內(nèi)科學(xué)教學(xué)課件：第十八章 肝性腦病

第十八章肝性腦病

HepaticEncephalopathy,HEHepaticcoma2023/3/232ConceptionAneuropsychiatricsyndromecausedbyseriousliverdiseasewith/orprotal-systemicshunt

2023/3/233EtiologyHepaticcirrhosis(chronicfailure)Protal-systemicshuntHepatomaAcutehepaticfailureAcutefattyliverofpregnancy,AFLPSeriousInfectionofbileduct2023/3/234ClassificationTypeA:acute(subacute)liverfaliureTypeB:porpal-systemicshuntTypeC:hepaticcirrhosis

2023/3/235pathogenesis

Hapeticfailure+porta-systemicshunt

toxicsubstanceintosystemiccirculationblood-brainbarrierdisfunction

biochemicaldisturbanceofbrainfunction

2023/3/236Pathogenesis

(hypothesis)AmmoniaFalseneurotransmitter&imbalanceofaminoacidgamma-aminobutyricacid(GABA)/BZMnAmmonia,mercaptans硫醇andshort-chainfattyacids

2023/3/237Pathogenesis

(hypothesis)Ammoniatoxicosisnitrogenoussubstancesproducedinthegut

bybacterialaction

2023/3/238氨中毒學(xué)說(shuō)：1）氨的形成和代謝：產(chǎn)生：主要來(lái)自腸道尿素蛋白質(zhì)

谷氨酰胺→

NH3+谷氨酸腸菌

NH3+CO22023/3/239局部pH對(duì)氨吸收的影響NH3＋H＋

NH4+OH-H+2023/3/2310發(fā)病機(jī)制

氨中毒學(xué)說(shuō)：1）氨的形成和代謝：產(chǎn)生：

主要來(lái)自腸道其次來(lái)自腎臟：谷氨酰胺酶分解谷氨酰胺，pH調(diào)節(jié)

谷氨酰胺→

NH3+谷氨酸

少量來(lái)自橫紋肌2023/3/2311發(fā)病機(jī)制

氨中毒學(xué)說(shuō)：1）氨的形成和代謝：產(chǎn)生：

主要來(lái)自腸道其次來(lái)自腎臟：谷氨酰胺酶分解谷氨酰胺，pH調(diào)節(jié)

少量來(lái)自骨骼肌

清除：

轉(zhuǎn)化：肝中：鳥(niǎo)氨酸循環(huán)合成尿素

腦肝腎中：

-酮戊二酸+NH3谷氨酸+NH3谷氨酰胺

2023/3/2312發(fā)病機(jī)制

氨中毒學(xué)說(shuō)：1）氨的形成和代謝：產(chǎn)生：清除：排泄：腎：排出尿素，排出NH4+主排

腸：NH3，pH<6

肺：呼出NH3少量

2023/3/2313發(fā)病機(jī)制

氨中毒學(xué)說(shuō)：1）氨的形成和代謝2）肝性腦病時(shí)血氨增高的原因氨的生成過(guò)多和代謝清除減少。腸道產(chǎn)氨增加：細(xì)菌，含氮物質(zhì)肝合成尿素的能力減弱，門(mén)體分流的存在。腎臟排泄減少2023/3/2314發(fā)病機(jī)制

氨中毒學(xué)說(shuō)：1）氨的形成和代謝2）肝性腦病時(shí)血氨增高的原因3）對(duì)中樞系統(tǒng)的毒性作用

a.干擾腦的能量代謝（干擾三羧酸循環(huán)，產(chǎn)

ATP減少；去氨代謝致ATP消耗增加。）

b.增加芳香族氨基酸的攝取

c.谷氨酸是大腦興奮的遞質(zhì)

d.

谷氨酰胺是滲透劑誘發(fā)腦水腫-酮戊二酸+NH3谷氨酸+NH3谷氨酰胺2023/3/2315Pathogenesis

(hypothesis)AmmoniatoxicosisFalseneurotransmitter&imbalanceof

aminoacidOctopamine(鱆胺）aromaticaminoacids

（芳香族氨基酸）2023/3/2316Pathogenesis

(hypothesis)Ammoniafalseneurotransmitter&imbalanceof

aminoacid-aminobutyricacid/benzodiazepine(GABA/BZ)

BZBARBGABA2023/3/2317Pathogenesis

(hypothesis)Ammoniafalseneurotransmitter&imbalanceofaminoacidgamma-aminobutyricacid(GABA)/BZMn++Ammonia,mercaptans硫醇andshort-chainfattyacids

2023/3/2318Pathogenesis

(disterbanceofbrianfunction)neurotransmitter

EnergydisterbanceAstrocyte2023/3/2319Pathogenesis

(precipitatefactors)GastrointestinalbleedingExcessdietaryproteinHypokalaemiaHypovolemia,hyoxemiaUraemia

InfectionDrugs:Sedatives,antidepressants,hypnotics

Constipation2023/3/2320Clinicfeatures

intellect,personality,emotionsandconsciousness2023/3/2321Clinicfeatures0期MinorHE2023/3/2322Clinicfeatures

前驅(qū)期

stage1:mildabnormalofcharacter&behavior,asterixis(撲翼樣震顫）2023/3/2323Clinicfeatures

Stage2:confusion,behavior,dyssomnia睡眠障礙Apathy淡漠,inabilitytoconcentrate,confusion,drowsiness困,hallucination幻覺(jué)slurringofspeech,mentalabnormal,hallucination,psychosis精神病-likedisorientation,inabilitytoperformsimplearithmetic,constructionalapraxia構(gòu)造性失用癥,Babinskisign,flappingtremor

2023/3/2324Clinicfeatures

Stage3:Lethargy昏睡,confusedstateofmind,Stage4:coma

2023/3/2325Investigations

Arterialammonia

Electroencephalogram(EEG)showsdiffuseslowingofthenormalalphawaveswitheventualdevelopmentofdeltawaves.evokedpotential(EP):VEP(visualEP);AEP(AuditoryEP);SEP(SomatosensoryEP)mentalarithmetictest心理智能檢測(cè)

2023/3/2326156161412137918421110517181920212223242532023/3/2327diagnosis

①serioushepaticdisorders/portalsystemicshunting;②clinicalmentalconfusion,lethargy,coma③precipitatefactors;④hepaticfunctionorammonia

2023/3/2328DifferentiationPrimarypsychiatricdisorders

Coma2023/3/2329Management

ControltheprecipitatefactorsGastrointestinalbleedingDuretics,Paracentesis(volumes>3-5litres)HypokalaemiaInfectionConstipationDrugs(Sedatives,antidepressants,hypnotics)2023/3/2330Management

ControltheprecipitatefactorsNutritionGlucoseforenergyProtein:prohibitingforacutelimitingforchronicHEbranchaminoacidsvegetableproteinbetter2023/3/2331Management

ControltheprecipitatefactorsNutritionreducingtoxicproductsingutEnema灌腸&catharsis導(dǎo)瀉:25~33%Mg2SO430~60ml;NS1000ml+vinegar50mlLactulose(30~60g/d)Lactitol(30~45g/d)Inhibitingintestinalbacteria:rifaximinMicroecologicagents2023/3/2332Management

ControltheprecipitatefactorsNutritionreducingtoxicproductsingut

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