肝性脑病急性失代偿期肝硬化和急性-ON-慢性肝衰竭

StephenW

SUMMARY AND COMMENT | GASTROENTEROLOGY

February 12, 2015

Hepatic Encephalopathy with Acute Decompensated Cirrhosis and Acute-on- Chronic Liver Failure

Atif Zaman, MD, MPH Reviewing Romero-Gómez M et al., J Hepatol 2015 Feb 62:437

This review article stresses the importance of providing intensive care, identifying precipitating events, and administering selective treatments.
Hepatic encephalopathy (HE) is one of the major complications of cirrhosis, and recent evidence suggests that hospitalized cirrhotic HE patients with acute decompensation and, especially, acute-on-chronic liver failure (ACLF) have extremely poor outcomes (NEJM JW Gastroenterol Sep 2013 and Gastroenterology 2013; 144:1426). The current review article discusses the pathophysiology and management of such patients. Highlights are as follows:

    Although the exact mechanism of HE in these patients is unknown, systemic inflammation (from bacterial translocation, sepsis, and insulin resistance), interorgan ammonia trafficking, and oxidative stress, all modulated by glutaminase gene alteration, likely play key roles.

    Because HE in this setting is associated with substantial morbidity and mortality, patients should be admitted to an intensive care unit, and general measures such as airway, breathing, and circulation should be considered.

    Because precipitating events occur in up to 60% of patients, identifying factors such as over-diuresis, intravascular volume depletion, bacterial infections, and gastrointestinal bleeding with subsequent correction is critical.

    Specific treatments for HE that should be considered once precipitating events are addressed include the use of lactulose as well as rifaximin, not only for HE treatment but also for its possible role in gut decontamination.


In cases of refractory HE where large spontaneous portacaval shunting is present, selective embolization may be effective when possible and in the appropriate patients (MELD score of ≤11 in one study).
Comment

The authors of this thorough review emphasize the importance of identifying and treating precipitating events in hospitalized cirrhotic patients with HE in the setting of acute decompensation or ACLF. They also stress considering specific treatments such as the use of rifaximin and embolization of spontaneous portacaval shunts in select patients.

Citation(s):

    Romero-Gómez M et al. Hepatic encephalopathy in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure. J Hepatol 2015 Feb; 62:437. (http://www.journal-of-hepatology.eu/article/S0168-8278(14)00646-1/abstract)

StephenW

要及评论|胃肠病

2015年2月12日

肝性脑病急性失代偿期肝硬化和急性-ON-慢性肝衰竭

与Atif扎曼，MD，MPH回顾罗梅罗 - 戈麦斯M等，肝脏病学杂志2015年62月：437

该评论文章强调提供重症监护，确定沉淀的事件，和管理的选择性治疗的重要性。
肝性脑病（HE）是肝硬化的主要并发症之一，最近的证据表明，肝硬化住院HE例急性失代偿，特别是急性发作，慢性肝功能衰竭（ACLF）具有极其不良后果（NEJM JW Gastroenterol2013年9月和消化2013;144：1426）。当前评论文章讨论了这类患者的病理生理学和管理。要点如下：

    虽然他在这些患者的确切机制不明，全身炎症反应（从细菌移位，败血症和胰岛素抵抗），interorgan氨贩运，和氧化应激，全部由调制谷氨酰胺酶的基因改造，有可能发挥关键作用。

    因为他在此设置有大量的发病率和死亡率，患者应住进重症监护病房，和一般的措施，如气道，呼吸，循环应予以考虑。

    因为发生在患者的高达60％的沉淀事件，识别因素，如过度利尿，血管内血容量不足，细菌感染，和胃肠道，随后校正出血是非常关键的。

    因为那应该算是一次沉淀事件解决的具体治疗方法包括使用乳果糖，以及利福昔明，不仅为HE治疗，但也为肠道去污其可能的作用。


在耐火材料的情况下，他在那里大的自发门腔分流是存在的，选择性栓塞可能是有效的，当可能的，在适当的患者（≤11在一项研究中MELD评分）。
评论

这种彻底的审查的作者强调识别和治疗住院肝硬化患者HE沉淀事件急性失代偿或ACLF的设置的重要性。他们还强调在考虑具体的治疗方法，如在选择患者使用利福昔明和自发的门腔分流栓塞。

引用（S）：

    罗梅罗 - 戈麦斯M等。肝性脑病患者肝硬化和急性上慢性肝功能衰竭失代偿严重。肝脏病学杂志2015年2月; 62：437。 （http://www.journal-of-hepatology.eu/article/S0168-8278(14)00646-1/abstract）