Dɔlékuiwo ƒe Dɔlékuiwo ƒe Dɔléle (SBP) kple Paracentesis ƒe Ʋuʋu ƒe Dɔmawɔmawɔ nyuie (PPCD): Dzoxɔxɔ alo Tɔtɔ le Ascites, Ascitic Fluid PMN >= 250/mm3, kple IV Albumin ɖɔliɖɔli si nye Sedziwɔwɔ¶
Xexlẽme kpatawo toa vovo le dukɔ ɖesiaɖe me. Axa sia zã 911, si nye xexlẽdzesi na United States kple Canada. Dukɔ bubu geɖewo zãa 112, 999, alo xexlẽdzesi bubu. Di xexlẽdzesi si le miaƒe dukɔa me.
Spontaneous Bacterial Peritonitis (SBP) kple Post-Paracentesis Circulatory Dysfunction (PPCD) nye ƒodo kple ʋumenugbagbeviɣidɔ kpata eve siwo ate ŋu ade ame ƒe agbe afɔku me siwo dzɔna le dɔnɔ siwo ŋu decompensated liver cirrhosis kple portal hypertensive ascites (kple ɖeviwo alo ame tsitsi siwo ŋu **nephrotic syndrome ** sesẽ) le. - Spontaneous Bacterial Peritonitis (SBP) nye dɔlékui ƒe dɔléle sesẽ si tso ascitic tsi si me dɔlékui mele tsã o me si dzɔna le amekokotsoƒe aɖeke si le ƒodo me ƒe anyimanɔmanɔ kura (abe akɔta si me do le, abi si me do le, alo abi si le diverticular abscess ene). Le decompensated cirrhosis me la, ʋusɔgbɔdɔ si le agbo nu hea dɔgbo ƒe ʋuka me ʋu ƒe sisi, dɔgbo ƒe ʋuʋudedi ƒe ʋuʋu ƒe gbegblẽ, dɔgbo me dɔlékuiwo ƒe tsitsi fũ akpa, kple ascitic fluid complement/opsonic activity si mehiã o (vevietɔ ne ascitic fluid total protein nye \(< 1.0\text{ va ɖo }1.5\text{ g/dL}\)). Dɔgbo me Gram-negative bacilli (Escherichia coli kple Klebsiella pneumoniae) kple Gram-positive cocci (Streptococcus pneumoniae kple Enterococcus) trɔna toa dɔgbo ƒe gli si me gblẽ o la dzi tẽ yia mesenteric lymph nodes me eye woƒãa tsi si le dɔgboa me. To vovo na amekoko ƒe dɔgbo ƒe dɔléle (si nana amekoko ƒe ƒodo sesẽ si le abe ʋuƒo ene) ascitic tsi si wotsɔa tsi ƒua gbe si ƒe didime nye lita 5 va ɖo 10 si wotsɔa akɔta ƒoa ƒui la ma visceral kple parietal peritoneum dome, eyata dɔnɔ siwo ŋu SBP si wua ame le la dometɔ 30 va ɖo 50 le alafa me ƒe ƒodo me vevesese ZERO, ZERO rebound tenderness, kple ZERO fever, si ɖee fia boŋ kple Aklã ƒe Tagbɔdɔléle si dze egɔme yeyee (tɔtɔ/ɣletivi ƒe ʋuʋu), Ayiku ƒe Nuveviwɔame Sesẽ si womeɖe o (Hepatorenal Syndrome Type 1 / HRS-AKI), jaundice, ileus, alo septic shock si nu sẽ ɖe edzi. Gaƒoƒo ɖesiaɖe si wohe ɖe megbe hafi woawɔ Diagnostic Paracentesis eye woado Dzidzime Etɔ̃lia ƒe Cephalosporin (Ceftriaxone \(2\text{ g}\) IV) ɖe ʋuka me dzia ame kuku le kɔdzi ɖe edzi 3.3 le alafa me le gaƒoƒo ɖeka me. Vevietɔ la, dɔlékuiwutikewo zazã ɖeɖe mesɔ gbɔ o: dɔlékuiwo ƒe aɖi siwo le dɔlékuiwo me hea ʋukawo me nitric oxide (NO) kple splanchnic arterial vasodilation ƒe dzidziɖedzi gã aɖe vɛ si nana ʋu ƒe sisi ƒe dɔ wua ayikuwo, si hea Aklã ƒe Dɔléle si wua ame vɛ negbe ɖe dɔnɔa xɔ Amegbetɔ ƒe Albumin si wodona ɖe ʋuka me \(25\%\) (\(1.5\text{text{\)) le ɣeyiɣi ɖeka me hafi. g/kg}$ le Ŋkeke 1 dzi, kple \(1.0\text{ g/kg}\) le Ŋkeke 3 lia dzi, Sort Landmark Protocol), si ɖea ku dzi kpɔtɔna le alafa memama 70 kloe. - Post-Paracentesis Circulatory Dysfunction (PPCD) nye iatrogenic hemodynamic collapse si dona ne atikewɔla wɔ Large-Volume Paracentesis (LVP, si ɖea \(> 5\text{ liters}\) ƒe tense ascites le ɣeyiɣi ɖeka me) eye medo \(25\%\) Amegbetɔ ƒe Albumin ɖe ʋuka me o (\(6\text{ va ɖo }8\text{ gram}\) albumin na ascites lita ɖesiaɖe si woɖe ɖa). Ne woɖe ƒodoa ƒe tete ɖa kabakaba la, eɖea ƒodo ƒe nyaƒoɖeamenu dzi kpɔtɔna eye wònana reflex splanchnic arterial vasodilation, ʋukawo me ʋu ƒe agbɔsɔsɔ si wɔa dɔ nyuie dzi ɖena kpɔtɔna, ʋumenugbagbeviɣi renin kple aldosterone ƒe agbɔsɔsɔ dzina ɖe edzi le ŋkeke 2 va ɖo 6 megbe, eye wònana tense ascites ƒe gbugbɔgaƒoƒo kabakaba, dilutional hyponatremia sesẽ, Hepatorenal Syndrome (AKI), . aklã ƒe tagbɔdɔléle, kple ku.
Ne dɔnɔ ɖesiaɖe si ŋu cirrhosis kple ascites le la xɔ asrã, ƒodove, tɔtɔ/alɔ̃dɔdɔ yeye, aɖuɖɔtoe ƒe dodo dzi ɖe kpɔtɔ, alo gbɔgbɔtsixe tsi ƒodo si vuvu si te ɖe edzi ta la, ƒo ka na miaƒe nutoa me tɔwo xexlẽdzesi siwo wozãna kpata enumake. Dzro mía nɔviwo ŋuti mɔfiamegbalẽ siwo ku ɖe... aklã ƒe tagbɔdɔléle ƒe hatsotso 3 kple 4 aklã ƒe alɔ̃madɔmadɔ, ɣletivimefakaka, kple lactulose enema, . nuɖuɖutome ƒe ʋukawo ƒe gbagbã, ʋu si dona le ahɔhɔ̃mekawo me, kple aklã ƒe tagbɔdɔléle, kple appendicitis, appendicitis si gbã, peritonitis, kple ɖusime ƒe akpa si le anyime ƒe vevesese.
Wɔ esia fifia¶
- Wɔ Abadzivɔ ƒe Ultrasound-Guided Diagnostic Paracentesis Le Gaƒoƒo 6 Me (Anyo wu le Gaƒoƒo 1 va ɖo 2 me) na Dɔnɔ ÐESIASI Si Ŋu Cirrhosis Kple Ascites Le Si Woxɔ Ðe Kɔdzi, Ne Woƒe Ƒodo Vevesese Zero Eye Asrã Zero Mele Wo Ŋu O Togbɔ. Ƒo ka na 911 le United States kple Canada, 999 le United Kingdom, 112 le Europa katã Union, 000 le Australia, alo kpɔ míaƒe xexeame katã ƒe nyatakakadzraɖoƒe si nye xexlẽdzesi siwo wozãna kpata. Dɔnɔ siwo katã woxɔ ɖe kɔdzi siwo ŋu ascites le la dometɔ siwo ade 15 va ɖo 30 le alafa me ƒe SBP wɔa dɔ ne woxɔ wo ɖe kɔdzi, eye zi geɖe la, tɔtɔ si menya kpɔna dzea sii bɔbɔe o (aklã ƒe tagbɔdɔ) alo serum creatinine si le dzidzim ɖe edzi koe woɖena fiana.
