培训课件--肝性脑病最终版.pptVIP

降氨药物： L-鸟氨酸-L门冬氨酸（OA ） 20g qd 静脉注射 鸟氨酸- ?-酮戊二酸 谷氨酸 谷氨酸钾、谷氨酸钠 精氨酸 四、促进体内氨的代谢 GABA/BZ复合受体拮抗药 氟马西尼 1mg/h持续静滴。 支链氨基酸 疗效不肯定 五、调节神经递质 改善肝功能 阻断肝外门-体分流：TIPS 人工肝 肝移植 六、基础疾病的治疗 预 后 诱因明确且易消除者预后较好 肝功能较好的门体性脑病预后较好 肝功能差者预后较差 暴发性肝功衰所致的HE预后最差 复习思考题 1.肝性脑病的常见诱因有哪些 ？ 2.肝性脑病各期的临床特点。 3.肝性脑病的诊断主要依据。 4.肝性脑病的治疗原则。 5.氨在肝昏迷的发病中对中枢的毒性作用主要有哪些？ 6.肝昏迷治疗使用乳果糖的机制是什么？ 病案分析 男性，45岁。10年前患乙型肝炎，经治疗后痊愈。近3年来常于劳累后乏力，进食后饱胀，纳差。半年来上述症状逐渐加重，腹胀、大便不成形，每日2次，无粘液和脓血。经常出现鼻和齿龈出血。近3天腹泻后出现精神状态差，反应迟钝、少言、随地便溺。2小时前始处于熟睡状态，呼之可醒，但不能正确回答问题。 辅助检查：HBsAg和HBeAg阳性。肝脏CT检查：肝脏体积缩小，肝叶比例失调，肝裂增宽，表面不平，门静脉内径1.5cm；脾厚5.7cm；腹腔中等量腹水。结果提示肝硬化、腹水。AFP 20 μg/L 。 体格检查：体温37.5℃ 脉搏78次/分 呼吸16次/分 血压15.0／8.0 kPa，嗜睡状态，压眶反射存在。面色灰暗黝黑，巩膜黄染。颈软，颈部、前胸有多个蜘蛛痣，可见肝掌。心肺检查正常。腹部呈蛙腹，肝脏右肋下未及，脾左助下4Cm，移动性浊音阳性，肠鸣音正常。腱反射亢进及肌张力增强，双手有轻微细震颤。 问题1：根据患者的病史特点，诊断什么疾病？请写出诊断依据？ 问题2：为进一步证实诊断，还需做哪些辅助检查？ 问题3：该患者使用利尿剂时的原则和注意事项有哪些？ Ammonia is detoxified in the liver mainly by synthesis of urea and glutamine. Both these detoxification pathways are arranged complementarily in the liver acini. While periportal hepatocytes have only a low affinity for ammonia detoxification through urea synthesis, glutamine synthesis occurs exclusively in a small around 5-10% of all liver parenchyma cells highly specialized cell population at the perivenous end of the liver acini. These cells perivenous scavenger cells are of particular importance for maintaining the ammonia equilibrium, as they have high affinity for removing ammonia through glutamine synthesis and therefore serve as a collection system for ammonia still not detoxified through upstream urea synthesis. In patients with cirrhosis of the liver two factors impair ammonia detoxification, resulting in hyperammonemia: - Ammonia formed in the intestine is channeled past the liver by portosystemic collateral circulation. - The urea-synthesizing capacity of the cirrhotic liver is reduced by some 80%. The same applies to its glutamine-synthesizing capacity, as cirrhosis patients have a severe scavenger-cell deficiency. Impa