肝性脑病中西医诊疗进展
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摘要
肝性脑病(HE)是门脉高压和肝硬化最常见的并发症,病情可从轻微的行为异常到深昏迷甚至死亡,给患者和社会都造成很大负担。肝性脑病的诊断应结合充分的病史和体格检查,目前还缺少"金标准"。该文旨在回顾现代医学和传统医学对肝性脑病的诊断和治疗进展,衷中参西,早日克服这一难题。
Hepatic encephalopathy(HE),a common complication in the progression of liver disease or portal hypertension. The condition ranges from mild behavior to deep coma and even death,which can be a great burden to both patients and society. Currently,HE is confirmed in condition of adequate medical history and physical examination and lack of"gold standard". The purpose of this article is to review the progression of diagnosis and treatment for hepatic encephalopathy in Western medicine and traditional Chinese medicine,and overcome the challenge as soon as possible.
Hepatic encephalopathy(HE),a common complication in the progression of liver disease or portal hypertension. The condition ranges from mild behavior to deep coma and even death,which can be a great burden to both patients and society. Currently,HE is confirmed in condition of adequate medical history and physical examination and lack of"gold standard". The purpose of this article is to review the progression of diagnosis and treatment for hepatic encephalopathy in Western medicine and traditional Chinese medicine,and overcome the challenge as soon as possible.
引文
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[2]高明生,李志红.肝性脑病发病机制的研究进展[J].临床合理用药杂志,2017,10(10):178-179.
[3]BustamanteJ,RimolaA,VenturaPJ,etal.Prognostic significance of hepatic encephalopathy in patients with cirrhosis[J].Journal of Hepatology,1999,30(5):890-895.
[4]Fichet J,Mercier E,Genée O,et al. Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy[J]. Journal of Critical Care,2009,24(3):364-370.
[5]Lauridsen M M,Jepsen P,Vilstrup H. Critical flicker frequency and continuous reaction times for the diagnosis of minimal hepatic encephalopathy. A comparative study of 154 patients with liver disease[J]. Me-tabolic Brain Disease,2011,26(2):135-139.
[6]Mullen K D,Prakash R K. Management of covert hepatic encephalopathy[J]. Clinics in Liver Disease,2012,16(1):91-93.
[7]Bajaj J S. Review article:the modern management of hepatic encephalopathy[J]. Alimentary Pharmacology&Therapeutics,2010,31(5):537-547.
[8]Diseases A A F O L. Corrigendum to“Hepatic encephalopathy in chronic liver disease:2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases”[J]. Journal of Hepatology,2014,61(3):642-659.
[9]FerenciP,LockwoodA,MullenK,etal.Hepatic encephalopathy—Definition,nomenclature,diagnosis,and quantification:Final report of the Working Party at the 11th World Congresses of Gastroenterology,Vienna,1998[J]. Hepatology,2002,35(3):716-721.
[10]Dharel N,Bajaj J S. Definition and Nomenclature of Hepatic Encephalopathy[J]. Journal of Clinical&Experimental Hepatology,2015,5(1):37-41.
[11]TorisGT,BikisCN,TsourouflisGS,etal.Hepatic encephalopathy:an updated approach from pathogenesis to treatment[J]. Medical Science Monitor International Medical Journal of Experimental&Clinical Research,2011,17(2):RA53-RA63.
[12]林志鹏,郭如意.乙型肝炎后肝硬化合并肝性脑病的危险因素分析[J].中国基层医药,2014,21(1):65-67.
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[15]聂鑫,贺勇,许树耘,等.血氨在急诊精神障碍患者鉴别诊断中的应用研究[J].检验医学,2013,28(1):72-76.
[16]VierlingJM,MokhtaraniM,JrBR,etal.Fasting Blood Ammonia Predicts Risk and Frequency of Hepatic Encephalopathy Episodes in Patients With Cirrhosis[J].Clinical Gastroenterology&Hepatology,2016,14(6):903-906.
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[19]孙润菲,武超,陈曦,等.轻微肝性脑病的中西医诊疗进展[J].临床肝胆病杂志,2016,32(9):1801-1805.
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[21]Kullmann F,Hollerbach S,Lock G,et al. Brain electrical activity mapping of EEG for the diagnosis of(sub)clinical hepatic encephalopathy in chronic liver disease[J]. European Journal of Gastroenterology&Hepatology,2001,13(5):513.