- MÈGAhe Diagnostic Paracentesis ɖe megbe GBEÐE Be Nàna Fresh Frozen Plasma (FFP) alo Ʋumenugbagbevi dzĩwo hena INR si Kɔkɔ alo Ʋumenugbagbeviɣi ƒe Xexlẽme si bɔbɔ o.
- Kɔdzi ƒe vodada si wowɔna le xexeame katãe nye be woahe ascitic tap si wotsɔ dia dɔlélewoe ɖe megbe gaƒoƒo 6 va ɖo 12 be woado FFP elabena dɔnɔ si ŋu ʋumenugbagbeviɣidɔ le ƒe \(\text{INR}\) ƒe \(\text{INR}\) nye \(2.2\) alo ʋumenugbagbevi dzĩwo ƒe home nye \(45,000/\text{\mu L}\).
- AASLD, EASL, kple BSG Mɔfiamewo gblɔe ɖikekemanɔmee be: Wogada asɔ le ʋumenugbagbeviɣidɔ me; afɔku si le ʋudodo gã aɖe si dona tso paracentesis si ultrasound-fia mɔe me la mede \(0.2\%\)** o, eye INR si dzi ɖe edzi alo thrombocytopenia menye nusi tsi tre ɖe paracentesis ŋu o (nusiwo woɖe ɖa koe nye fibrinolysis alo disseminated intravascular coagulation [DIC] si dze le atikewɔnyawo me). Zã abadzivɔ ƒe ultrasound kple Color Doppler nàtsɔ aɖo taɖodzinu na Miame Lower Quadrant (afisi ƒodo ƒe gli le tsɛ wu eye woƒo asa na cecum) eye nànɔ \(5\text{ cm}\) ya teti le axadzi na titina fli la be nàƒo asa na inferior epigastric artery.
- Bu akɔnta le Ascitic Fluid Absolute Polymorphonuclear Leukocyte (PMN / Neutrophil) Xexlẽme ŋu EYE Do Ascitic Fluid \(10\text{ mL}\) Tsã ɖe Aerobic kple Anaerobic Ʋu Dekɔnu Tuwo me le Abati ƒe Akpa:
- SBP ƒe Diagnostic Threshold: Ascitic tsi Absolute PMN (Neutrophil) Count \(\ge 250\text{ cells/mm}3\) (\(0.25 \times 109\text{/L}\)) ɖo kpe Dɔlékui ƒe Dɔlékuiwo ƒe Dɔléle si Le eɖokui si dzi eye wòde se be woawɔ dɔlékuiwutike siwo wodona ɖe ʋuka me si wokpɔna enumake manɔmee lala gaƒoƒo 48 hafi dekɔnuwo me tsonu.
- Ʋu ƒe Tap Correction Formula: Ne tap si wɔ nublanui na ʋumenugbagbevi dzĩwo (\(\text{RBCs}\)) de tsia me la, ɖe \(1\text{ PMN}\) le \(250\text{ RBCs/mm}3\) ɖesiaɖe ta be nàkpɔ PMN xexlẽme si woɖɔ ɖo vavã.
- Nusitae Ʋu ƒe Dekɔnu ƒe Aŋetu Siwo Le Abati Dzi Nye Sedede: Ascitic tsi ɖoɖo ɖe dodokpɔxɔ me le syringe alo kplu gbadza si me dɔlékui mele o me naa dekɔnu nyuiwo le SBP ƒe dɔléle siwo mede \(40\%\) o me (elabena SBP ƒe dɔlékui ƒe ƒuƒoƒo ƒe xexlẽme le sue ŋutɔ si nye \(\approx 1\text{ organism/mL}\)). Ascitic tsi \(10\text{ mL}\) dodo ɖe ʋu ƒe aŋetu siwo me ya kple ya mele o me tẽ le aba to doa dekɔnu ƒe seselelãme ɖe ŋgɔ wu \(80\%\).
- Na Dɔlékuiwutike Siwo Wodona Le Ʋuka Me Si Wokpɔna Le Dɔlékuiwutikewo Me Enumake Le Tsi Me:
- SBP si woxɔ le nutoa me (Septic Shock aɖeke meli o, Beta-Lactam ƒe dodokpɔ aɖeke meli nyitsɔ laa o): Do Ceftriaxone \(2\text{ grams}\) IV le ʋuka me gaƒoƒo 24 ɖesiaɖe (alo IV Cefotaxime \(2\text{ grams}\) gaƒoƒo 8 ɖesiaɖe) hena ŋkeke 5 va ɖo 7.
- Nosocomial / Healthcare-Associated SBP, Septic Shock, alo Recent Hospitalization: Esi wònye be SBP si woxɔna le kɔdzi ƒe alafa memama 30 va ɖo 40 tso Extended-Spectrum Beta-Lactamase (ESBL) Gram-negatives alo Enterococcus / MRSA gbɔ ta la, dze broad-spectrum Intravenous Meropenem gɔme (\(1\text{ g}\) IV gaƒoƒo 8 ɖesiaɖe) alo Piperacillin-Tazobactam (\(4.5\text{ g}\) IV gaƒoƒo 6 va ɖo 8 ɖesiaɖe) PLUS Vancomycin alo Daptomycin (alo Tigecycline le VRE/MDRO teƒewo).
- Na Amegbetɔ ƒe Albumin \(25\%\) si Wodona Ðe Ʋuka Me si Wobia Ðe Ame Ŋu To Ðoɖowɔɖia Zazã Me (\(1.5\text{ g/kg}\) le Ŋkeke 1 + \(1.0\text{ g/kg}\) le Ŋkeke 3 dzi) eye nàlé Beta-Blockers, Diuretics, Kple NSAIDs Katã.
- Le dzesi si nye Sort et al. (NEJM 1999) dodokpɔ, tsɔ Amegbetɔ ƒe Albumin si wodona ɖe ʋuka me \(25\%\), \(1.5\text{ grams/kg}\) ƒe ŋutilã ƒe kpekpeme kpe ɖe eŋu le gaƒoƒo 6 me tso esime wokpɔ SBP le Ŋkeke 1 dzi (si sɔ gbɔ wu \(100\text{ g}\)), eye wotsɔ \(1.0\text{ gram/kg}\) si sɔ gbɔ wu le Ŋkeke 3 lia (si sɔ gbɔ wu \(100\text{{ g}\)), ɖe Aklãdɔléle ƒe agbɔsɔsɔ dzi kpɔtɔ tso \(30\%\) va ɖo \(10\%\) eye wòɖe ku le kɔdzi dzi kpɔtɔ tso \(29\%\) va ɖo \(10\%\). (Ele vevie ŋutɔ ne gɔmedzedzea me Serum Creatinine \(> 1.0\text{ mg/dL}\) [\(88\text{ \mu mol/L}\)], BUN \(> 30\text{ mg/dL}\), alo Total Bilirubin \(> 4.0\text{ mg/dL}\) [\(68\text{ \mu mol/L}\)]).
- KPƆ Beta-Blockers siwo Metia Tiatia O (Propranolol, Nadolol, Carvedilol), Diuretics (Furosemide, Spironolactone), ACE Inhibitors/ARBs, kple Aminoglycosides enumake le SBP si le dɔ wɔm me: beta-blockers siwo xea mɔ na dzi ƒe dɔwɔwɔ le SBP ƒe splanchnic vasodilation me dzia Hepatorenal ƒe afɔkua ɖe edzi ŋutɔ Dɔléle kple ku.
