摘要
目的 腹水指游离液体在腹腔内的病理性积聚，是内科常见的症状，可由多种疾病引起。传统方法以腹水蛋白总量(ascitic fluid total protein，AFTP)将腹水分为渗出液和漏出液，AFTP≥25g／L为渗出液，＜25g／L为漏出液。界限划分基于腹水是炎症或肿瘤腹膜浸润形成渗出，或是由于Starling力的平衡而漏出至腹腔液体形成腹水的理论概念。然而，通过大量临床观察发现，渗-漏出液概念存在很多问题和异议，许多感染性、癌性病人的腹水总蛋白浓度在漏出液范围内，而一些肝硬化、心源性腹水、Budd-Chiari综合征患者腹水总蛋白较高。另外，由2种或2种以上病因导致的混合性腹水，也无法通过AFTP进行正确划分。因此，长期以来致使腹水的鉴别诊断一直是临床上一个困扰的问题。自从1978年Hoefs提出血清腹水白蛋白梯度(Serum-ascites albumin gradient，SAAG)的概念以来，国外学者相继研究表明SAAG与门静脉压力密切相关，被认为是区分门脉高压性腹水和非门脉高压性腹水的可靠指标，准确性达95％以上。目前SAAG检测及其临床价值已被国外学者肯定并载入专业教科书中。但是在我国绝大多数医院和临床生化室仍沿用传统的一套渗—漏出液常规检查方法，显然落后于时代的概念。本研究的目的一是验证SAAG在腹水鉴别中的优越性，二是唤醒广大临床医生和生化工作者的注意，缩小与国外在这方面的差距。本研究国内尚未见临床系统资料报道。
材料与方法 收集郑州大学第一附属医院2003年3月到2004年4月住院及门诊的腹水患者共99例，男69例，女30例，年龄18～89岁，其中失代偿期肝硬化61例(肝炎后肝硬化56例，酒精性肝硬化5例)，腹腔恶性肿瘤18例(其中伴肝转移者9例)，结核性腹膜炎9例，Budd-Chiari综合征5例，肾病综合征3例，右
郑州大学ZIX鸿届硕士研究生毕业论文
血清腹水白蛋白梯度和渗一漏出液概念临床价值的比较
心功能不全3例。根据临床体征(胸腹壁静脉曲张、脾肿大、腹水)和腹部B超
检查结果(脾大、门静脉宽>13rn刃。、脾静脉宽>7。)分为门脉高压性腹水和非
「1脉高压性腹水两组。全部病人在就诊时同一天分别抽取血清、腹水检测血清、
腹水总蛋白，血清、腹水白蛋白，血清、腹水胆红素和腹水细胞计数、比重。SAAG
是血清白蛋白减去腹水白蛋白值，即SAAG=血清白蛋白(岁L)一腹水白蛋白(岁L)。
sAAG)n留L表明存在门脉高压，sAAG<11岁L为非门脉高压。最后分析比较基
于SAAG的腹水分类方法与传统渗一漏出液的分类方法在腹水病因鉴别诊断中存
在的偏差。统计学处理应用sPSS10一统计软件，取p<0.05为显著性差异。
结果
1.门脉高压组和非门脉高压组SAAG值分别为21 .6处5.24和9.材士4.20，门
脉高压组明显高于非门脉高压组，两组之间比较差异有显著性(p<0.001)。
2.门脉高压组78例中有76例SAAG)11岁L，21例非门脉高压组中有18例
sAAG 为渗出液和漏出液两组，各项指标诊断准确率分别为腹水总蛋白79.8%、腹水血清
总蛋白比值83.8%、腹水白蛋白78.8%、腹水血清胆红素比值74.7%、腹水细胞数
68.7%。SAAG的诊断准确率明显高于其它各项指标的诊断准确率，差异具有显著
性(夕<0.05)。
3.不伴肝转移的腹腔恶性肿瘤组和结核性腹膜炎组SAAG值分别为9.73士2.60
和9.98士5.72，两组之间比较差异无显著性勿习.05)。两组AFTP值分别为38.5壮9.68
和45.0见9.53，两组之间比较差异无显著性勿>0 .05)。
4.肝硬化组和伴肝转移的腹腔恶性肿瘤组SAAG分别为22.23士5.16和
19.40士4.68，两组之间比较差异无显著性伽习.05)。两组冉于Tp值分别为n.85士9.96
和34.06士14.90，两组之间比较差异有显著性(p<0.01)。
结论
1.门脉高压组SAAG值显著高于非门脉高压组，表明SAAG可以作为腹水病
因分类的指标，将腹水分为门脉高压性和非门脉高压性。
2.不伴肝转移的腹腔恶性肿瘤组和结核性腹膜炎组SAAG值比较差异无显著
性，两组均不存在门脉高压，表明SAAG对鉴别不伴肝转移的腹腔恶性肿瘤和结
核性腹膜炎无意义。
3.比较肝硬化组和伴肝转移的腹腔恶性肿瘤组SAAG值差异无显著性，提示
郑州大学2004届硕士研究生毕业论文
血清腹水白蛋白梯度和渗一漏出液概念临床价值的比较
伴肝转移的腹腔恶性肿瘤存在门脉高压，SAAG对肝硬化和伴肝转移的腹腔恶性
肿瘤的鉴别无意义。
4.SAAG的诊断准确率明显高于其它各项指标的诊断准确率，由于SAAG
对腹水病因的鉴别诊断意义远远优于传统的由AfTP规定的渗一漏出概念，根据
SAAG将腹水分为门脉高压性或非门脉高压性，将有助于提示其相应的病因。
SAAG应取代AFTP规定的渗一漏出概念，作为腹水分类的首选指标。
Objectivel Ascites is pathologic accumulation of fluid within the peritoneal cavity. It is a familiar symptom and can be caused by various diseases. Traditionally, the ascetic fluid total protein concentration (AFTP) has been used to classify specimens into broad categories of exudative or transudative samples were classified as exudates if the AFTP was 25 g/L or more and as transudates if the AFTP was less than 25 g/L. This exudate-transudate concept was based on the assumption that fluid that formed by "exudation" from an inflamed or tumor-laden peritoneal surface was high in protein. Fluid that "transuded" from a normal peritoneal surface because of imbalance of Starling force. By lots of clinical observations, many problems and exceptions have been noted, however, with the exudate-transudate concept. Many infected or malignancy-related samples have been reported to have protein concentration in the transudate rang, and many samples obtained from patients with cirrhosis, heart failure or Budd-Chiari syndr