[22]高妙,魏伦收,汪国栋.肝性脑病患者的发病以及病情程度与其脑电图变化的关系[J].世界华人消化杂志,2014(31):4840-4843.
[23]MarchettiP,D'AvanzoC,OrsatoR,etal.Electroencephalography in patients with cirrhosis[J]. Gastroenterology,2011,141(5):1680-1689.
[24]Jackson C D,Gram M,Halliday E,et al. New spectral thresholds improve the utility of the electroencephalogram for the diagnosis of hepatic encephalopathy[J]. Clinical Neurophysiology,2016,127(8):2933-2941.
[25]Li Y,Liu H,Yang J,et al. Combining arterial-spin labeling with functional magnetic resonance imaging measurement for characterizing patients with minimal hepatic encephalopathy[J].Hepatology Research,2017,47(9):862-871.
[26]Jao T,Schr?ter M,Chen CL,et al. Functional brain network changes associated with clinical and biochemical measures of the severity of hepatic encephalopathy[J]. NeuroImage,2015,122(15):332-344.
[27]周治明,赵建农,王康程,等.基于脑皮层厚度分析在肝性脑病结构改变的研究[J].临床放射学杂志,2017,36(2):171-175.
[28]中华预防医学会微生态学分会.中国消化道微生态调节剂临床应用专家共识(2016版)[J].中华临床感染病杂志,2016,9(3):621-631.
[29]None. EASL Clinical Practical Guidelines on the management of acute(fulminant)liver failure[J]. Journal of Hepatology,2017,66(5):1047-1081.
[30]阎明,崔瑞冰.肝性脑病治疗的新进展[J].中华消化病与影像杂志(电子版),2015(2):1-3.
[31]Campillo B,Richardet J P,Scherman E,et al. Evaluation of nutritional practice in hospitalized cirrhotic patients:Results of a prospective study[J]. Nutrition,2003,19(6):515-521.
[32]Amodio P,Bemeur C,Butterworth R,et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis:International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus.[J]. Hepatology,2013,58(1):325-336.
[33]Simonsen K,Rode A,Nicoll A,et al. Vitamin B12 and its binding proteins in hepatocellular carcinoma and chronic liver diseases[J]. Scandinavian Journal of Gastroenterology,2014,49(9):1-7.
[34]GluudLL,VilstrupH,MorganMY.Non-absorbable disaccharides versus placebo/no intervention and lactulose versus lactitol for the prevention and treatment of hepatic encephalopathy in people with cirrhosis[J]. Cochrane Database of Systematic Reviews,2016,4(4):34-36.
[35]MorganMY.Currentstateofknowledgeofhepatic encephalopathy(part III):non-absorbable disaccharides[J].Metabolic Brain Disease,2016,31(6):1361-1364.
[36]Als-Nielsen B,Gluud L L,Gluud C. 204 Nonabsorbable disaccharides for hepatic encephalopathy:A systematic review of randomised trials[J]. Journal of Hepatology,2004,40(4):66-66.
[37]Mendes Natália Ferreira,Mariotti F F N,de Andrade JoséSimoes,et al. Lactulose decreases neuronal activation and attenuates motor behavioral deficits in hyperammonemic rats[J].Metabolic Brain Disease,2017,32:2073-2083.
[38]YangN,LiuH,JiangY,etal.Lactuloseenhances neuroplasticity to improve cognitive function in early hepatic encephalopathy[J]. Neural Regeneration Research,2015,10(9):1457-1462.
[39]SarangiAN,GoelA,SinghA,etal.Faecalbacterial microbiota in patients with cirrhosis and the effect of lactulose administration[J]. Bmc Gastroenterology,2017,17(1):125.
[40]Rahimi R S,Singal A G,Cuthbert J A,et al. Lactulose vs polyethylene glycol 3350--electrolyte solution for treatment of overt hepatic encephalopathy:the HELP randomized clinical trial[J]. Jama Internal Medicine,2014,174(11):1727-1733.
[41]Peleman C,Camilleri M. Rifaximin,Microbiota Biology,and Hepatic Encephalopathy[J]. Clinical&Translational Gastroenterology,2016,7(10):e195.
[42]Kowdley K V,Burman B E. ACP Journal Club. Adding rifaximin to lactulose increased reversal and decreased mortality in hepatic encephalopathy[J]. Annals of Internal Medicine,2013,159(8):JC8.
[43]Hawkins R A,Jessy J,Mans A M,et al. Neomycin reduces the intestinal production of ammonia from glutamine[J]. Oxygen Transport to Tissue XXXIII,1994,368:125-134.