- Xɔ Mɔ na Paracentesis megbe Ʋukawo ƒe Dɔmawɔmawɔ nyuie (PPCD) le Paracentesis si ƒe lolome lolo ɖesiaɖe me (\(> 5\text{ Lita}\) Woɖee ɖa): Do \(6\text{ ɖe }8\text{ Grams}\) si nye \(25\%\) IV Albumin ɖe Lita ɖeka si Woɖe ɖa me.
- Mègawɔ Large-Volume Paracentesis (LVP \(> 5\text{ L}\)) gbeɖe le Spontaneous Bacterial Peritonitis si le dɔ wɔm me o (tsi si le agbɔsɔsɔ gã me le SBP si le dɔ wɔm me nana ayiku ƒe abi sesẽ xɔxɔ kabakaba; wɔ diagnostic tap sue aɖe ko [\(30\text{ to }50\text{ mL}\)] vaseɖe esime woada SBP, negbe ɖe tense ascites le hehe vɛ ko gbɔgbɔtsixe tsia ƒo enumake).
- Ɣesiaɣi si nèle Large-Volume Paracentesis (\(> 5\text{ L}\) si woɖe le ascites si me dɔlékui mele o me) si woatia alo si hiã kpata wɔm la, tsɔ \(6\text{ va ɖo }8\text{ grams}\) si nye \(25\%\) Intravenous Human Albumin ɖe ascites lita ɖesiaɖe si woɖe ɖa (le kpɔɖeŋu me, ne \(8\text{ lita}\) tsi le eme la, doe \(48\text{ va ɖo }64\text{ grams}\) [\(200\text{ va ɖo }250\text{ mL}\) ƒe \(25\%\) Albumin] IV le dɔwɔwɔa me alo le ewɔwɔ vɔ megbe teti).
Alesi Nàƒo Asa na Dɔwɔwɔ le SBP Ŋu, Kple Alesi Nàwɔ Aƒo Asa na Dɔgbo si me do le ƒe To (Runyon ƒe Dzesidede na Dɔlékui Evelia ƒe Dɔgbo ƒe Dɔléle) .
Dɔnɔ si ƒe ʋuka me ʋu ƒe sisi le lãme na ame si ŋu Spontaneous Bacterial Peritonitis (SBP) le ŋutɔŋutɔ ƒe dɔgbo ɖeɖeɖa si wotsɔa numekuku wɔe la hea amekoko ƒe ku ƒe agbɔsɔsɔme 80 le alafa me le aklã ƒe dɔmawɔmawɔ nyuie kple ʋu ƒe dodo ta. Le go bubu me la, duodenal ulcer si me do le, appendix si me do le, alo diverticulitis si me do le (Secondary Bacterial Peritonitis) le ascitic ƒodo me kple atikewɔwɔ me ceftriaxone ɖeɖeko amekoko manɔmee nye wu 100 le alafa me. Zã Runyon ƒe Ascitic Fluid Criteria le pɔmpi ɖesiaɖe dzi: ɖikeke Secondary Bacterial Peritonitis (Surgical Perforation) eye nàbia be woawɔ Abdominal CT kple IV kple Oral/Rectal Contrast enumake ne ascitic fluid la ɖe \(\text{PMN} \ge 250/\text{mm}3\) PLUS ** TWO ya teti fia le esiwo gbɔna me Nudokpɔƒe ƒe dzesi ETƆ̃**: 1. **Ascitic Tsi Protein Katã $> 1.0 nuŋɔŋlɔ { g / dL} $ ($ 10 nuŋɔŋlɔ { g / L} $) **; 2. **Ascitic Tsi Glucose $< 50 nuŋɔŋlɔ { mg / dL} $ ($ 2.8 nuŋɔŋlɔ { mmol / L} $) **; 3. Ascitic Fluid LDH \(>\) Dzigbe Seɖoƒe si le Normal na Serum LDH (alo polymicrobial flora/fungi si wokpɔ le Gram stain dzi).
Nyametsotso ƒe ati: dɔlélenutsiŋutete ƒe paracentesis, SBP vs. Secondary Peritonitis triage, kple PPCD mɔxexe ɖe enu¶
flowchart TD
A["Dɔnɔ si ŋu Cirrhosis Kple Ascites Le la Va Kɔdzi kple NU SIWO Mekpɔa Dɔléle O: Asrã/Dzoxɔxɔ si mebɔ o, Ƒodo me Vevesese, Aklã ƒe Tagbɔdɔ Yeye (Tɔtɔ/Asterixis), Creatinine si le Dzi yim (AKI), GI Ʋuʋu, Leukocytosis, AL Tense Ascites Causing Dyspnea"] --> B["Afɔɖeɖe 1: Wɔ Ultrasound-Guided Bedside Diagnostic Paracentesis Le < Gaƒoƒo 6 Me (Miame Lower Quadrant, Ƒo asa na Inferior Epigastric Artery; MÈGAHE ɖe megbe na INR alo Ʋumenugbagbevi dzĩ siwo bɔbɔ o)"]
B --> C["Afɔɖeɖe 2: Ðo Ascitic Fluid STAT ɖa na: 1. Lãmenugbagbeviwo ƒe Xexlẽme & Vovototo (PMN Xexlẽme Blibo); 2. Protein & Albumin Katã (Bu akɔnta le SAAG ŋu: Serum Albumin ɖe Ascites Albumin ɖa >= 1.1 g/dL ɖo kpe Portal Hypertension dzi); 3. Glucose, LDH, Gram ƒe ɖiɖi; 4. Do 10 mL Tsã ɖe Aerobic & Anaerobic Ʋu Dekɔnu Tuwo me le Abati xa"]
C --> D{"Da Ascitic Fluid Absolute Neutrophil (PMN) Xexlẽme Kpɔ (Ðe PMN 1 le RBC 250 ɖesiaɖe me ne Ʋu le dodom)"}
D -->|Corrected Ascitic PMN >= 250 cells/mm3| E{"Kpɔ Runyon ƒe Dzesiwo Na Amekoko ƒe Dɔléle Evelia: Ðe Tsi Me >= 2 le 3 me: 1. Protein > 1.0 g/dL; 2. Sukli ƒe agbɔsɔsɔ < 50 mg/dL; 3. LDH > Serum ULN (alo Gram Stain si me dɔlékui geɖe le)?"}
E -->|YES: Runyon's Criteria Positive| F["WOBU BE DƆLƆ̃ EVELIA ƑE ƲUƲU ƑE ƲUƲU (Abi si me do le, Megbenyawo, alo Diverticulum): Ðo gbe STAT Ƒodo/Akɔta ƒe CT + Tsɔ Anaerobic Coverage (IV Piperacillin-Tazobactam alo Ceftriaxone + Metronidazole) kpee + Amekoko ƒe Aɖaŋuɖoɖo Kpata"]
E -->|NO: Classic Low-Protein Monomicrobial Ascites| G["AMESIWO WOÐO ÐE EDZI BE DƆLÉLE ƑE ƲUƲU ƑE ƲUƲU ƑE ƲUƲU (SBP): MÈGAWƆ Paracentesis Siwo Ƒe Agbɔsɔsɔme Gãwo Le SBP Si Le Dɔ Wɔm Me O"]
