肝硬化和并发症.ppt

* Figure 10-49. Although peritoneovenous shunt can improve systemic hemodynamics and sodium homeostasis, its beneficial effects are usually short lived because of the high incidence of obstruction. Morbidity and survival correlate with the degree of hepatic dysfunction. Poor prognostic indicators are nonalcoholic etiology, a Pugh score 10, an ascitic protein concentration of 15g/L and a previous history of spontaneous bacterial peritonitis [27]. Recent multicenter randomized control trials did not show the shunt to be superior to either routine medical therapy or repeated paracentesis in terms of hospital readmission rate or survival. (Adapted from Gines et al. [28].)  * Table 10-50. Peritoneovenous shunt (PVS) should be restricted to be used in patients with refractory ascites and preserved hepatic function who are not candidates for liver transplantation or who are not candidates for serial paracenteses because of distance from a physician who is willing and capable of performing paracentesis. The criteria listed in the table for patient selection for PVS are recommended for improved long-term shunt function and survival. It is likely that transjugular intrahepatic portosystemic shunt may ultimately replace PVS as a treatment of choice for refractory ascites in patients with relatively well-preserved liver and renal functions and absence of infection. (Adapted from Wong and Blendis [29].)  * Figure 10-51. Transjugular intrahepatic portosystemic shunt has been used as an alternative treatment for patients with variceal bleeding who have failed sclerotherapy. It was observed that patients who had concomitant ascites either had reduction or disappearance of their ascites. The very first transjugular intrahepatic portosystemic shunt was a venous shunt in the liver parenchyma between the portal and hepatic veins. It was initially devised to decompress the portal system as a treatment for esophageal varices. The major complication with the tissue shunt was shunt