[44]中华预防医学会微生态学分会,李兰娟.中国消化道微生态调节剂临床应用共识(2016版)[J].中国实用内科杂志,2016,28(10):621-631.
[45]Zhao L N,Yu T,Lan S Y,et al. Probiotics can improve the clinical outcomes of hepatic encephalopathy:An update meta-analysis.[J]. Clinics&Research in Hepatology&Gastroenterology,2015,39(6):674-682.
[46]Horvath A,Leber B,Schmerboeck B,et al. Randomised clinical trial:the effects of a multispecies probiotic vs. placebo on innate immune function,bacterial translocation and gut permeability in patients with cirrhosis[J]. Alimentary Pharmacology&Therapeutics,2016,44(9):926-935.
[47]Rahimi R S,Rockey D C. Novel Ammonia-Lowering Agents for Hepatic Encephalopathy[J]. Clinics in Liver Disease,2015,19(3):539-549.
[48]Berry S A,Longo N,Diaz G A,et al. Safety and efficacy of glycerol phenylbutyrate for management of urea cycle disorders in patients aged 2,months to 2,years[J]. Molecular Genetics and Metabolism,2017,122(3):46-53.
[49]Bajaj J S,Kassam Z,Fagan A,et al. Fecal Microbiota Transplant from a Rational Stool Donor Improves Hepatic Encephalopathy:A Randomized Clinical Trial[J]. Hepatology,2017,66:1727-1738.
[50]Wang W W,Zhang Y,Huang X B,et al. Fecal microbiota transplantation prevents hepatic encephalopathy in rats with carbon tetrachloride-induced acute hepatic dysfunction[J].World Journal of Gastroenterology,2017,23(38):6983-6994.
[51]于冰雪,吴健林,吴继周,等.血浆置换对肝性脑病患者血锰水平的影响[J].临床肝胆病杂志,2015,31(8):1311-1313.
[52]何小凤,罗玲,袁春兰,等.两种人工肝方法治疗重型乙型肝炎的近期疗效对比分析[J].重庆医学,2017,46(18):2475-2477.
[53]张洪斌,邓华亮,艾邸.肝性脑病的中医研究进展[J].实用中医内科杂志,1997(3):16-18.
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[56]万凌峰.邵铭主任医师辨证论治肝性脑病经验[J].成都中医药大学学报,2010,33(3):38-44.
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[2]高明生,李志红.肝性脑病发病机制的研究进展[J].临床合理用药杂志,2017,10(10):178-179.
[3]BustamanteJ,RimolaA,VenturaPJ,etal.Prognostic significance of hepatic encephalopathy in patients with cirrhosis[J].Journal of Hepatology,1999,30(5):890-895.
[4]Fichet J,Mercier E,Genée O,et al. Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy[J]. Journal of Critical Care,2009,24(3):364-370.
[5]Lauridsen M M,Jepsen P,Vilstrup H. Critical flicker frequency and continuous reaction times for the diagnosis of minimal hepatic encephalopathy. A comparative study of 154 patients with liver disease[J]. Me-tabolic Brain Disease,2011,26(2):135-139.
[6]Mullen K D,Prakash R K. Management of covert hepatic encephalopathy[J]. Clinics in Liver Disease,2012,16(1):91-93.
[7]Bajaj J S. Review article:the modern management of hepatic encephalopathy[J]. Alimentary Pharmacology&Therapeutics,2010,31(5):537-547.
[8]Diseases A A F O L. Corrigendum to“Hepatic encephalopathy in chronic liver disease:2014 Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases”[J]. Journal of Hepatology,2014,61(3):642-659.
[9]FerenciP,LockwoodA,MullenK,etal.Hepatic encephalopathy—Definition,nomenclature,diagnosis,and quantification:Final report of the Working Party at the 11th World Congresses of Gastroenterology,Vienna,1998[J]. Hepatology,2002,35(3):716-721.
[10]Dharel N,Bajaj J S. Definition and Nomenclature of Hepatic Encephalopathy[J]. Journal of Clinical&Experimental Hepatology,2015,5(1):37-41.
[11]TorisGT,BikisCN,TsourouflisGS,etal.Hepatic encephalopathy:an updated approach from pathogenesis to treatment[J]. Medical Science Monitor International Medical Journal of Experimental&Clinical Research,2011,17(2):RA53-RA63.