G --> H["SBP ƑE ƉEÐEŊU ƑE ƑOMEDODO SI WOÐO: 1. Dɔlékuiwutike siwo wozãna enumake le ʋuka me: Ceftriaxone 2 g IV q24h (alo Meropenem/Pip-Tazo + Vancomycin ne Nosocomial/Septic Shock); 2. Sedziwɔwɔ IV 25% Amegbetɔ ƒe Albumin (Sort Protocol): 1.5 g/kg Ŋkeke 1 (le gaƒoƒo 6 me) + 1.0 g/kg Ŋkeke 3; 3. LƆ Beta-Blockers (Propranolol/Carvedilol), Aɖuɖɔtoemedɔlékuiwo, Kple NSAIDs Katã; 4. Dze Mɔxexeɖedɔléle Nu Evelia Gɔme Hafi Woado Go"]
D -->|Corrected Ascitic PMN < 250 cells/mm3 (Sterile Ascites on Initial Count)| I{"Kpɔ Dɔdaƒe ƒe Nɔnɔme & Gaƒoƒo 48 ƒe Ʋu Dekɔnu ƒe Aŋetu ƒe Emetsonu si kplɔe ɖo"}
I -->|Culture Turns Positive at 24-48h ("Dɔlékui Siwo Menye Neutrocytic o siwo me dɔlékuiwo le")| J["Ne Dzesiwo Le Wo Ŋu (Asrã, Vevesese, Tagbɔdɔléle, AKI): Woadae le SBP Bliboe Nu; Ne Dzesi aɖeke Mele Eme Kekeake O: Gbugbɔ Diagnostic Paracentesis Gbugbɔ Enumake"]
I -->|Patient Has Tense Sterile Ascites Causing Respiratory Distress / Severe Discomfort Requiring Large-Volume Paracentesis (LVP > 5 Liters)| K["LARGE-VOLUME PARACENTESIS (LVP) + PPCD PREVENTION PROTOCOL: Tsi Ascites vaseɖe esime wòaƒu le ɣeyiɣi ɖeka me eye nàde 25% IV Amegbetɔ ƒe Albumin Gram 6 va ɖo 8 ɖe Lita ÐESIASI si woɖe ɖa (e.g., 50-64 g Albumin for 8 L Removed)"]Dɔléle ƒe dɔwɔwɔ ŋuti nunya: dɔlékuiwo ƒe ʋuʋu yi teƒe bubu, nitric oxide splanchnic vasodilation, kple nusita SBP kple Large-Volume Paracentesis hea Aklã ƒe Dɔléle vɛ¶
1. Nusitae Cirrhotic Ascitic Fluid Xɔa Dɔlékuiwo Ne Ŋutinu Meɖe Do Mele O¶
Le ʋumenugbagbeviɣidɔ si de ŋgɔ me la, ʋusɔgbɔdɔ si le lãkusi me ʋua tsi si me protein mele o to aklã ƒe sinusoids kple splanchnic capillaries me yia akɔta ƒe do me (Serum-Ascites Albumin Gradient [SAAG] \(\ge 1.1\text{ g/dL}\) kple Ascitic Total Protein \(< 1.5\text{ g/dL}\)). Gblẽƒe etɔ̃ ƒoa ƒu tsɔ dea dzo Dɔlékui ƒe Dɔlékui Siwo Le Ðokuisi me: 1. Dɔgbome Dɔlékuiwo ƒe Tsitsi Gã & Dysbiosis: Dɔgbo sue ƒe ʋuʋu ƒe gbegblẽ kple bile acid ƒe dodo dzi ɖeɖe kpɔtɔ na be Gram-negative Enterobacteriaceae (E. coli, Klebsiella) tsina akpa le dɔgbo suea me (egagblẽ ɖe edzi to Proton Pump Inhibitor [PPI] zazã atraɖii me). 2. Gut Barrier Failure & Bacterial Translocation: Portal venous congestion hea dɔgbo ƒe gli ƒe subepithelial edema vɛ eye wòkekea lãmenugbagbeviwo dome kadodo sesẽwo ɖe enu, si wɔnɛ be dɔlékui siwo ate ŋu anɔ agbe la te ŋu tsoa mesenteric lymph nodes, thoracic duct lymph, kple ʋukawo me. 3. Ascitic Fluid Opsonic Activity si Mehiã o: Esi wònye be protein bliboa le cirrhotic ascitic fluid si le sue ŋutɔ (\(< 1.0\text{ va ɖo }1.5\text{ g/dL}\)) ta la, Complement C3 kple immunoglobulins si hiã be woatsɔ awɔ opsonize ahawu dɔlékui siwo woɖe yi teƒe bubu la mele esi o. Dɔlékui ɖeka si gena ɖe tsi si ƒe kpekpeme nye lita 8 ƒe tsilele me dzina ɖe edzi makpɔmakpɔe wòzua Dɔlékui ƒe Dɔlékui si Le Eɖokui Dzesi.
HOW SBP & UNPROTECTED LARGE-VOLUME PARACENTESIS CAUSE HEPATORENAL SYNDROME
==========================================================================
[PATHWAY 1: SPONTANEOUS BACTERIAL PERITONITIS] [PATHWAY 2: LARGE-VOLUME PARACENTESIS]
Gram-Negative Endotoxin (LPS) + Cytokines Draining > 5 Liters of Tense Ascites
(TNF-alpha, IL-6) flood the peritoneum. without IV Albumin abruptly drops
\ intra-abdominal pressure.
\ /
v v
[MASSIVE SPLANCHNIC ARTERIAL VASODILATION (Nitric Oxide Surge)]
Blood pools inside dilated mesenteric/splanchnic arteries;
Systemic Vascular Resistance (SVR) and Mean Arterial Pressure (MAP) drop.
|
v
[EFFECTIVE ARTERIAL HYPOVOLEMIA & BARORECEPTOR ACTIVATION]
Extreme activation of:
1. Renin-Angiotensin-Aldosterone System (RAAS)
2. Sympathetic Nervous System (Norepinephrine)
3. Non-Osmotic Antidiuretic Hormone (ADH / Vasopressin)
|
+-----------------------------+-----------------------------+
| |
v v
[INTENSE RENAL ARTERIOLAR VASOCONSTRICTION] [FREE-WATER & SODIUM RETENTION]
Renal cortical blood flow & GFR collapse Dilutional Hyponatremia (Na+ < 125)
--> HEPATORENAL SYNDROME (HRS-AKI) + Rapid Re-Accumulation of Ascites
& Multi-Organ Failure / Death. (PPCD).
==========================================================================
*HOW IV 25% HUMAN ALBUMIN SAVES LIFE IN BOTH EMERGENCIES:*
1. Oncotic Volume Expansion: Pulls interstitial fluid into the central arterial
tree, restoring Effective Arterial Blood Volume and shutting off Renin/ADH.
2. Non-Oncotic Scavenging: Albumin binds bacterial Endotoxin (LPS), Nitric Oxide,
Prostaglandin E2, and reactive oxygen species, reversing endothelial shock.