ome have had concentration in the exudate rang. Also the exudate-transudate concept makes no provision for those patients who have "mixed" ascites which have two cause or more of ascites formation. So the differential diagnosis of ascites remains a clinical problem. Since Hoefs brought forward serum ascites albumin gradient (SAAG) in 1978,many investigators have demonstrated that SAAG
derectly correlated with portal pressure and was considered to be a credible parameter identifying portal hypertension and nonportal hypertension. Diagnostic accuracy of SAAG was or more 95%. Recently, importantce and clinical value of SAAG was accepted by many scholars overseas and recorded in professional textbook. The traditional methods based on exudate-transudate concept was obviously lagged the time, but it was also applied in most of our hospital and clinical biochemical laboratory. The aims of our study, on the one hand was to confirme the priority of SAAG as a parameter identifying the ascitec fluid cause, on the other hand, the research could attract attention of clinical and biochemical worker and shrink the gap between home and abroad.
Materials and methods: Ninety-nine patients with ascites admitted to the first affitiated hospital Zheng Zhou University during the period between march 2003 and April 2004. The series consisted of 99 patients (69 men and 30 women; age range, 18 to 89 years). Patients with ascites included 61 patients with decompensated cirrhosis(posthepatitic cirrhosis in 56; alcoholic cirrhosis in 5), 18 patients with malignancy(9 malignancy with liver involvement), 9 patients with tuberculous peritonitis,5 patients with Budd-Chiari syndrome, 3 patients with heart failure, 3 patients with nephritic syndrome. In accordance with clinical sign(thoraco-abdominal wall varicosis,splenomegaly,ascitic fluid) and abdominal ultrasonography(splenomegaly, portal vein > 13mm, splenic vein > 7mm), ascitic fluid was classified as portal hypertensive and nonportal hypertensive ascitic fluid. All patients serum and ascites obtained in the same day and tested serum total protein, ascitic fluid total protein, serum albumin, ascitic fluid albumin, serum bilirubin, ascitic fluid bilirubin, ascitic fluid white blood cell number and specific gravity, respectively. SAAG was defined as the serum albumin concentration minus ascitic fluid albumin concentration. Finally, we analyzed and compared clinical value of SAAG and exudate-transudate concept. The data were
analyzed by soft ware SPSS 10.0. p value of less than 0.05 was considered statistically
significant.
Results:
1. SAAG in group with portal hypertension and group in with nonportal hypertension was 21.69+5.24 and 9.44+4.20. SAAG in group with portal hypertension was significantly higher than that in group with nonportal hvpertension(p < 0.001).
2. 76 of the 78 samples fit the expected pattern of high gradient in patientrs with portal hypertension and 18 of 21 samples fit low gradient in patients without partal hypertenson. Diagnostic accuracy of SAAG was
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