2013酒精性肝炎的診斷與處理（天壇）課件

1、曾留學(xué)日本4年.在國內(nèi)外發(fā)表論文170余篇，其中1篇文章被Am J gastroenterol 推薦為2010年CME教材。主編或參編了《消化病手冊》、《脂肪性肝病》、《消化內(nèi)科門診手冊》等8部著作兼任《實(shí)用肝臟雜志》共同主編,《中國實(shí)用鄉(xiāng)村醫(yī)學(xué)雜志》副主編，《Hepatobiliary & Pancreatic Diseases International》、《WJG》、《國際消化病雜志》等十?dāng)?shù)家雜志的編委,王炳元教授,中國

2、醫(yī)大一院消化科 主任醫(yī)師、教授、博士生導(dǎo)師主要從事胃腸疾病和肝膽胰疾病的臨床診斷和治療，尤其重視慢性病毒性肝病、脂肪肝、酒精性肝病的基礎(chǔ)和臨床研究獲遼寧省科技成果2等獎1項(xiàng)、3等獎2項(xiàng)，沈陽市科技成果1等獎1項(xiàng)、3等獎1項(xiàng)中國醫(yī)師協(xié)會脂肪肝專業(yè)委員會副主任委員，中華肝病學(xué)會脂肪肝和酒精性肝病學(xué)組副組長，中華消化學(xué)會肝膽協(xié)作組委員，遼寧省消化分會和遼寧省中西醫(yī)結(jié)合肝病學(xué)會副主委，遼寧省肝病分會常委,王炳元（中國醫(yī)大第一醫(yī)院消化科）

3、,ALCOHOLIC HEPATITISDIAGNOSIS and TREATMENT,wangby@medmail.com.cn,Main Point：,1. Excessive alcohol intake 2. Spectrum of ALD 3. Who develop ALD?4. What’s the clinical diagnosis of alcoholic hepatitis?5. Prognostic a

4、ssessment6. Major therapeutic measures,1. Excessive alcohol intake,Continuum of Risk Associated with Alcohol Use and Possible Clinical Responses.,Etiology of Mortality in ALD,Lin CW, Yang SS Hepatogestroenterology 2009,

5、2. Spectrum of ALD,Lin CW,Yang SS. Hepatogastroenterology 2009,Alcoholic Liver Disease (1992-2003),Natural history of alcoholic liver disease (ALD). The spectrum of ALD is comprised of steatosis, steatohepatitis, ?bros

6、is, cirrhosis, and superimposed hepatocellular carcinoma. Both environmental and genetic factors are known to modify the progression of ALD (adapted from [2] with permission from the American Gastroenterological Associat

7、ion).,3. Who develop ALD?,4. What’s the clinical diagnosis of alcoholic hepatitis?,Checklist of DSM-IV-TR Criteria for Alcohol-Use Disorders.,AUDIT questionnaire. To score the AUDIT questionnaire, sum the scores for each

8、 of the 10 questions.,A total ≧8 for men up to age 60, or ≧4 for women, adolescents, or men over age 60 is considered a positive screening test.,Differential diagnosis of alcoholic hepatitis,Biliary obstruction Decompen

9、sated alcoholic cirrhosis including sepsis-induced cholestasis Alcoholic foamy degeneration Zieve’s syndrome Non-alcoholic liver disease – Malignant in?ltrative disease – Drug-induced liver injury

10、 – Viral hepatitis (including acute hepatitis E) – Hereditary hemochromatosis – Autoimmune liver disease,The Alcoholic Liver Disease/Nonalcoholic Fatty Liver Disease Index (ANI),http://www.mayoclinic.o

11、rg/gi-rst/mayomodel10.html,5. Prognostic assessment,Novel histological grading systems for alcoholic hepatitis,Ballooning and in?ammatory score– No ballooning; no in?ammation: 0– 5–10%

12、 ballooning; no/mild in?ammation: 2– >10–20% ballooning; mild in?ammation: 3– >20–50% ballooning; mild in?ammation: 4– >50% ballooning; mild/moderate i

13、n?ammation: 5Histological grade– Score 0–1: Grade 0, no significant evidence of histological AH– Score 2–3: Mild/moderate AH, Grade 1– Score 4–5: Moderately severe/severe AH,Mookerjee et al. 2011,Fibrosis st

14、age– None/portal: 1– Expansive fibrosis: 2– Bridging ?brosis or cirrhosis: 3Bilirubinostasis– None: 1– Hepatocellular bilirubinostasis: 2– Canalicular/ductular: 3– Hepatocellular and canalicular/ductular: 4Neutr

15、ophil in?ltration– None/mild: 0– Severe: 1Megamitochondria– None: 0– Present: 1,Histological grade– Score 0–2: Mild AH– Score 3–5: Moderate AH– Score 6–7: Severe AH,Novel histological grading systems for alcoholi

16、c hepatitis,Altamirano et al. 2011,Prognostic models in severe alcoholic hepatitis,Comparison of the elements that constitute 5 prognostic instruments in alcoholic hepatitis,Maddrey score, Maddrey discriminant function

17、GAHS, Glasgow Alcoholic Hepatitis Score ABIC score, age, serum Bilirubin, INR, and serum CreatinineMELD score, Model-for-End-Stage-Liver-Disease score,www.lillemodel.com,6. Major therapeutic measures,（1） Abstinence,Abs

18、tinence from alcohol reduces the risks ofcomplications and mortality in patients with alcoholic cirrhosis and represents a major therapeutic goal(Recommendation A1),A speci?c analysis of fatality and its causes in alco

19、holic withdrawal syndrome (AWS) has rarely been made.misdiagnosis and missed diagnosis was frequent and very hight,250ml X 50% X 0.8 X 7 = 700 cal (2000cal/d 35%),Identification and management of cofactors, includi

20、ng obesity and insulin resistance, malnutrition, cigarette smoking, iron overload and viral hepatitis are recommended(Recommendation B1),（2）Nutritional supplements,General recommendations for screening and management of

21、 complications of cirrhosis should be applied to patients with alcoholic cirrhosis (Recommendation A1)No specific pharmacological therapy for alcoholic cirrhosis has demonstrated unequivocal efficacy (Recommendation A1)

22、,Glycyrrhizic acid products, silymarin, polyene phosphatidylcholine and reduced glutathione have various degrees of anti-oxidative, antiinflammatory and hepatocyte membrane protective efficacy and can improve liver bioch

23、emical tests in some clinical trials (II-2, II-3). Bicyclol therapy can also alleviate the symptoms of ALD (II-2).,（3） Hepatoprotective drugs,,Chinese association for the study of liver disease：uidelines for the diagnos

24、is and management of alcoholic liver disease: Update 2010. Journal of Digestive Diseases 2011; 12; 45–50,（4） Detection and treatment of SAH,Liver transplantation confers a survival benefit in patients with ALD classifie

25、d as Child-Pugh C and/or MELD ≥15 (Recommendation A1)A 6-month period of abstinence before listing patients obviates unnecessary LT in patients who will spontaneously improve (Recommendation A1)Regular screening for

26、cardiovascular disease and neoplasms is of particular importance before and after LT (Recommendation A1)Risk factors for cardiovascular disease and neoplasms, particularly cigarette smoking, should be controlled (Rec

27、ommendation B1),（5）Liver transplantation,Kaplan-Meier survival curves comparing patient survival of patients transplanted for alcoholic hepatitis (gray line) and patients transplanted for alcoholic cirrhosis (black line)