==========================================================================
Ascitic Fluid Dɔlékuiwo ƒe Dzesidede Bliboe: SBP kple Dekɔnu-Negative Neutrocytic Ascites kple Bacterascites kple Secondary Peritonitis¶
Ele be woama ascitic tsi ƒe pɔmpi ɖesiaɖe ɖe nu vovovo atɔ̃ dometɔ ɖeka me le Corrected Absolute PMN Count (\(\text{Total WBC} \times \%\text{Neutrophils}\)), Bedside Blood-Culture Bottle Result, kple Runyon ƒe Biochemistry nu:
| Ascitic Tsi ƒe Ƒomedodo | Ascitic PMN Xexlẽme si woɖɔ ɖo (\(\text{cells/mm}3\)) | Ascitic Fluid Dɔlékuiwo ƒe Dekɔnu ƒe Emetsonu | Ascitic Protein, Glucose & LDH (Runyon ƒe Dzesiwo) . | Dɔnɔdzikpɔƒe ƒe Gɔmesese & Sedziwɔwɔ Kpata ƒe Afɔɖeɖe |
|---|---|---|---|---|
| 1. Dɔlékuiwo ƒe Dɔlékuiwo ƒe Dɔléle si Le Eɖokui Si (SBP) | \(\ge 250/\ nuŋɔŋlɔ {mm} 3\) | Enyo na nugbagbe ÐEKA (E. coli, Klebsiella pneumoniae, alo Streptococcus pneumoniae) | Zi geɖe la, protein nye \(< 1.0\text{ g/dL}\); Glukose $ ge 50 nuŋɔŋlɔ { mg / dL} $; LDH \(<\) Serum ULN ƒe ʋumenugbagbeviɣidɔ. | SBP si le dɔ wɔm: Dze IV Ceftriaxone \(2\text{ g}\) q24h (alo Meropenem ne nosocomial) + IV \(25\%\) Albumin (\(1.5\text{ g/kg}\) Ŋkeke 1, \(1.0\text{ g/kg}\) Ŋkeke 3). |
| 2. Dekɔnu-Nexeme Neutrocytic Ascites (CNNA) . | \(\ge 250/\ nuŋɔŋlɔ {mm} 3\) | Negative (zi geɖe la, le dɔlékuiwutike ƒe agbɔsɔsɔme si wozã do ŋgɔ alo dekɔnu ƒe mɔnu gbegblẽ ta; woɖee ɖa be dɔgbo ƒe dɔléle, dɔgbo ƒe dɔdzẽ, alo yɔmekpe ƒe dɔgbo ƒe dɔléle) | Nenema kee wòle le Classic SBP (protein si mesɔ gbɔ o, sukli si sɔ, LDH si mebɔ o) gome. | Dada 100% Abe alesi SBP Klasik: Etsɔa ku kple aklã ƒe afɔku si sɔ pɛpɛpɛ kple dekɔnu-positive SBP; na Ceftriaxone IV + Albumin si nye IV. |
| 3. Dɔlékui Siwo Menye Neutrocytic O (MNB) . | \(< 250/\nuŋɔŋlɔ{mm}3\) | Enyo na nugbagbevi ÐEKA (wokpɔnɛ le gaƒoƒo 24 va ɖo 48 megbe ne dodokpɔxɔ yɔ kple ʋu ƒe dekɔnu ƒe aŋetu si me dɔléle le) | Normal / gɔmedzedze ƒe transudative cirrhotic ascites. | Mɔ Eve: - Ne Dzesiwo le eŋu (asrã, vevesese, tɔtɔ/HE, alo AKI): Dɔe enumake abe SBP blibo ene. - Ne Dzesi aɖeke mele eŋu kura o: Gbugbɔ di diagnostic paracentesis enumake (60% kɔ le eɖokui si; ne gbugbɔ \(\text{PMN} \ge 250\) alo dekɔnua gakpɔtɔ nye nyuitɔ la, bu eŋu abe SBP ene). |
| 4. Dɔlékui Evelia ƒe Akɔtadɔ (Viscus alo Abscess si me do le) | \(\ge 250/\text{mm}3\) (zi geɖe la, \(> 1,000\text{ va ɖo }10,000/\text{mm}3\)) | Nulékui geɖe (Gram-negatives geɖe siwo le dɔgboa me + anaerobes + Enterococcus alo Candida) | Runyon ƒe Nu Nyui (\(\ge 2\) le 3 me): 1. Protein $> 1.0 nuŋɔŋlɔ{ g / dL} $ 2. Glucose ƒe agbɔsɔsɔ \(< 50\text{ mg/dL}\) 3. LDH \(>\) Serum ULN ƒe ʋumenugbagbeviɣidɔ (Azɔ hã, kpɔ Ascitic CEA \(> 5\text{ ng/mL}\) alo Alk Phos \(> 240\text{ U/L}\) hena viscus ƒe do si me do le). |
AKPAÐEKA ƑE NU KPƆKPƆ: Se STAT Abdominal/Pelvic CT with contrast, tsɔ anaerobic coverage (IV Piperacillin-Tazobactam alo Ceftriaxone + Metronidazole) kpee, eye nàkpɔ General Surgery enumake. |
| 5. Dɔlékui Siwo Me Nu Gbagbewo Le (Aŋe ƒe Dɔgbo Me Tome) | \(< 250/\nuŋɔŋlɔ{mm}3\) | Polymicrobial (dɔgbo me nugbagbe geɖe + ya ƒe kuɖɔ/nu suesuesue siwo woɖena le pɔmpi me) | PMN ƒe xexlẽme si sɔ le gɔmedzedzea me elabena paracentesis ƒe aŋea ge ɖe dɔgboa ƒe ʋuƒo aɖe me le vo me. | Wo dometɔ akpa gãtɔ nu tsona amekoko manɔmee; gbugbɔ paracentesis tso akpa enelia si tsi tre ɖe wo nɔewo ŋu eye nàtsɔ dɔlékuiwutike siwo ƒe dɔwɔwɔ keke ta (Ceftriaxone + Metronidazole) atsyɔ edzi ne dzesiawo do mo ɖa. |
Afɔɖeɖe ɖesiaɖe Kɔdzi ƒe Ðoɖowɔɖi hena Ultrasound-mɔfiame Paracentesis Wɔwɔ, SBP Dada, Kple Mɔxexe Ðe PPCD Nu¶
Afɔɖeɖe 1: Dedie Ultrasound-mɔfiame Mɔnu (Miame Lower Quadrant & "Z-Track" Mɔnu)¶
- Nusita Wolɔ̃a Miame ƒe Akpa Ene (LLQ) Wu Nuɖusi ƒe Akpa Ete:
- Ƒodo ƒe gli si le Miame Lower Quadrant (\(2\text{ fingerbreadths}\) [\(3\text{ cm}\)] cephalad kple \(2\text{ fingerbreadths}\) medial to the anterior superior iliac spine [ASIS]) le tsɛ wu eye ascitic tsi ƒe ta si goglo wu titina fli la le eme, eye wòƒoa asa na cecum si keke ɖe enu le Right Lower Quadrant (si wotsɔa gas si tso lactulose-dɔdamɔnu me kekena zi geɖe) kpakple ɖusime-upper-quadrant hepatomegaly.
- Blidzi Ultrasound si wòle be woawɔ + Amadede Doppler Dodokpɔ:
- De dzesi kotoku si me goglo wu si me tsi si me gbeɖiɖi mele o si le tsia dzi faa si me dɔgbo ƒe ʋuƒo alo omentum mele o le.
- Zã Color Doppler nàtsɔ adi Inferior Epigastric Artery (si zɔna le tsitrenu le rectus sheath me \(4\text{ vaseɖe }8\text{ cm}\) le axadzi na umbilicus) kple caput medusae / abdominal wall portosystemic collateral veins ɖesiaɖe si keke eye nàƒo asa nɛ.
- "Z-Track" Aŋe Dede Mɔnu (Mexea Mɔ na Post-Tap Ascitic Tsi Sisi):
- Ne sterile chlorhexidine prep kple \(1\%\) lidocaine wheal yi anyime va ɖo peritoneum megbe la, he ŋutigbalẽa \(2\text{ centimeters}\) caudally (downward) kple wò asi si meɖua dzi o esime nèle paracentesis needle la dom ɖe ŋgɔ wòtsi tre ɖe ƒodo ƒe gli ŋu, nànɔ egbɔm atraɖii vaseɖe esime peritoneal tsi nage ɖe syringe la me. Ne woɖe aŋea le pɔmpia ƒe nuwuwu la, ŋutigbalẽa trɔna yia eƒe nɔƒe gbãtɔ, si wɔnɛ be wowɔa offset "Z-track" seal ale be ascitic tsi megadona ɖe aba dzi o. (Ne ascitic leak si nɔa anyi ɖaa le paracentesis megbe dzɔ gbeɖeka la, da ostomy kotoku si me dɔlékui mele o ɖe teƒea dzi be nàbu nusiwo bu ƒe agbɔsɔsɔme alo nàtsɔ aŋe ɖeka si ƒe xexlẽme nye enyi alo lãmenugbagbeviwo ƒe nulénu atu ŋutigbalẽ ƒe pinhole la esime nèna dɔnɔa mlɔ akpa si tsi tre ɖe eŋu).
