ʻO ka huikau ʻole o ka ate (Hepatic Encephalopathy) a me ke koko ʻokoʻa¶

ʻO nā poʻe maʻi e noho ana me ka maʻi ate mau, cirrhosis, a i ʻole ka hōʻino ʻana o ka ate, ke kū nei lākou i ʻekolu mau pilikia decompensation weliweli i ke ola e hiki ke hū me ka ʻole o ka ʻōlelo ʻana ma ka home: ruptured gastroesophageal varices (masive upper gastrointestinal hemorrhage where engorged veins in the lower esophagus open), hepatic encephalopathy a me ka hoʻololi ʻana o ka maʻi maʻi coma ma muli o ka ammonia a me nā neurotoxins o ka ʻōpū e kāʻalo ana i ke akepaʻa ʻulaʻula a me ka pehu ʻana i ka lolo), a me ** sppontaneous bacterial peritonitis (SBP)** (he maʻi maʻi bacteria wikiwiki a hoʻoweliweli i ka wai i loko o ka ʻōpū pehu).

ʻO kāu kuleana koke i ka wā e mālama ai i ka mea maʻi ate i ka pilikia, ʻo ia ke kāhea koke i nā lawelawe lapaʻau pilikia, pale i ke alaloa ma ka ʻōwili ʻana i kahi maʻi luaʻi a hiamoe paha ma ko lākou ʻaoʻao ma ka ** kūlana hoʻōla ** (ʻoiai ʻo ka lumo ʻana i ke koko aspirated ke kumu nui o ka make koke i ka variceal rupture) "ka haʻalulu lima" (asterixis) no ka ʻike ʻana i ka encephalopathy hepatic mua, a pale loa i ka hāʻawi ʻana i nā lāʻau hiamoe, nā mea hoʻomaha, nā ibuprofen/NSAID, a i ʻole nā ​​acetaminophen keu.

E hana i kēia i kēia manawa¶

1. Kahea koke i nā lawelawe lapaʻau pilikia: Kāhea i kāu helu ulia pōpilikia kūloko (911 ma ʻAmelika Hui Pū ʻIa a me Kanada, 112 ma waena o ʻEulopa, 999 ma United Kingdom, 000 ma Australia) a i ʻole e nānā i kā mākou papa kuhikuhi o helu pilikia. E haʻi aʻe i ka maʻi he cirrhosis a i ʻole maʻi ate a e luaʻi ana ʻo ia i ke koko, e hele ana i ka ʻeleʻele ʻeleʻele o ka noho ʻana, huikau/ ʻaʻole hiki ke hoʻoulu ʻia, a i ʻole e holo ana i ke kuni me ka ʻeha o ka ʻōpū.
2. Inā luaʻi koko a hiamoe paha, e waiho ma ka ʻaoʻao e hoʻihoʻi koke i ke kūlana: Mai ʻae i ka mea maʻi e luaʻi ana i ke koko a i ʻole ka hiamoe ʻana mai ka hepatic encephalopathy e moe palahalaha ma kona kua. E ʻōwili iā lākou ma ko lākou ʻaoʻao hema me ka hiʻi iki ʻana o ko lākou ʻauwae i lalo i ka papahele no laila e kahe ana ke koko, ka luaʻi ʻeleʻele "kofe", a i ʻole ke kahe ʻana o ke kohu ma waho o ka waha ma mua o ka ʻoki ʻana i ka māmā.
3. E hoʻokō i ka NPO koʻikoʻi (ʻaʻohe mea ma ka waha) i ka wā o ke koko a i ʻole ka hiamoe nui: Mai hāʻawi i ka wai, ka waiū, ka meaʻai, a i ʻole nā ​​​​palapala waha inā luaʻi ka mea maʻi i ke koko, hele i ka ʻeleʻele o ka noho ʻana, a i ʻole ka hiamoe nui e noho i luna a kamaʻilio maikaʻi. Pono ka poʻe gastroenterologist o ka haukapila i ka ʻōpū ʻole e hana i ka ligation endoscopic variceal band ligation i loko o nā hola o ka hōʻea ʻana.
4. E nānā i ka "asterixis" (asterixis) inā pilihua a huhū paha ka mea maʻi: E noi i ka mea maʻi e ala pololei e ʻō pololei i nā lima ʻelua i mua o lākou, e kulou i hope i ko lākou mau lima lima ("e like me ka mākaʻikaʻi e hoʻomaha i ke kaʻa"), a hohola i ko lākou manamana lima ākea no 15 a 30 kekona. Inā hāʻule ko lākou mau lima a me nā pulima lima i mua a hoʻihoʻi i luna me kahi ʻēheu manu, aia lākou i ka acute hepatic encephalopathy.
5. Mai hāʻawi i nā lāʻau lapaʻau hiamoe, nā mea hoʻomaha hopohopo, nā opioids, a i ʻole nā ​​mea hōʻeha ʻeha NSAID: Mai hāʻawi i nā benzodiazepine maʻi hoʻomaha, insomniac, a i ʻole nā ​​​​mea maʻi ʻehaʻeha (lorazepam, alprazolam, diazepam), kōkua hiamoe (zolpidem, diphenhydramine), nā lāʻau lapaʻau opioid, a i ʻole NSAIDs, (naixbuprofen, naprofen). Hoʻokomo pololei nā mea hoʻomaʻamaʻa i ka mea maʻi me ka encephalopathy hepatic i loko o kahi coma unrousable, ʻoiai nā NSAID e hoʻoulu i ke koko variceal fatal a me ka pani koke ʻana o ke kīpē (hepatorenal syndrome).
6. E hoʻomaʻamaʻa i ka mea maʻi a hōʻiliʻili i nā lāʻau lapaʻau a pau: E uhi i ka mea maʻi me nā pākeʻe maloʻo mahana e pale ai i ka hypothermia (ʻo ia ka mea e hoʻopaʻa hou ai i ke koko i loko o ka cirrhosis), a e hōʻiliʻili i kā lākou mau hue o lactulose, rifaximin, beta-blockers (propranolol, nadolol, carvedilol), a me **diuretics no ka fusuronolactone

