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2004-11-22Hepatology 2004;39(3):841-856
推荐意见所基于的证据分级
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1、 腹腔穿刺的指征
1. 有临床明显新出现腹水的住院和门诊病人应该接受腹腔穿刺术并留取腹水液（Ⅱ-3）。
2. 因为出血的可能性很小，所以不推荐在腹水穿刺前预防性的应用新鲜冰冻血浆或血小板（Ⅲ）。
2、 腹水化验检查
3. 初步的腹水实验室检查应包括腹水细胞计数和分类，腹水总蛋白和血清－腹水白蛋白梯度（SAAG，即血清－腹水白蛋白梯度＝血清白蛋白g/L－腹水白蛋白g/L）（Ⅱ-2）。
4. 如果怀疑腹水有感染，应在床旁用血培养瓶进行腹水培养（Ⅱ-2）。
5. 为证实所怀疑的可能疾病，可进行其它检查（Ⅲ）。
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3、 腹水的治疗
6. 如果考虑腹水病人的肝损害与酒精性损伤有关，应戒酒（Ⅱ-2）。
7. 肝硬化腹水病人的一线治疗包括限钠【88mmol/d（2000mg/d）】和利尿(口腹螺内酯和呋噻米)（Ⅰ）。
8. 除非血钠低于120～125mmol/L，限水并不是必须的（Ⅲ）。
9. 对于腹水张力很大的病人，可先进行治疗性腹腔穿刺术。随后限纳和口腹利尿药（Ⅲ-3）。
10. 对利尿剂敏感的病人应采用限纳和口腹利尿药治疗，而不是系列穿刺放腹水治疗（Ⅲ）。
11. 有腹水的肝硬化病人应考虑进行肝移植治疗（Ⅱ-3）。
4、 顽固性腹水的治疗
【顽固性腹水的定义：对限制钠的摂入和大剂量的利尿剂【螺内酯（400mg/d）和呋噻米（160mg/d）】无效的腹水，或者治疗性腹穿放腹水后很快复发；利尿治疗失败表现为：（1）应用利尿剂但体重降低很少或无降低，同时尿钠的排出低于78mmol/d。或者（2）利尿剂导致有临床意义的并发症，如肝性脑病、血肌酐>2.0mg/dL、血钠<120mmol/L或血清钾>6.0mmol/L.】
12. 对顽固性腹水的病人可行系列治疗性腹腔穿刺术（Ⅲ）。
13. 一次放腹水量如果小于4～5升，在腹腔穿刺后可不必输注白蛋白。如果大量放腹水，可每放1升腹水输注8～10g白蛋白（Ⅱ-2）。
14. 有难治性腹水的病人要尽快转诊进行肝移植治疗（Ⅱ-3）。
15. 与已发表的随机临床试验中的入选标准相符的病人可考虑行TIPS治疗（Ⅰ）。
16. 不能行穿刺、肝移植或TIPS的病人可考虑腹腔静脉分流术（Ⅰ）。
5、 肝肾综合征的治疗
肝肾综合征（HRS）的主要诊断标准：
（1） 慢性或急性肝病伴有严重的门脉高压。
（2） 肾小球滤过率降低，如血清肌酐>1.5mg/dL，或24小时肌酐清除率<40ml/min。
（3） 无休克、细菌感染及近期肾毒性药物使用史，无胃肠道液体丢失或肾脏液体丢失。
（4） 停用利尿剂并给1.5L等张盐水扩容后无持续肾功能改善（血肌酐降低到≤1.5mg/dL，或肌酐清除率<40ml/dL）。
（5） 蛋白尿<500mg/d，且超声检查示无尿路梗阻及肾实质改变。
HRS分型：
HRS-Ⅰ型：是指肝硬化患者突然发生急性进展的肾功能衰竭，在2周内血清肌酐倍增达到2.5mg/dL以上，或肌酐清除率倍减达到20ml/min以下。
HRS-Ⅱ型：进展较慢，达不到HRS-I型标准者。
17. 可应用白蛋白和血管活性药物如奥曲肽和米多君（Midodrine）联合治疗I型HRS（Ⅱ-1）。
18. 有肝硬化、腹水和I型HRS的病人应该尽快转诊进行肝移植手术治疗（Ⅱ-3）。
6、 自发性细菌性腹膜炎
自发性细菌性腹膜炎（SBP）的诊断标准：腹水培养阳性且腹水中中性粒细胞计数升高（>250/mm3），且没有腹腔内的、可手术治疗的感染来源。
19. 有腹水的住院病人都要进行腹腔穿刺术检查。一旦提示有腹水感染的症状、体征和实验室检查异常（如：腹痛或肌紧张、发热、肝性脑病、肾衰、酸中毒或外周血白细胞增多）的病人应重复进行腹腔穿刺术检查（无论是否住院病人）（Ⅲ）。
20. 腹水中性粒细胞计数<250/mm3（0.25*109/L），但有感染的症状或体征(如体温大于37.3度或腹痛或腹肌紧张)的病人，也要接受经验性抗感染治疗，如静脉注射头孢噻肟2g，q8h，同时等待腹水培养的结果（Ⅰ）。
21. 腹水中性粒细胞计数>250/mm3（0.25*109/L）的病人应该接受经验性抗感染治疗，如静脉注射头孢噻肟2g，q8h（Ⅱ-3）。
22. 如果肝硬化病人的腹水中性粒细胞结数≥250/mm3（0.25*109/L），还要行腹水总蛋白、LDH、糖和革兰染色检查，以鉴别自发性细菌性腹膜炎（SBP）和继发性感染（Ⅰ）。
23. 在没有呕吐、休克、2级以上肝性脑病或血清肌酐>3mg/dL的住院病人，口腹氧氟沙星（400mg，bid）可替代静脉注射头孢噻肟（Ⅱ-2）。
24. 对腹水中性粒细胞数≥250/mm3（0.25*109/L），并有临床症状提示为SBP的病人，可在诊断后6小时内应用白蛋白1.5g/kg体重，并在第3天给予白蛋白1.0g/kg（Ⅰ）。
7、 预防自发性细菌性腹膜炎
25. 对有肝硬化和胃肠道出血的住院病人短期≤7天，应用诺氟沙星（或甲氧苄啶/磺胺甲基异噁唑）每天两次，有助于预防感染；当病人有活动性出血的时候，可静脉应用喹诺酮类抗生素治疗（Ⅰ）。
26. 一次SBP发作后存活下来的病人应该接受每天诺氟沙星（或甲氧苄啶/磺胺甲基异噁唑）的长期预防性治疗，因为经过大量数据证实这是对非住院病人有效的预防方法（Ⅰ）。