Afɔɖeɖe 2: SBP Kɔdzi ƒe Dɔdamɔnu Blibo (Dɔlékuiwutikewo, Albumin, Atikewo Léle Ðe Asi, Kple Gaƒoƒo 48 ƒe Tap Check) .¶
| SBP Bundle ƒe akpa aɖe | Ðoɖowɔɖi & Ɣeyiɣi Si Wozãna Kpata | Dɔnɔdzikpɔƒe ƒe Susu & Mɔfiame Kpeɖodziwo |
|---|---|---|
| 1. Empiric IV Antibiotics (Le Gaƒoƒo 1 me tso esime wokpɔ dɔlélea) | - SBP si woxɔ le nutoa me: IV Ceftriaxone \(2\text{ g}\) gaƒoƒo 24 ɖesiaɖe (alo IV Cefotaxime \(2\text{ g}\) gaƒoƒo 8 ɖesiaɖe) hena ŋkeke 5 va ɖo 7. (Ne beta-lactam ƒe dɔmawɔmawɔ nyuie sesẽ: IV Levofloxacin \(500\text{ mg}\) q24h alo IV Ciprofloxacin \(400\text{ mg}\) q12h KO KO ne dɔnɔa MELE fluoroquinolone SBP mɔxexeɖedɔléle nu zãm xoxo o; ne menye nenema o la, zã Aztreonam + Vancomycin).). - Dɔdzikpɔƒe / ICU / Septic Shock SBP: IV Meropenem \(1\text{ g}\) q8h (alo Piperacillin-Tazobactam) + IV Vancomycin alo Daptomycin. |
Cephalosporin si nye dzidzime etɔ̃lia zazã ŋkeke 5 ƒe dɔwɔwɔ sɔ kple ŋkeke 10 ƒe dodokpɔ le SBP si mesesẽ o me. Ƒo asa na Aminoglycosides (Gentamicin, Tobramycin, Amikacin) vevie, siwo hea aɖi si gblẽa nu le ayiku me le ʋumenugbagbeviɣidɔ me. |
| 2. Amegbetɔ ƒe Albumin 25% si wodona ɖe ʋuka me (Sort Protocol) | - Ŋkeke 1 (Le Gaƒoƒo 6 me tso esime wokpɔ dɔlélea): \(1.5\text{ grams/kg}\) ƒe \(25\%\) Amegbetɔ ƒe Albumin IV (max \(100\text{ g}\), si wodo ɖe lãme na ame le gaƒoƒo 4 va ɖo 6 me). - Ŋkeke 3 (Gaƒoƒo 48 megbe): \(1.0\text{ gram/kg}\) ƒe \(25\%\) Amegbetɔ ƒe Albumin IV (max \(100\text{ g}\)). |
Woɖo kpe edzi be Sort kple exɔlɔ̃wo. (NEJM) be woaɖe Aklã ƒe Dɔléle Ƒomevi 1 dzi akpɔtɔ tso \(30\%\) va ɖo \(10\%\) eye woaɖe ku dzi akpɔtɔ tso \(29\%\) va ɖo \(10\%\). Viɖe gãtɔ kekeake ne Serum Creatinine \(> 1.0\text{ mg/dL}\), BUN \(> 30\text{ mg/dL}\), alo Bilirubin \(> 4.0\text{ mg/dL}\). (Zã \(25\%\) concentrated hyperoncotic albumin, ke menye \(5\%\) albumin le saline me o, be nàƒo asa na sodium/tsi ƒe agbɔsɔsɔ fũ; doe blewu ne dzidɔ alo portopulmonary hypertension si le ete le eme). |
| 3. Atikewo Ŋuti Numekuku si Wobia (Hold Beta-Blockers, Diuretics & PPIs) | - STOP Non-Selective Beta-Blockers (Propranolol, Nadolol, Carvedilol) enumake le SBP si le dɔ wɔm me (dzudzɔ tegbee ne SBP sesẽ le ʋusɔgbɔdɔ ta [\(\text{SBP} < 90\text{ mmHg}\) or \(\text{MAP} < 65\text{ mmHg}\)] or Hepatorenal Syndrome). - LE Furosemide & Spironolactone vaseɖe esime SBP kple AKI naɖe ɖa. - Dzudzɔ Proton Pump Inhibitors (PPIs) siwo mehiã o (omeprazole, pantoprazole) zazã negbe ɖe dɔgbo ƒe abi/GI ʋu le dodom le dɔ me. |
Mandorfer kple exɔlɔ̃wo. (Gastroenterology) ɖo kpe edzi be beta-blockers zazã dzi yiyi le SBP si le dɔ wɔm me xea mɔ na compensatory tachycardia, si naa Hepatorenal Syndrome kple ku ƒe dzidziɖedzi zi gbɔ zi eve. PPI siwo nɔa anyi didi gblẽa dɔgbo ƒe acid ƒe mɔxenu kple SBP ƒe afɔku si gbugbɔna zi gbɔ zi etɔ̃. |
| 4. Ɣekaɣie Woawɔ Gaƒoƒo 48 ƒe Dɔléle Si Woagbugbɔ Akpɔ Paracentesis | Gbugbɔ di diagnostic tap le gaƒoƒo 48 ne dɔnɔa mete ŋu nyo ɖe edzi le dɔdamɔnu me ALOO si atypical/nosocomial SBP le eŋu. | Le SBP si woda nyuie me la, ele be gaƒoƒo 48 ƒe ascitic PMN ƒe xexlẽme naɖiɖi \(25\%\) ya teti tso gɔmedzedzea gbɔ. Ne gaƒoƒo 48 ƒe PMN ƒe xexlẽme le teƒe ɖeka alo le dzi yim la, keke dɔlékuiwutikewo ɖe enu enumake na MDRO / ESBL / Enterococcus EYE nàɖe gbe be woawɔ CT scan be woaɖe Secondary Surgical Peritonitis ɖa. |
| 5. Dɔlékuiwutike Evelia Si Wonona le Agbe Me Hafi Woaɖe Wo Do Go | Dze Trimethoprim-Sulfamethoxazole si woano (Bactrim DS, atikekui 1 si ƒe ŋusẽ nye eve [\(160/800\text{ mg}\)] PO zi ɖeka gbesiagbe) ALOO Ciprofloxacin si woano \(500\text{ mg}\) PO zi ɖeka gbesiagbe (alo Norfloxacin \(400\text{ mg}\) PO gbesiagbe gɔme li) ne wowu IV-dɔdamɔnua nu, tsɔ kpe ɖe Aklã Dodo Ŋuti Numekuku Kpata ŋu. | Ne womewɔ mɔxexeɖedɔléle nu gbesiagbe o la, Amesiwo tsi agbe le SBP me dometɔ 70 le alafa me kpea fu le ƒe 1 me gbugbɔgadzɔ le ƒe 1 me, eye ƒe 1 ƒe agbetsitsi le SBP ƒe dzɔdzɔ gbãtɔ megbe nye \(30\%\text{ va ɖo }50\%\) ko ne womedo aklã nɛ o. |
Afɔɖeɖe 3: Paracentesis Gãwo (LVP) Wɔwɔ Dedie Kple Mɔxexe Ðe Paracentesis megbe Lãmetsiŋusẽ ƒe Dɔmawɔmawɔ nyuie (PPCD) Nu .¶
Ne sterile tense ascites (\(\text{PMN} < 250/\text{mm}3\)) le dɔnɔ aɖe ŋu si hea akɔta ƒe ʋuʋudedi, gbɔgbɔtsixetsixe, alo ɖuɖu kabakaba vɛ: 1. Àte Ŋu Aɖe Tsiawo Katã Le Ɣeyiɣi Ðeka Me ("Total Paracentesis to Dryness")? - Ẽ, nenye be wodo Albumin ɖe ʋuka me ɖekae. Egbegbe dodokpɔ siwo wowɔ le vome (Ginès, Tito et al.) ɖo kpe edzi be ne woɖe tsi 8, 10, alo 15 le ascites si me dɔlékui mele o me keŋkeŋ vaseɖe esime wòƒu keŋkeŋ le gaƒoƒo 1 va ɖo 2 ƒe ɣeyiɣi ɖeka me la, ele dedie wu, kabakaba wu, eye wòhea teƒea ƒe kuxi siwo mebɔ o vɛ wu esiwo wogbugbɔ do pɔmpi suewo, NE kple NE KO ètsɔ \(25\%\) Amegbetɔ ƒe Albumin si Wodona Ðe Ʋuka me ɖɔlia ʋuka me dɔdzẽ ƒe nyaƒoɖeamenu. 2. Albumin ɖɔliɖɔli ƒe se siwo sɔ pɛpɛpɛ le gbeɖiɖi ƒe sesẽme si woɖe ɖa nu (AASLD / EASL): - Woɖe Agbɔsɔsɔme ɖa \(< 4\text{ va ɖo }5\text{ Lita}\): Afɔku si le PPCD me le sue; mehiã vevie be woatsɔ albumin ade ʋuka me o negbe ɖe aklã ƒe Dɔmawɔmawɔ nyuie (ACLF) alo Ayiku ƒe Nuveviwɔame Sesẽe le dɔnɔa ŋu le ɣeyiɣi ɖeka me hafi. - Woɖe Volume \(\ge 5\text{ Liters}\) (Large-Volume Paracentesis): Na \(6\text{ va ɖo }8\text{ grams}\) si nye \(25\%\) Amegbetɔ ƒe Albumin si wodona ɖe ʋuka me na ascitic tsi lita ÐESIAÐE si woɖe ɖa (wobu akɔnta le blita agbɔsɔsɔme si woɖe ɖa, alo lita ɖesiaɖe si wu \(5\text{ L}\) ɖe dɔwɔƒe ɖesiaɖe si le nutoa me dzi protocol;AASLD kple EASL kafui \(6\text{ vaseɖe }8\text{ g}\) le lita ɖeka me tsi bliboa si woɖe ɖa ne \(> 5\text{ L}\) tsi do). - Kpɔɖeŋu si wɔa dɔ: Na \(10\text{-liter}\) Large-Volume Paracentesis la, na \(60\text{ vaseɖe }80\text{ grams}\) si nye \(25\%\) Amegbetɔ ƒe Albumin (le kpɔɖeŋu me, \(100\text{-mL}\) vials etɔ̃ siwo nye \(25\%\) Albumin [\(25\text{ g/vial} = 75\text{ g}\) total]), doa \(50\%\) ɖe tsia ƒe dodo me eye \(50\%\) le gaƒoƒo 1 va ɖo 2 me le catheter la ɖeɖeɖa vɔ megbe teti.