flowchart TD
    Start["ʻO ka mea maʻi me ka maʻi cirrhosis a i ʻole ka maʻi ate e hoʻopōʻino ma ka home"] --> Triage{"1. E ʻike i ka pilikia o ka hoʻopau ʻana"}
    Triage -->|Vomiting Bright Red Blood, Clots, Coffee Grounds, or Passing Black Tarry Stools| Varices["Nā ʻano ʻokoʻa o ka esophageal ʻāhaʻi: E kelepona iā 911/112/999 koke, ka maʻi koko kiʻekiʻe."]
    Triage -->|New Confusion, Reversed Sleep-Wake Cycle, Irritability, Slurred Speech, or Flapping Hands| HE["Hepatic Encephalopathy: E kelepona iā 911/112/999 a i ʻole Hepatologist, E nānā no ka Huna Huna (Bleed, Infection, Constipation)"]
    Triage -->|Swollen Ascites Belly With New Fever, Chills, Belly Tenderness, or Low Blood Pressure| SBP["ʻO Spontaneous Bacterial Peritonitis (SBP) / Sepsis: E kelepona iā 911/112/999 koke no IV Antibiotics"]
    Varices --> Airway["2. E kaa koke i ka mea ma'i ma ka aoao (ke kulana Hoola) i kahe ke koko mailoko mai o ka waha, mai waiho palahalaha ma ke kua."]
    Airway --> NPO["3. E mālama pono i ka NPO (ʻAʻohe mea ma ka waha), E mahana me nā Blankets, E hoʻomākaukau no ka Endoscopy Emergency"]
    HE --> CheckAwake{"4. Ua ala pono anei ka ma'i huikau a hiki ke ale me ka maluhia?"}
    CheckAwake -->|No: Drowsy, Stuporous, or Slurring| Airway
    CheckAwake -->|Yes: Alert Grade 1 or 2 Encephalopathy| Lactulose["E hahai i ka papahana Lactulose no ka lā maʻi o ke kauka inā ʻōlelo ʻia, mai hāʻawi i nā lāʻau hoʻomaha a i ʻole nā ​​lāʻau hiamoe, lawe i ka haukapila."]
    SBP --> NPO

Nā ʻano ʻokoʻa o ka gastroesophageal: no ke aha ke kumu o ka cirrhosis i hoʻopōʻino i ke koko¶

I loko o ke kino maika'i, e kahe ana ke koko a pau mai ka 'ōpū, ka 'ōpū, ka pancreas, a me ka spleen i loko o kekahi ipu nui i kapa 'ia 'o ka portal vein i loko o ke akepa'a palupalu a spongy e kānana ma mua o ka ho'i 'ana i ka pu'uwai. Ke hoʻololi ka maʻi ate maʻi (mai ka waiʻona, ka maʻi hepatitis B a i ʻole C, metabolic dysfunction-associated steatohepatitis / MASH, a i ʻole ka maʻi autoimmune) ke hoʻololi i ka ʻiʻo palupalu palupalu me ka ʻiʻo ʻili paʻakikī, fibrous (cirrhosis), ʻaʻole hiki ke kahe maʻalahi ke koko ma o ke ake.

