc/dayVery low urine sodium concentration Low serum sodium Fluid retention in the abdomen or extremities Increased BUN and creatinine levels 6.Dilutional hyponatremiaLab TestDecreased number of red blood cells (anemia) Decreased number of white blood cells (leukopenia) Decreased number of platelets (thrombocytopenia) A tendency to bleed (coagulopathy)liver function test Test What Is Measured What the Test May Indicate Alkaline phosphatase An enzyme produced in the liver, bone, and placenta that is released into the blood during injury Bile duct obstruction, liver injury, and some cancers Alanine transaminase (ALT) An enzyme produced in the liver that is released into the blood during injury Liver cell injury (as in hepatitis) Aspartate transaminase(AST) An enzyme released into the blood when the liver, heart, muscle, or brain is injured Injury to liver, heart, muscles, or brain Bilirubin A component of the digestive juice (bile) produced by the liver Obstruction, liver damage, excessive breakdown of red blood cells Gamma-glutamyl transpeptidase produced by the liver, pancreas, and kidneys and released into the blood when these organs are injured Organ damage, drug toxicity, alcohol abuse, disease of the pancreas Lactic An enzyme released into the blood Damage to the liver, heart

重庆医科大学临床学院教案讲稿制表时间：2004 年 8 月 4 dehydrogenase when certain organs are injured lung, or brain and excessive breakdown of RBC Albumin produced by the liver and normally released into the blood; one of it's functions is to hold fluid inside the blood vessels Liver damage Alpha-fetoprotein A protein produced by the fetal liver and testes Severe hepatitis or cancer of the liver or testes Mitochondrial antibodies Circulating antibodies against mitochondria, an inner component of cells Primary biliary cirrhosis and certain autoimmune diseases Prothrombin time Time needed for blood to clot (clotting requires vitamin K and substances made by the liver) Liver damage or poor absorption of vitamin K caused by a lack of bile Special testChild Pugh Classification 六、MANAGEMENTGeneral A.Cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. B.Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis C.corticosteroids for autoimmune hepatitis. D.In all cases, regardless of the cause, following a healthy diet and avoiding alcohol are essential because the body needs all the nutrients it can get, and alcohol will only lead to more liver damage Dietary changes that may be helpful: people with liver cirrhosis may be unable to tolerate normal amounts of dietary protein because the cirrhotic liver is less able to detoxify ammonia, a major product of protein digestion. Lifestyle changes that may be helpful: Avoidance of alcohol is strongly recommended for people with liver cirrhosis. Alcohol is directly toxic to the liver. In people with alcohol-induced liver cirrhosis, even moderate alcohol consumption increases the risk of portal hypertension, a dangerous blood pressure abnormality in the liver’s circulation. Supplements that may be helpful: Phosphatidylcholine (PC) breaks down scar tissue in the liver and may be able to reverse tissue changes that cause cirrhosis. In a placebo-controlled trial, Czech researchers found that PC supplementation improved liver function in people with cirrhosis. Management of Ascites A. A healthy diet and avoiding alcohol B. Usually combined with drugs called diuretics, which make the kidneys excrete more fluid in the urine. C. If the ascites makes breathing or eating difficult, the fluid may be removed through a needle-a procedure called therapeutic paracentesis. Often, large amounts of albumin are lost from the blood into the abdominal fluid, so albumin may be administered intravenously. E. Trans jugular intrahepatic portosystemic shunt，TIPSManagement of Coplication 4. Liver Transplantation