Nutome ƒe xexlẽdzesi siwo ku ɖe nudzɔdzɔ kpatawo ŋu kple atikewɔƒe ƒe mɔfiamewo¶
- United States kple Canada: Ƒo ka na 911 na dɔnɔ ɖesiaɖe si ŋu cirrhosis kple ascites le si xɔ asrã, ƒodo me vevesese, tɔtɔ, ʋu si dona le dɔgboa me, alo gbɔgbɔtsixetsixe vevie. Dɔdzikpɔkpɔ zɔna ɖe Amerika Habɔbɔ si Kpɔa Aklãdɔlélewo Ŋuti Nusɔsrɔ̃ Gbɔ (AASLD) ƒe 2021 ƒe Dɔwɔwɔ Ŋuti Mɔfiame le Ascites, Dɔlékuiwo ƒe Dɔlékui Siwo Gbɔna Le Wo Nɔewo Me, kple Aklãdɔléle (Biggins SW et al., Hepatology) ƒe Dɔlélewo Didi, Wo Me Dzodzro, Kple Wo Dzi Kpɔkpɔ Ŋu**.
- United Kingdom: Ƒo ka na 999 alo nàde NHS ƒe Dɔwɔƒe si Kpɔa Nya Kpatawo Gbɔ. Atikewɔlawo zɔna ɖe British Society of Gastroenterology (BSG) kple BASL Guidelines on the Management of Ascites in Cirrhosis (Aithal GP et al., Gut) kple BSG Decompensated Cirrhosis Care Bundle (si nye ascitic tap si wobia tso ame si be wòanya dɔléle si nye ascitic tap le gaƒoƒo 6 me tso esime woxɔe ɖe kɔdzi, dɔlékuiwutikewo enumake + albumin, kple \(8\text{ g}\) albumin le lita ɖeka me le LVP me \(> 5 \ nuŋɔŋlɔ{ L}\)).
- Europa Dukɔwo ƒe Habɔbɔ: Ƒo 112. Atikewɔlawo zɔna ɖe Europa Habɔbɔ si Kpɔa Aklã Ŋuti Nusɔsrɔ̃ Gbɔ (EASL) ƒe Dɔdamɔnu ƒe Mɔfiamewo dzi hena Dɔnɔ siwo ŋu Decompensated Cirrhosis (Journal of Hepatology) ƒe Dɔwɔnawo.
- Australia kple New Zealand: Ƒo ka na 000 le Australia alo 111 le New Zealand eye nàwɔ ɖe Gastroenterological Society of Australia (GESA) ƒe ʋumenugbagbeviɣidɔ kple SBP dzikpɔkpɔ ƒe mɔfiamewo dzi.
Nya siwo wobiaa amewo enuenu¶
Nukatae dɔgbo me vevesese aɖeke mele dɔnɔ siwo katã ŋu Spontaneous Bacterial Peritonitis (SBP) si ate ŋu ade woƒe agbe afɔku me la ƒe afã o?¶
Le amesi me aklãdɔléle mele o gome la, ƒodo me dɔlékui (abe akɔta ƒe gbagbã ene) nana dɔgbo si me dɔdzẽ le la ƒoa xlã ƒodo ƒe gli si le gota (parietal peritoneum) ƒe akpa si sea veve la tẽ, si hea vevesese sesẽ kple ƒodo sesẽ si le abe ʋuƒo ene vɛ ɣesiaɣi si ɖɔkta te ɖe edzi. Le dɔnɔ si ŋu ʋumenugbagbeviɣidɔ kple ascites le gome la, tsi lita 5 va ɖo 15 wɔa dɔ abe tsi ƒe akɔtaɖonu si ma ŋutinu ememetɔwo ɖa le ƒodo ƒe gli gota gome le ŋutilã me ene, si xea mɔ na ƒodo ƒe ʋuʋu eye wòtsyɔa ƒodo ƒe vevesese kple eƒe vevesese si gbugbɔna la dzi. Le ɣeyiɣi ma ke me la, dɔlélenutsiŋutete ƒe cytokine ƒe dɔwɔwɔ me gblẽna le dɔnɔ siwo ŋu ʋusɔgbɔdɔ le ŋu eye woƒe ŋutilã ƒe dzoxɔxɔ le gɔmedzedzea me medea ame dzi o, eyata zi geɖe la, womate ŋu axɔ asrã o. Le esi teƒe be woase veve alo asrã nadze wo dzi la, zi geɖe la, woƒe SBP ƒe dzesi gbãtɔe nyea tɔtɔ kpata (Hepatic Encephalopathy), ʋu ƒe sisi, alo ayiku ƒe dɔmawɔmawɔ nyuie, si tae wòle be ɖɔktawo natsɔ aŋe aƒo dɔnɔ ɖesiaɖe si ƒe dɔgbo le ʋuka me si woxɔ ɖe kɔdzi la ƒe ƒodo ɖo.
Nukatae wònye vodada si me afɔku le be woalala Fresh Frozen Plasma (FFP) alo ʋumenugbagbeviɣidɔ hafi awɔ paracentesis si woatsɔ akpɔ dɔlélea?¶
Ɣesiaɣi kloe la, wowɔa ʋu ƒe sisi ƒe dodokpɔ si mesɔ o (INR si dzina ɖe edzi tso INR 1.8 va ɖo 2.5) kple ʋumenugbagbeviɣidɔ si mebɔ o (40,000 va ɖo 70,000) na dɔnɔ siwo ŋu ʋumenugbagbeviɣidɔ deŋgɔ le elabena woƒe aklã mewɔa ʋumenugbagbeviɣidɔ boo aɖeke o eye woƒe aklã si lolo la léa ʋumenugbagbevi dzĩwo ɖe mɔ̃ me. Gake egbegbe ʋumenugbagbeviɣidɔ ŋuti nunya ɖo kpe edzi be ʋumenugbagbeviɣidɔlélawo hã mewɔa dzɔdzɔme ʋumenugbagbeviɣitike ʋɛ aɖewo (Protein C kple antithrombin), eyata le nyateƒe me la, woƒe ʋu ƒe sisi "gadaa asɔ." Numekuku siwo wowɔ le paracenteses akpe geɖe siwo wotsɔa ultrasound fiaa mɔe ŋu ɖo kpe edzi be ʋudodo ƒe afɔkua mede ame 1 le 500 ɖesiaɖe me o eɖanye INR alo ʋumenugbagbevi dzĩwo ƒe xexlẽme ka kee woɖale o, evɔ ne wohe dɔlélenutsiŋutete ƒe pɔmpi kple dɔlékuiwutikewo ɖe megbe gaƒoƒo 6 pɛ ko be woatsɔ aƒu gbe ahado ʋumenugbagbevi dzĩ si mehiã o la dzia ku si tso SBP ƒe dɔlékuiwutikewo me ɖe edzi alafa memama 20 kloe.