ʻO ke kaomi ʻana i loko o ka ʻāʻī puka e hoʻi i hope e like me nā kaʻa ma hope o kahi alaloa i ālai ʻia, kahi kūlana i kapa ʻia ʻo portal hypertension. No ka makemake e ʻimi i kahi alahele e hoʻi ai i ka puʻuwai, ua hoʻoneʻe ʻia ke koko puka paʻa i nā ʻaʻa liʻiliʻi liʻiliʻi, palupalu, ʻeleʻele ʻeleʻele e pili ana i ka lalo o ka esophagus (puu ʻai) a me ka piko o ka ** ʻōpū**. I loko o nā mahina, ʻaloʻalo kēia mau aʻa palupalu i loko o nā kaula wili a me ke kaomi kiʻekiʻe i kapa ʻia ʻo esophageal and gastric varices.

ʻElua kumu i ʻoi aku ka make o ke koko variceal ma mua o ke koko o ka ʻōpū maʻamau¶

1. Ke kiʻekiʻe kiʻekiʻe portal venous pressure: ʻAʻole e like me ka peptic ulcer liʻiliʻi, he esophageal varix ma lalo o ke kaomi hydrostatic kiʻekiʻe mau; i ka wā e haki ai kona pā lahilahi, e kahe ana ke koko i loko o ka esophagus a me ka ʻōpū ma ka wikiwiki o 100 a 500 milliliters i ka minuke.
2. Coagulopathy a me ka thrombocytopenia o ka hāʻule ʻole o ke ake: Na ke ake ola kino e hana i nā protein e hoʻopaʻa koko i ke kino (prothrombin, fibrinogen, Factors V, VII, IX, X) ʻoiai ka nui o ka spleen i loko o nā pahele hypertension portal a hoʻopau i ke koko platelets. No laila, i ka wā e poha ai ka varix i loko o ka mea maʻi cirrhotic, nele ke koko i nā platelets a me nā kumu hoʻopaʻapaʻa e pono ai e hoʻopili i ka lua iā ia iho.

Nā hōʻailona makaʻala o nā varices naha (ʻoiai ma mua o ka luaʻi ʻana o ke koko)¶

ʻAʻole e luaʻi mau ka mea maʻi i ke koko ʻulaʻula ʻulaʻula i ka wā e hoʻomaka ai ke kahe ʻana o ka varix i loko o ka ʻōpū:

• Hematemesis (Ka luaʻi koko): ʻO ka luaʻi nui ʻole o ka ** koko wai ʻulaʻula ʻulaʻula**, ** ʻulaʻula ʻulaʻula ʻulaʻula koko ʻulaʻula** ka nui o nā plums, a i ʻole ** nā mea ʻeleʻele ʻeleʻele ʻeleʻele e like me ka paʻa kofe pulu** (kahe koko ʻōpū).
• ** Melena (ʻeleʻele, lōʻihi, ʻala ʻala):** ʻO ke koko e ʻauʻau ana i loko o ka ʻōpū a hele i lalo i loko o ka ʻōpū e ʻeli ʻia e ka ʻakika o ka ʻōpū a me ka maʻi bacteria i loko o ** ʻeleʻele-ʻeleʻele, paʻa, ʻālohilohi e like me ke kua o ke alanui** a loaʻa ka ʻala metala paʻa ʻole. ** ʻO ka hele ʻana i nā ʻeke ʻeleʻele i loko o ka mea maʻi me ka cirrhosis he maʻi hemorrhage GI kiʻekiʻe **, ʻo ke kumu hoʻokahi wale nō o ka huikau a maule paha inā ʻaʻohe luaʻi.
• Hematochezia (Maroon a i ʻole ke koko ʻulaʻula ʻulaʻula mai ka ʻāʻī): Inā ʻoi aku ka wikiwiki o ke koko variceal (ʻoi aku ma mua o 1,000 milliliters), holo wikiwiki ke koko ma ka ʻāpana ʻōpū holoʻokoʻa a puka i waho o ka ʻāʻī me ka ʻulaʻula ʻeleʻele a i ʻole ka ʻulaʻula, i hele pū ʻia me ka poni a me ka haʻalulu.
• Maʻule koke ʻole ka ʻeha (Syncope) a me ka hou anu: Ma muli o ka hana ʻana o ke koko e hoʻopiha ana i ka ʻōpū ma ke ʻano he cathartic ikaika, nui ka poʻe maʻi e manaʻo koke i ka pono e hoʻohana i ka lua, hele i loko o ka lumi ʻauʻau, a hāʻule me ka ʻike ʻole ma ka papahele o ka lua ma mua o ka ʻike ʻana o kekahi e kahe ana ke koko i loko.