[12]林志鹏,郭如意.乙型肝炎后肝硬化合并肝性脑病的危险因素分析[J].中国基层医药,2014,21(1):65-67.
[13]中华医学会消化病学分会.中国肝性脑病诊治共识意见(2013年,重庆)[J].中华消化杂志,2013,6(9):81-93.
[14]Kramer L,Tribl B,Gendo A,et al. Partial pressure of ammonia versus ammonia in hepatic encephalopathy[J]. Hepatology,2000,31(1):30-34.
[15]聂鑫,贺勇,许树耘,等.血氨在急诊精神障碍患者鉴别诊断中的应用研究[J].检验医学,2013,28(1):72-76.
[16]VierlingJM,MokhtaraniM,JrBR,etal.Fasting Blood Ammonia Predicts Risk and Frequency of Hepatic Encephalopathy Episodes in Patients With Cirrhosis[J].Clinical Gastroenterology&Hepatology,2016,14(6):903-906.
[17]龙莉.肝性脑病患者血氨水平相关因素分析[D].南昌:南昌大学,2013.
[18]V Bhatia,R Singh,S K Acharya. Predictive value of arterial ammonia for complications and outcome in acute liver failure[J].Gut,2006,55(1):98-104.
[19]孙润菲,武超,陈曦,等.轻微肝性脑病的中西医诊疗进展[J].临床肝胆病杂志,2016,32(9):1801-1805.
[20]Andrés Duarte-Rojo,JoséEstradas,Roberto HernándezRamos,etal.ValidationofthePsychometricHepatic Encephalopathy Score(PHES)for Identifying Patients with Minimal Hepatic Encephalopathy[J]. Digestive Diseases&Sciences,2011,56(10):3014-3023.
[21]Kullmann F,Hollerbach S,Lock G,et al. Brain electrical activity mapping of EEG for the diagnosis of(sub)clinical hepatic encephalopathy in chronic liver disease[J]. European Journal of Gastroenterology&Hepatology,2001,13(5):513.
[22]高妙,魏伦收,汪国栋.肝性脑病患者的发病以及病情程度与其脑电图变化的关系[J].世界华人消化杂志,2014(31):4840-4843.
[23]MarchettiP,D'AvanzoC,OrsatoR,etal.Electroencephalography in patients with cirrhosis[J]. Gastroenterology,2011,141(5):1680-1689.
[24]Jackson C D,Gram M,Halliday E,et al. New spectral thresholds improve the utility of the electroencephalogram for the diagnosis of hepatic encephalopathy[J]. Clinical Neurophysiology,2016,127(8):2933-2941.
[25]Li Y,Liu H,Yang J,et al. Combining arterial-spin labeling with functional magnetic resonance imaging measurement for characterizing patients with minimal hepatic encephalopathy[J].Hepatology Research,2017,47(9):862-871.
[26]Jao T,Schr?ter M,Chen CL,et al. Functional brain network changes associated with clinical and biochemical measures of the severity of hepatic encephalopathy[J]. NeuroImage,2015,122(15):332-344.
[27]周治明,赵建农,王康程,等.基于脑皮层厚度分析在肝性脑病结构改变的研究[J].临床放射学杂志,2017,36(2):171-175.
[28]中华预防医学会微生态学分会.中国消化道微生态调节剂临床应用专家共识(2016版)[J].中华临床感染病杂志,2016,9(3):621-631.
[29]None. EASL Clinical Practical Guidelines on the management of acute(fulminant)liver failure[J]. Journal of Hepatology,2017,66(5):1047-1081.
[30]阎明,崔瑞冰.肝性脑病治疗的新进展[J].中华消化病与影像杂志(电子版),2015(2):1-3.
[31]Campillo B,Richardet J P,Scherman E,et al. Evaluation of nutritional practice in hospitalized cirrhotic patients:Results of a prospective study[J]. Nutrition,2003,19(6):515-521.
[32]Amodio P,Bemeur C,Butterworth R,et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis:International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus.[J]. Hepatology,2013,58(1):325-336.
[33]Simonsen K,Rode A,Nicoll A,et al. Vitamin B12 and its binding proteins in hepatocellular carcinoma and chronic liver diseases[J]. Scandinavian Journal of Gastroenterology,2014,49(9):1-7.
[34]GluudLL,VilstrupH,MorganMY.Non-absorbable disaccharides versus placebo/no intervention and lactulose versus lactitol for the prevention and treatment of hepatic encephalopathy in people with cirrhosis[J]. Cochrane Database of Systematic Reviews,2016,4(4):34-36.