Aleke Albumin si wodona ɖe ʋuka me xɔa amewo ɖe agbe le SBP me esime Ceftriaxone le dɔlékuiawo wum xoxo?¶
Ne Ceftriaxone si wodona ɖe ʋuka me wu E. coli alo Klebsiella dɔlékui siwo le ascitic tsi me kabakaba gɔ̃ hã la, dɔlékui siwo le kukum la ɖea endotoxin (lipopolysaccharide) si hea nitric oxide ƒe gbagbã gã aɖe vɛ le dɔgboa ƒe ʋukawo me. Nitric oxide ma nana ʋuka siwo katã le ƒodoa me kekena, si ƒoa ʋu nu ƒu ɖe dɔgboa me eye ʋu ƒe sisi ƒe dɔ nana ayikuwo, si hea Hepatorenal Syndrome (ayiku ƒe dɔmawɔmawɔ nyuie) si wua ame vɛ le dɔnɔ 30 le alafa me ŋu. Amegbetɔ ƒe Albumin 25% si me wode tsii dodo ɖe lãme le Ŋkeke 1 (1.5 g/kg) kple Ŋkeke 3 (1.0 g/kg) dzi wɔa nu eve siwo xɔa ame ɖe agbe siwo dzetsi ƒe IV tsiwo mate ŋu awɔ o: eƒe oncotic ƒe nyaƒoɖeamenu sesẽa léa tsi ɖe titina ʋukawo me be ayikuawo nayi edzi anɔ ʋu me, eye albumin protein molecule la blaa dɔlékuiwo ƒe endotoxin, nitric oxide, kple dɔdzẽ ƒe molecule tẽ eye wòɖea wo ɖa cytokines, si na ku ƒe agbɔsɔsɔ dzi ɖe kpɔtɔ zi gbɔ zi eve le etɔ̃ me.
Nukae adzɔ ne ɖɔkta ɖe tsi lita 8 le ƒodo si vuvu (Large-Volume Paracentesis) me evɔ mena IV Albumin o?¶
Ne ɖɔkta ɖe tense ascitic tsi si wu lita 5 le ɣeyiɣi ɖeka me evɔ metsɔ Albumin 25% de ʋuka me o la, nyaƒoɖeamenu si le ƒodoa me ƒe ɖiɖi kpata nana ʋuka siwo naa nuɖuɖu dɔgboa kekena kabakaba. Le gaƒoƒo 24 va ɖo 72 siwo kplɔe ɖo me la, tsi dona le ʋukawo me trɔna yia ƒodoa me be yeagayɔ teƒea, si wɔnɛ be dɔnɔa ƒe ʋukawo me ʋu ƒe agbɔsɔsɔ si wɔa dɔ nyuie la mu, si nye nɔnɔme si woyɔna be Post-Paracentesis Circulatory Dysfunction (PPCD). Ayikuawo wɔa esia to renin, aldosterone, kple antidiuretic hormone (ADH) ƒe dzidziɖedzi gã aɖe dodo me, si wɔnɛ be sodium si le ʋu me dzi ɖena kpɔtɔna vevie (hyponatremia), ayiku ƒe dɔmawɔmawɔ nyuie (Hepatorenal Syndrome), ascites la trɔna kabakaba, eye wònana ame geɖe kuna. IV Albumin 25% gram 6 va ɖo 8 dodo ɖe tsi lita ɖesiaɖe si woɖe ɖa me xea mɔ na PPCD keŋkeŋ.
Dzɔtsoƒewo kple dziɖuɖumegãwo ƒe mɔfiame¶
- Amerikatɔwo ƒe Habɔbɔ si Kpɔa Aklãdɔlélewo Ŋuti Nusɔsrɔ̃ Gbɔ (AASLD 2021 Practice Guidance, Biggins SW, Angeli P, Garcia-Tsao G et al., Asiklãŋutinunya): Ascites, Dɔlékuiwo ƒe Dɔlékui Siwo Gbɔna Le Wo ɖokui Si, Post-Paracentesis Circulatory Dysfunction, kple Hepatorenal Syndrome ƒe dɔlélewo didi, wo me dzodzro, kple wo dzi kpɔkpɔ.
- New England Journal of Medicine (Sort Landmark Trial, Sort P, Navasa M, Arroyo V et al., NEJM 1999): Ŋusẽ si Albumin si wodona ɖe ʋuka me kpɔna ɖe ayiku ƒe dɔmawɔmawɔ nyuie kple ku dzi le Dɔnɔ siwo ŋu Aɖuɖɔtoedɔ kple Dɔlékuiwo ƒe Dɔlékui Siwo Dzɔna Le Wo Nɔewo Me.
- Europa Habɔbɔ si Kpɔa Aklã Ŋuti Nusɔsrɔ̃ Gbɔ (EASL): EASL ƒe Dɔdamɔnu ƒe Mɔfiamewo na Dɔnɔ siwo ŋu Decompensated Cirrhosis Le (Journal of Hepatology).
- British Society of Gastroenterology (BSG) kple BASL (Aithal GP et al., Gut): Mɔfiamewo le Ascites dzi kpɔkpɔ le Cirrhosis me kple BSG Decompensated Cirrhosis 6-Hour Care Bundle.
- Runyon ƒe Ascitic Fluid Criteria (Runyon BA, Hepatology): Vovototodede Dɔlékui ƒe Akɔtadɔ si Le Eɖokui Me kple Dɔlékui Evelia ƒe Akɔtadɔ (Perforated Viscus) dome to Ascitic Fluid Protein, Glucose, kple LDH zazã me.
Wɔ kpekpeɖeŋunana gbãtɔ ƒe hehexɔxɔ si ŋu woɖo kpee eye nàbia gbe eŋutinunyalawo
Mɔfiame sia naa hehe le dzesidede nu kpata kple kɔdzi ƒe vovototodedeameme ŋu eye mexɔ ɖe aklãŋutinunyala bibiwo, dɔgboŋutinunya, keklẽŋusẽdɔdamɔnu si dea nu nyawo me, alo atikewɔwɔ kpata teƒe o. Be nàtu aɖaŋu ŋutɔŋutɔwo ɖo le dzesidede dɔlékuiwutike, dzidziƒoame, kple susu ƒe nɔnɔme si trɔ kple agbemenuhiahiã veviwo wɔwɔ me la, wɔ kpekpeɖeŋunadɔ gbãtɔ si ŋu woɖo kpee to Atitsoga Dzĩ Habɔbɔ, St John Ambulance, alo nutoa me dɔwɔƒe aɖe dzi.
Mɔfiame siwo do ƒome kplii¶
- Aklã ƒe tagbɔdɔléle (aklã ƒe alɔ̃madɔmadɔ ƒe Dzeside 3 kple 4), ɣletivimefakaka, kple lactulose enema
- Nuɖuɖutome ƒe ʋukawo ƒe gbagbã, ʋu si dona le ahɔhɔ̃mekawo me, kple aklã ƒe tagbɔdɔléle
- Nephrotic syndrome, ŋku ƒe ʋuʋu le ŋdi me le periorbital, protein ƒe aɖuɖɔ si me ʋuʋudedi le, kple SBP le ɖeviwo me
- Appendicitis, appendicitis ƒe gbagbã, peritonitis, kple ɖusime ƒe akpa si le anyime ƒe vevesese
- Xexlẽdzesi siwo woxɔna kpata le dukɔwo nu