Ke kōkua mua i kēlā me kēia ʻanuʻu no ka hemorrhage variceal ikaika¶

1. E kiʻi koke i nā mea lapaʻau a wehe i ka puka mua: He helu kēlā me kēia minuke; ʻO ke ola o ka haukapila e pili ana i ka loaʻa ʻana o nā lāʻau vasoactive intravenous (octreotide a i ʻole terlipressin no ka hoʻohaʻahaʻa ʻana i ke kaomi vein portal), nā lāʻau antibiotic prophylactic intravenous (ceftriaxone), ka hoʻokahe koko makaʻala, a me ka **kekahi endoscopic variceal band ligation ** i loko o 12 mau hola.
2. Paʻa i ke ala ea ma ke kūlana hoʻihoʻi ʻaoʻao hema:
3. E ʻōwili i ka mea maʻi ma ko lākou ʻaoʻao hema ma ka papahele a i ʻole kahi moe.
4. E hoʻohuli iki i ko lākou mau maka i lalo ma luna o ke kīʻaha a i ʻole ke kāwele i kahe pololei mai ke koko a me nā ʻōpala mai ka papalina lalo.
5. E hoʻohana i ka manamana lima lima lima i wahī ʻia i kahi lole e kahili i nā ʻōpuʻu koko nui e like me ka jeli mai ke alo o ka waha inā lākou e ʻakaʻaka. Mai hoʻopaʻa i ka mea maʻi luaʻi ma luna o kona kua, a mai hoʻopololei iā lākou e noho pololei inā nalo lākou a maule paha, no ka mea, ʻo ka noho pololei ʻana e hoʻoulu ai i ka hypoperfusion o ka cerebral a me ka syncope koke me ka manaʻo.
6. E hoʻomaʻamaʻa i ka mea maʻi me nā pākeʻe maloʻo: E ʻōwili i ka ʻōpū a me nā wāwae i nā pākeke mahana. ʻO ka Hypothermia ma lalo o 36.0 degere Celsius (96.8 degere Fahrenheit) e hoʻopau i ka liʻiliʻi o nā enzyme clotting a me nā platelets i waiho ʻia e ka mea maʻi.
7. **Mai hāʻawi i ka wai, nā ʻāpana hau, nā antacids, a i ʻole nā ​​​​lāʻau paʻi koko ma ka waha: ** Inā e noi ka mea maʻi i ka wai e holoi ai i ka ʻono o ke koko mai loko mai o ko lākou waha, e holoi wale i ko lākou mau lehelehe me kahi lole pulu. ʻO ka hāʻawi ʻana i ka wai e hoʻopiha ai i ka ʻōpū me ka wai e hūnā i ke kiʻi endoscopic o ka gastroenterologist a hoʻoulu hou i ka luaʻi a me ka manaʻo.

Hepatic encephalopathy (HE): no ke aha ke kumu o ka hana ʻole o ka ate i ka huikau a me ka coma¶

Ma ke ola kino, hoʻopau nā hua bacteria e noho ana i loko o ke kolonā i ka protein meaʻai a hoʻohua i nā mea ʻōpala nitrogen ʻona, ʻo ammonia (\(NH_3\)), me nā mercaptans, nā ʻakika momona pōkole, a me ka manganese. ʻO ka maʻamau, lawe pololei ke koko vein portal i kēia ammonia a pau i loko o ke ake, kahi e hoʻohuli ai nā pūnaʻi ate olakino (hepatocytes) i ka amonia ʻona i urea ʻinoʻole ma o ka pōʻaiapuni urea i hiki ai i nā puʻupaʻa ke hoʻokahe ia i loko o ka mimi.

I ka cirrhosis a i ʻole ʻāʻī ʻole o ka ate, ʻelua mau mea i hewa: nalowale nā ​​​​pūnaewele ate ʻulaʻula a hiki i ka 80 pakeneka o ko lākou hiki ke hoʻomaʻemaʻe i ka amonia, a ʻo ke kiʻekiʻe kiʻekiʻe o ka portal e hoʻoikaika i ke koko o ka ʻōpū e kaʻe loa i ke ake ma o nā collateral shunt (a i ʻole kahi ʻoki ʻia ** TIPS stent**: transjugular intrahepatic portosystemic shunt). Holo pololei ʻo amonia i kānana ʻole i loko o nā ʻaʻaʻa ʻōnaehana a hele i ka pale koko-lolo. I loko o ka lolo, e kākoʻo ana i nā sela lolo i kapa ʻia ʻo astrocytes e hoʻāʻo e hoʻomaʻemaʻe i ka amonia ma ka hoʻololi ʻana i ka glutamate i glutamine. Hana ʻo Glutamine me he ʻōhuʻu osmotic i loko o nā astrocytes, e huki ana i ka wai i loko o nā pūnaʻi lolo a hoʻoulu i ka ** diffuse cerebral edema (ka pehu ʻana o ka lolo)** a me ka hoʻopaʻa ʻana i nā neurochemical nui (hepatic encephalopathy).