27. 有肝硬化和腹水但没有胃肠道出血的病人，当腹水白蛋白≤10g/L或血清胆红素>2.5mg/dL的时候，无论是短期（住院病人）还是长期每天应用诺氟沙星（甲氧苄啶/磺胺甲基异噁唑）都是合理的（Ⅰ）。
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Abdominal Paracentesis
Recommendations
1. Abdominal paracentesis should be performed and ascitic fluid should be obtained from inpatients and outpatients with clinically apparent new-onset ascites. (Grade II-3)
2. Since bleeding is sufficiently uncommon, the prophylactic use of fresh frozen plasma or platelets before paracentesis is not recommended. (Grade III)
Ascitic Fluid AnalysisRecommendations
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3. The initial laboratory investigation of ascitic fluid should include an ascitic fluid cell count and differential, ascitic fluid total protein, and SAAG. (Grade II-2)
4. If ascitic fluid infection is suspected, ascitic fluid should be cultured at the bedside in blood culture bottles. (Grade II-2)
5. Other studies can be ordered based on pretest probability of disease (Table 2). (Grade III)
Treatment of AscitesRecommendations
6. Patients with ascites who are thought to have an alcohol component to their liver injury should abstain from alcohol consumption. (Grade II-2)
7. First-line treatment of patients with cirrhosis and ascites consists of sodium restriction (88 mmol per day [2000 mg per day]) and diuretics (oral spironolactone and furosemide). (Grade I)
8. Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L. (Grade III)
9. An initial therapeutic abdominal paracentesis should be performed in patients with tense ascites. Sodium restriction and oral diuretics should then be initiated. (Grade II-3)
10. Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses. (Grade III)
11. Liver transplantation should be considered in patients with cirrhosis and ascites. (Grade II-3)
Refractory Ascites
Refractory ascites is defined as fluid overload that (1) is unresponsive to sodium-restricted diet and high-dose diuretic treatment (400 mg per day of spironolactone and 160 mg per day furosemide), or (2) recurs rapidly after therapeutic paracentesis. Failure of diuretic therapy may bemanifested by (1) minimal to no weight loss together with inadequate (_78 mmol per day) urinary sodium excretion despite diuretics, or (2) development of clinically significant complications of diuretics, e.g., encephalopathy, serum creatinine greater than 2.0 mg/dL, serum sodium less than 120 mmol/L, or serum potassium greater than 6.0 mmol/L.