[35]MorganMY.Currentstateofknowledgeofhepatic encephalopathy(part III):non-absorbable disaccharides[J].Metabolic Brain Disease,2016,31(6):1361-1364.
[36]Als-Nielsen B,Gluud L L,Gluud C. 204 Nonabsorbable disaccharides for hepatic encephalopathy:A systematic review of randomised trials[J]. Journal of Hepatology,2004,40(4):66-66.
[37]Mendes Natália Ferreira,Mariotti F F N,de Andrade JoséSimoes,et al. Lactulose decreases neuronal activation and attenuates motor behavioral deficits in hyperammonemic rats[J].Metabolic Brain Disease,2017,32:2073-2083.
[38]YangN,LiuH,JiangY,etal.Lactuloseenhances neuroplasticity to improve cognitive function in early hepatic encephalopathy[J]. Neural Regeneration Research,2015,10(9):1457-1462.
[39]SarangiAN,GoelA,SinghA,etal.Faecalbacterial microbiota in patients with cirrhosis and the effect of lactulose administration[J]. Bmc Gastroenterology,2017,17(1):125.
[40]Rahimi R S,Singal A G,Cuthbert J A,et al. Lactulose vs polyethylene glycol 3350--electrolyte solution for treatment of overt hepatic encephalopathy:the HELP randomized clinical trial[J]. Jama Internal Medicine,2014,174(11):1727-1733.
[41]Peleman C,Camilleri M. Rifaximin,Microbiota Biology,and Hepatic Encephalopathy[J]. Clinical&Translational Gastroenterology,2016,7(10):e195.
[42]Kowdley K V,Burman B E. ACP Journal Club. Adding rifaximin to lactulose increased reversal and decreased mortality in hepatic encephalopathy[J]. Annals of Internal Medicine,2013,159(8):JC8.
[43]Hawkins R A,Jessy J,Mans A M,et al. Neomycin reduces the intestinal production of ammonia from glutamine[J]. Oxygen Transport to Tissue XXXIII,1994,368:125-134.
[44]中华预防医学会微生态学分会,李兰娟.中国消化道微生态调节剂临床应用共识(2016版)[J].中国实用内科杂志,2016,28(10):621-631.
[45]Zhao L N,Yu T,Lan S Y,et al. Probiotics can improve the clinical outcomes of hepatic encephalopathy:An update meta-analysis.[J]. Clinics&Research in Hepatology&Gastroenterology,2015,39(6):674-682.
[46]Horvath A,Leber B,Schmerboeck B,et al. Randomised clinical trial:the effects of a multispecies probiotic vs. placebo on innate immune function,bacterial translocation and gut permeability in patients with cirrhosis[J]. Alimentary Pharmacology&Therapeutics,2016,44(9):926-935.
[47]Rahimi R S,Rockey D C. Novel Ammonia-Lowering Agents for Hepatic Encephalopathy[J]. Clinics in Liver Disease,2015,19(3):539-549.
[48]Berry S A,Longo N,Diaz G A,et al. Safety and efficacy of glycerol phenylbutyrate for management of urea cycle disorders in patients aged 2,months to 2,years[J]. Molecular Genetics and Metabolism,2017,122(3):46-53.
[49]Bajaj J S,Kassam Z,Fagan A,et al. Fecal Microbiota Transplant from a Rational Stool Donor Improves Hepatic Encephalopathy:A Randomized Clinical Trial[J]. Hepatology,2017,66:1727-1738.
[50]Wang W W,Zhang Y,Huang X B,et al. Fecal microbiota transplantation prevents hepatic encephalopathy in rats with carbon tetrachloride-induced acute hepatic dysfunction[J].World Journal of Gastroenterology,2017,23(38):6983-6994.
[51]于冰雪,吴健林,吴继周,等.血浆置换对肝性脑病患者血锰水平的影响[J].临床肝胆病杂志,2015,31(8):1311-1313.
[52]何小凤,罗玲,袁春兰,等.两种人工肝方法治疗重型乙型肝炎的近期疗效对比分析[J].重庆医学,2017,46(18):2475-2477.
[53]张洪斌,邓华亮,艾邸.肝性脑病的中医研究进展[J].实用中医内科杂志,1997(3):16-18.
[54]钱普明.肝昏迷从毒辨治研探[J].浙江中医杂志,1997(2):56-57.
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