The West Haven Grading Scale: ʻike i ka encephalopathy hepatic mai ka Papa 1 a i ka Papa 4¶

ʻO nā lālā o ka ʻohana e noho ana me ka maʻi akepaʻa ka mea mua e ʻike i ka Grade 1 a i ʻole Grade 2 hepatic encephalopathy, ma mua o ka ʻike ʻana o kahi malihini i kekahi hewa. E hoʻohana i ka West Haven Criteria no ka ʻimi ʻana a hōʻike i ka pae pololei o ka mea maʻi:

Pehea e hana ai i ka ho'āʻo "Asterixis" (Flapping Tremor).¶

ʻO Asterixis ʻaʻole ia he haʻalulu o nā ʻiʻo ʻokoʻa; ma ka neurophysiologically, he negative myoclonus, he 50-a-200-millisecond uwila pōkole ** hoʻomaha (pani)** i loko o nā kikowaena cortex kaʻa e mālama ana i ke kūlana kūʻē i ka umekaumaha, ma muli o ka make ʻana o ka amonia.

1. E noho pololei ka mea maʻi ma kahi moe a i ʻole kahi noho (a moe i luna paha) a hohola pololei i nā lima ʻelua i mua o ko lākou umauma me nā kuʻekuʻe lima pololei.
2. E aʻo iā lākou e kulou i hope i nā lima ʻelua (ka hoʻololi ʻana, nā lima e kū i mua me he mea lā e hoʻokuʻi ana i ka paia ʻike ʻole ʻia) a hohola ākea ko lākou mau manamana lima.
3. E haʻi iā lākou e pani i ko lākou mau maka a paʻa mau i kēlā kūlana kūpono no 30 kekona.
4. He aha ke ʻano o ka hoʻāʻo maikaʻi: Ma hope o ka lōʻihi o 5 a 15 kekona, hāʻule koke nā manamana lima a me ka lima lima i mua i kekahi mau kenimika i ka nalo ʻana o ke kani o ka ʻiʻo no kekona kekona, a laila hoʻi koke i luna i ka wā e hopu ai ka mea maʻi, e hana hou ana me ka leo e like me ka manu e pāpaʻi ana i kona mau ʻēheu ("liver flap").
5. He ho'āʻo ʻē aʻe no nā maʻi nāwaliwali: Inā nāwaliwali loa ka mea maʻi ʻaʻole hiki ke hoʻopaʻa i nā lima ʻelua i luna i ka lewa, e hoʻomaha paʻa ko lākou mau lima ma luna o ka moena a hāpai wale i ko lākou mau lima i luna ma ka pulima no 20 kekona, a i ʻole e noi iā lākou e ʻomi mau i ʻelua o kou mau manamana lima ("ʻaʻa waiu").

ʻO ka 6 mau mea huna e hoʻopiʻi i ka encephalopathy hepatic¶

Hepatic encephalopathy aneane ʻaʻole loa e ʻike ʻia i waho o ka ea lahilahi i kahi maʻi cirrhosis paʻa mua; ma ** ʻoi aku ma mua o 80 pakeneka o ka hoʻokomo ʻana i ka haukapila**, kahi hōʻino kino koʻikoʻi i hoʻomaka i ka piʻi ʻana o ka ammonia. Huli koke nā kauka ulia pōpilikia i kēia ʻeono mau mea hoʻoheheʻe maʻamau (a pono e haʻi i nā mea mālama i nā paramedics nā mea i hana ʻia i nā hola 72 i hala iho nei):

1. ** ʻO ke koko ʻāʻai haʻahaʻa (He "ʻai protein" nui o ke koko):** Hoʻopiha ʻia ke koko me ka protein hemoglobin (100 milliliters o ke koko aia ma kahi o 15 a 20 grams o ka protein maʻemaʻe). Ke kahe malie nei ka ma'i ma'i varix a i 'ole ka ma'i o ka opu i loko o ka'ōpala ho'ohehe'e, 'a'ai ka ma'i bacteria i ka protein koko i ho'okahe 'ia a ho'ololi 'ia i loko o ka nalu nui o ka ammonia. E nānā mau i ka halepaku a i ʻole e nīnau e pili ana i ka ʻeleʻele a me ka moe (melena) ke huikau ka maʻi ate.
2. ** Ka maʻi maʻi (ʻoi aku ka Spontaneous Bacterial Peritonitis, UTI, a i ʻole Pneumonia): ** ʻO ka ʻāʻī ʻana o ka ʻōnaehana a me nā mea ʻawaʻawa bacteria e hoʻoheheʻe i ka pale o ka lolo-koko a hoʻonui i ka neurotoxicity ammonia ʻelima.
3. ** ʻO ka paʻa ʻana a me ka hala ʻole ʻana o nā kumu Lactulose:** Inā noho ʻia ka ʻōpala i loko o ke kolone no 24 a 48 mau hola ma mua o ka hoʻokuʻu ʻia ʻana i waho 2 a 3 mau manawa i kēlā me kēia lā, hoʻohua a hoʻopaʻa ʻia nā huakini colonic i ka amonia.
4. Dehydration, Over-Diuresis, Vomiting, or Diarrhea (Electrolyte & Kidney Crisis): ʻO ka lawe ʻana i ka nui loa o nā lāʻau wai i kuhikuhi ʻia (furosemide a me spironolactone), ka hou ʻana i ka wela, a i ʻole ka loaʻa ʻana o ka ʻōpū i ke kumu ** ʻeha puʻupaʻa nui**, **hypokalemia (haʻahaʻa koko. Hoʻoulu pololei ka pāhaʻi koko haʻahaʻa i nā puʻupaʻa e hana i ka amonia hou, ʻoiai hoʻohuli ka alkalosis i nā ion ammonium (\(NH_4^+\), ʻaʻole hiki ke komo i loko o ka lolo) i ke kinoea amonia uncharged (\(NH_3\), e hele pololei ana i ka lolo).
5. Nā Laʻau Hoʻohaʻahaʻa Pūnaehana Nervous Center: ʻO ka lawe ʻana i hoʻokahi maʻa o ka benzodiazepine (lorazepam, diazepam, clonazepam), pila moe (zolpidem), antihistamine sedating (diphenhydramine, hydroxyzine), a i ʻole opioid painkiller (oxycodone, morphine, tramadol).
6. Acute Portal Vein Thrombosis or New TIPS Shunt: He koko koko hou e ālai ana i ka ʻaʻa puka a i ʻole he shunt ate i kau hou ʻia.