Recommendations
12. Serial therapeutic paracenteses may be performed in patients with refractory ascites. (Grade III)
13. Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. For large-volume paracenteses, an albumin infusion of 8 to 10 g per liter of fluid removed can be considered. (Grade II-2)
14. Referral for liver transplantation should be expedited in patients with refractory ascites. (Grade II-3)
15. TIPS should be considered in appropriately selected patients who meet criteria similar to those of published randomized trials. (Grade I)
16. Peritoneovenous shunt should be considered for patients with refractory ascites who are not candidates for paracenteses, transplant, or TIPS. (Grade I)
Hepatorenal Syndrome
Major criteria include (1) advanced chronic or acute liver failure with portal hypertension; (2) serum creatinine greater than 1.5 mg/dL or 24-hour creatinine clearance less than 40 mL per minute; (3) absence of shock, ongoing bacterial infection, recent treatment with nephrotoxic
drugs, or massive gastrointestinal or renal fluid losses; (4) no sustained improvement in renal function following diuretic withdrawal and expansion of plasma volume with 1.5 L of isotonic saline; and (5) less than 500 mg/dL proteinuria and no ultrasonographic evidence of obstructive uropathy or parenchymal kidney disease.
Two types of hepatorenal syndrome have been described. Type I is characterized by rapidly progressive reduction in renal function as defined by a doubling of the initial serum creatinine to a level greater that 2.5 mg/dL or a 50% reduction of the initial 24-hour creatinine clearance to a level lower that 20 mL per minute in less that 2 weeks; type II does not have a rapidly progressive course.
Recommendations
17. Albumin infusion plus administration of vasoactive drugs such as octreotide and midodrine should be considered in the treatment of type I hepatorenal syndrome.
(Grade II-1)
18. Patients with cirrhosis, ascites, and type I hepatorenal syndrome should have an expedited referral for liver transplantation. (Grade II-3)
Spontaneous Bacterial Peritonitis
The diagnosis of spontaneous bacterial peritonitis (SBP) is made when there is a positive ascitic fluid bacterial culture and an elevated ascetic fluid absolute PMN count (i.e.,≥250 cells/mm3 [0.25 x 109/L]) without an evident intra-abdominal, surgically treatable source of infection.
Recommendations
19. Patients with ascites admitted to the hospital should undergo abdominal paracentesis. Paracentesis should be repeated in patients (whether in the hospital or not) who develop signs or symptoms or laboratory abnormalities suggestive of infection (e.g., abdominal pain or
tenderness, fever, encephalopathy, renal failure, acidosis, or peripheral leukocytosis). (Grade III)
20. Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 (0.25 _ 109/L) should receive empiric antibiotic therapy, e.g., intravenous cefotaxime 2 g every 8 hours. (Grade I)
21. Patients with ascitic fluid PMN counts less than 250 cells/mm3 (0.25 _ 109/L) and signs or symptoms of infection (temperature_100°F or abdominal pain or tenderness) should also receive empiric antibiotic therapy, e.g., intravenous cefotaxime 2 g every 8 hours, while
awaiting results of cultures. (Grade II-3)
22. When the ascitic fluid of a patient with cirrhosis is found to have a PMN count greater than or equal to 250 cells/mm3 (0.25_109/L), it should also be tested for total protein, LDH, glucose, and Gram’s stain to assist with the distinction of SBP from secondary peritonitis. (Grade II-2).
23. Oral ofloxacin (400 mg twice per day.) can be considered a substitute for intravenous cefotaxime in inpatients without vomiting, shock, grade II (or higher) hepatic encephalopathy, or serum creatinine greater than 3 mg/dL. (Grade I) 24. Patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 (0.25 _ 109/L) and clinical suspicion of SBP should receive 1.5 g albumin per kg body weight within 6 hours of detection and 1.0 g/kg on day 3. (Grade I)
Prevention of SBPRecommendations
25. Short-term (7 days) inpatient twice-daily norfloxacin (or trimethoprim/ sulfamethoxazole) should be given to prevent bacterial infections in patients with cirrhosis and gastrointestinal hemorrhage; a quinolone antibiotic can be given intravenously while the patient is actively bleeding. (Grade I)
26. Patients who have survived an episode of SBP should receive long-term prophylaxis with daily norfloxacin (or trimethoprim/sulfamethoxazole) because this is the most data-supported indication for long-term outpatient prophylaxis. (Grade I)
27. In patients with cirrhosis and ascites but no gastrointestinal bleeding, either short-term (inpatient-only) or long-term outpatient use of daily norfloxacin (or trimethoprim/
sulfamethoxazole) can be justified when the ascitic fluid total protein is less than or equal to 1g/dL) or serum bilirubin greater than 2.5 mg/dL. (Grade I)
[此贴子已经被作者于2005-6-23 14:35:21编辑过]
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发表于 2005-6-24 03:30