Ka hoʻomaopopo ʻana iā Lactulose a me Rifaximin (A i ka wā ʻaʻole e hāʻawi i ka Lactulose waha)¶

ʻO ka poʻe maʻi me ka cirrhosis a me ka encephalopathy hepatic mua e kuhikuhi mau ʻia i ʻelua mau lāʻau mālama mālama i kēlā me kēia lā e hoʻomaʻemaʻe i ka amonia mai ka ʻōpū:

• Lactulose (a i ʻole Lactitol): He mānoanoa, ʻono, ʻaʻole hiki ke hoʻopaʻa ʻia i ka syrup synthetic sugar. Ke hiki aku ka lactulose i ke kolonā, e hoʻomoʻa ʻia ka hua bacteria maikaʻi i loko o ka waikawa lactic a me ka waikawa acetic. Hoʻokuʻu kēia acidification i ka pH i loko o ke kolonā, kahi e pahele kemikika ai ammonia (\(NH_3\)) ma ka hoʻohui ʻana i kahi hydrogen ion e hoʻololi iā ia i ammonium (\(NH_4^+\)). No ka mea, ʻaʻole hiki i ka ammonium i hoʻopaʻa ʻia ke hele i loko o ka pā ʻōpū i loko o ke kahe koko, paʻa mau ia i loko o ka waihona a hoʻokuʻu ʻia i waho o ke kino e ka lactulose's osmotic laxative hana. Hoʻopaneʻe nā kauka i ka nui o ka lactulose i kēlā me kēia lā no laila e hele ka mea maʻi i 2 a 3 mau ʻōpū palupalu palupalu i kēlā me kēia lā.
• Rifaximin: He lāʻau antibiotic waha hiki ʻole ke komo i loko o ka ʻōpū a hoʻemi i ka heluna kanaka o ka maʻi bacteria e hana ana i ka ammonia.

ʻO ke kānāwai palekana koʻikoʻi i ka wā o ka pilikia encephalopathy ma ka home¶

• Inā ʻo ka mea maʻi ma ka Papa 1 mua a i ʻole ka Papa 2 HE (ala ākea, noho i luna, ʻaʻo maʻamau, a hiki ke inu i ka wai me ka ʻoki ʻole ʻana) a ua nele i kā lākou lactulose a paʻa paha, e kāhea aku i kā lākou hepatologist a i ʻole ka hoʻouna pilikia e komo pū me ka hāʻawi ʻana i ka lāʻau lactulose o ka lā maʻi waha i ka wā e hoʻonohonoho ana i ka loiloi olakino.
• ** ʻAʻole e ninini i ka lactulose waha (a i ʻole kekahi wai) i loko o ka waha o ka mea maʻi Papa 3 (huhū/moe) a i ʻole Papa 4 (comatose):** I ka wā e hiamoe ai ka mea maʻi, uwē nui, a paʻakikī paha e ala aʻe, ʻōpuʻu ko lākou gag reflex. ʻO ka ninini ʻana i ka lactulose syrup mānoanoa i loko o ko lākou waha e hoʻoulu koke i ka pulmonary aspiration i loko o ka māmā. Hoʻohana ka poʻe lapaʻau a me nā kahu hānai i nā maʻi ma ka Papa 3 a me ka Papa 4 me ka palekana me ka hoʻohana ʻana i ka ** lactulose retention enemas** a i ʻole ka nasogastric tube i pale ʻia ma hope o ka hoʻopaʻa ʻana i ke alaloa.

ʻO Spontaneous Bacterial Peritonitis (SBP) a me nā pilikia ulia pōpilikia¶

He nui nā poʻe maʻi me ka cirrhosis decompensated e hōʻiliʻili i nā lita o ka wai kala mauʻu i loko o ko lākou ʻōpū o ka ʻōpū (ascites), e hōʻemi ana i ka ʻōpū, pehu, ʻākea. Ma muli o ka haʻahaʻa loa o ka wai ascitic o nā protein immune (complement), hiki i ka bacteria maʻamau mai ka ʻōpū ponoʻī o ka mea maʻi ke neʻe i ka microscopically ma o ka paia o ka ʻōpū (translocation bacterial) a hoʻopōʻino i ka wai ʻōpū me ka ʻole o ka puka ʻana o ka ʻōpū. Ua kapa ʻia kēia maʻi hoʻoweliweli ʻo Spontaneous Bacterial Peritonitis (SBP) a loaʻa i ka 20 a 30 pakeneka ka nui o ka make inā hoʻopaneʻe ʻia nā lāʻau antibiotic intravenous i kekahi mau hola.

Nā hae ʻulaʻula o Spontaneous Bacterial Peritonitis (SBP)¶

ʻAʻole e like me ka peritonitis o ka ʻokiʻoki ʻana mai kahi ʻāpana pohā (ʻo ia ka mea e paʻakikī ai ka ʻōpū o ka ʻōpū), ʻo ka cushion wai o nā ascites i loko o kahi maʻi cirrhosis e pale ai i nā ʻiʻo o ka ʻōpū mai ka paʻakikī. E ʻimi i kekahi o kēia mau hōʻailona maʻalahi i ka mea maʻi me ka ascites:

• ** ʻO ke kuni ma luna o 37.8 degere Celsius (100.0 degere Fahrenheit) a i ʻole hypothermia ma lalo o 36.0 degere Celsius (96.8 degere Fahrenheit)**, a i ʻole ka haʻalulu haʻalulu i wehewehe ʻole ʻia.
• Ka ʻeha ʻōpū hou, ka ʻūhā, ka ʻehaʻeha, a i ʻole ka ʻoluʻolu ke kaomi mālie ʻana i ka ʻōpū pehu, a i ʻole ka ʻōpū i ʻoi aku ka ʻoi aʻe o ka ʻoi aʻe o ka ʻeha ma mua o ka maʻamau.
• Hūhū hou a ʻoi paha ka ʻino / hepatic encephalopathy me ke kumu ʻike ʻole (a hiki i ka 30 pakeneka o nā hihia SBP, ʻo ka huikau ka wale hōʻailona waho, ʻaʻohe kuni a ʻaʻohe ʻeha ʻōpū).
• Kuhi koko i wehewehe ʻole ʻia, noʻonoʻo, a i ʻole ka emi koke ʻana o ka mimi (hepatorenal syndrome, kahi e hoʻomaka ai ka maʻi SBP i nā puʻupaʻa e pani loa).
• Ka hana koke: E hele pololei i kahi keʻena pilikia. E hoʻohana nā kauka o ka haukapila i kahi nila lahilahi ma lalo o ke alakaʻi ultrasound e huki i kahi liʻiliʻi o ka wai ʻōpū (diagnostic paracentesis) no ka helu ʻana i nā keʻokeʻo keʻokeʻo (>250 polymorphonuclear cell per cubic millimeter e hōʻoia ana i ka SBP) a hāʻawi koke iā intravenous third-generation cephalosporin antibiotic a me ** intravenous albumin** no ka mālama ʻana i nā puʻupaʻa.

He aha ka mea e hana ai inā kahe ka wai mai kahi hernia umbilical ("Flood Syndrome")¶

I nā poʻe maʻi me nā ascites koʻikoʻi, ʻo ke kaomi ʻana i loko o ka ʻōpū e hoʻokuke pinepine i ka pihi ʻōpū i loko o kahi ** umbilical hernia ** ʻili lahilahi. Inā loaʻa ka ʻili ma luna o ka ʻōpū i ka pehu ʻeleʻele a i ʻole ka maʻi ʻaʻai a ʻaʻai koke ** ʻāhaʻi**, hiki i nā lita o ka wai ascitic melemele maʻemaʻe ke kahe i waho o nā lole (Flood syndrome).

• Kōkua mua koke no ka ʻāʻī ʻana o ka umbilical hernia:
• E kāhea koke i kāu helu ulia pōpilikia a i ʻole ka lawe ʻana i ke keʻena ulia pōpilikia (inā kokolo ka hua bacteria *i loko o ia lua, hele mai ka peritonitis make i loko o nā hola, a hāʻule ka wai wikiwiki i ke kahe koko).
• E moe palahalaha ka mea ma'i ma kona kua a i 'ole e hili iki i hiki ke kiko i luna.
• E uhi i ka puka e kahe ana me ka aahu gauze manoanoa a i ole ka lole ma'ema'e hou i holoiia i paa pono me ka lipine (mai hookui i kekahi mea iloko o ka lua), a e paa malie i ke kaomi lima mawaho a hiki i ka manawa e hiki ai i na limahana o ka halemai ke lawelawe i na antibiotic intravenous, albumin, a me ka hooponopono oki.

ʻO nā kānāwai palekana lāʻau koʻikoʻi no kēlā me kēia me ka cirrhosis¶

Hoʻopili mālie ke akepaʻa ʻulaʻula i nā lāʻau lapaʻau, ʻoiai ʻo ke kiʻekiʻe kiʻekiʻe o ka portal e hana i ka ʻōpū o ka ʻōpū a me nā puʻupaʻa i mea palupalu. Pono kēlā me kēia mea mālama i ka mea maʻi cirrhosis e hoʻokō i kēia mau lula lāʻau lapaʻau hale ʻekolu:

1. Kāpono loa i nā NSAID a pau (Ibuprofen, Naproxen, Aspirin, Meloxicam, Diclofenac): ʻO ka lawe ʻana i kekahi mau papa o ka ibuprofen a i ʻole naproxen i loko o nā ʻāpana cirrhosis e pale ana i nā prostaglandins mai ka ʻōpū o ka ʻōpū (e hoʻoulu ai i ka catastrophic variceal a i ʻole portal hypertensive gastropathy bleeding pinepine) syndrome**).
2. Ka palena palena koʻikoʻi ma ka Acetaminophen (Paracetamol): ʻOiai ʻo ka acetaminophen kiʻekiʻe (> 4,000 mg / lā) ke kumu o ka hāʻule ʻana o ka ate, ʻike nā alakaʻi hepatology (AASLD a me EASL) no nā poʻe maʻi cirrhosis maʻi i ** ʻaʻole inu waiʻona **, hoʻopaʻa paʻa ʻia ka acetaminophen haʻahaʻa ma **s ʻoi aku ma mua o 500 mg. ʻOi aku ka palekana o ka mea maʻi ma mua o nā NSAID, **koe naʻe ** ka mea maʻi i loko o ka maʻi maʻi maʻi i loko o ka maʻi maʻi maʻi maʻi ʻaʻole i inu i ka waiʻona a i ʻole nā ​​mea ʻai ʻole a i ʻole ka hoʻokē ʻai ʻana, a laila pono e hāʻawi ʻia ** ʻaʻohe acetaminophen ** me ka ʻole o ke kauoha a ke kauka.
3. E hoʻopaʻa i nā diuretics ("pili wai") i ka luaʻi ʻana, ka maʻi ʻaʻai, a i ʻole ka huikau: Mai hāʻawi i nā kīʻaha kakahiaka o spironolactone a i ʻole furosemide inā ʻeha ka mea maʻi, huikau, luaʻi, a i ʻole he >4 mau ʻauʻau maloʻo i kēlā me kēia lā a hiki i ke kauka ke nānā i ko lākou koko sodium, potassium, a me creatinine.

Nīnau pinepine¶

Nānā ʻia nā kumu¶

• ** ʻAhahui ʻAmelika no ke aʻo ʻana i nā maʻi ate (AASLD) a me ka Hui ʻEulopa no ke aʻo ʻana i ka ate (EASL): ** Nā kuhikuhi no ka hoʻomaʻamaʻa kino ma ka Hepatic Encephalopathy i ka maʻi ʻāʻī maʻi (West Haven Criteria), Management of Ascites and Spontaneous Bacterial Peritonitis, a me *Portal Hypertensive Bleeding.
• Ka Hana Manaʻo Kūkākūkā ʻo Baveno VII (International Portal Hypertension Consensus): Baveno VII, Hoʻohou i ka ʻaelike i ka Portal Hypertension a me Acute Variceal Hemorrhage Resuscitation.
• National Institute for Health and Care Excellence (NICE) and British Society of Gastroenterology (BSG, United Kingdom): Cirrhosis in Over 16s: Assessment and Management (NG50) a me Acute Upper Gastrointestinal Bleeding in Cirrhosis Guidelines.
• World Gastroenterology Organization (WGO, International): Global Guidelines on Esophageal Varices and Hepatic Encephalopathy Triage.

Nā alakaʻi pili¶

• ʻO ke koko o ka ʻōpū, ka luaʻi koko, a me ke kōkua mua melena
• ʻO ka ʻike ʻana i ka Sepsis a me ka haʻalulu septic a me ke kōkua mua
• ʻO ka haʻalulu a me ka hāʻule ʻana o ke kahe koko kōkua mua
• ʻO ka ʻona ʻona, hangover, a me ka hoʻihoʻi palekana
• Nā helu pilikia ma ka ʻāina