怎样判断肝炎病情的轻重?| 专家视角

2018-06-24 骆抗先 南方医院骆抗先工作室

从慢性肝炎到肝硬化常要经过许多年,许多肝硬化、甚至已经是晚期的肝硬化病人过去自觉良好,血清转氨酶也只是轻中度升高。但有些慢性乙肝病毒携带者却有很多症状, 跑了许多医院、做过许多检查也没有发现多大问题。到底要怎样来判断肝炎病情的轻重呢?

从慢性肝炎到肝硬化常要经过许多年,许多肝硬化、甚至已经是晚期的肝硬化病人过去自觉良好,血清转氨酶也只是轻中度升高。但有些慢性乙肝病毒携带者却有很多症状, 跑了许多医院、做过许多检查也没有发现多大问题。到底要怎样来判断肝炎病情的轻重呢?

慢性乙型肝炎最常见的症状是疲乏和食欲减退,什么病都可这样,这些只是难以定性的非特异的症状。慢性乙型肝炎起病缓慢,肝脏的代偿性很强,甚至晚期肝病的病人症状也可不明显,难以正确说明病情程度。病人对自己的病情常有许多迷惑,列举如下:

“大三阳”是不是病情很重?

可能你感到很意外、或者不理解,乙肝病毒本身不会致病;发生肝炎还有其他因素,主要是感染者的免疫状态。你如果不相信,可以看下面的事实:许多“大三阳”的慢性病毒携带者、尤其是小儿携带者病毒水平很高,却没有肝功能损害;而病毒水平较低、却长期炎症活动的“小三阳”病人反而有更高的机率发生肝硬化。乙肝病毒当然是引起肝炎发病和发展的始作俑者,但感染后的结局还另有影响因素参与。

因而,“大三阳”只能说明体内存在乙肝病毒,而且病毒数量也较多,传染性也较强,但不等于肝脏的炎症和损害就重。

转氨酶越高是不是病情越重?

谷丙酶最敏感,升高的幅度可以从几十到几千,起病急骤的幅度大,缓慢起病的幅度小,升高幅度能正确反映病变的活动性。即使升高的幅度很大,及时降酶治疗未必使病变很快加重,谷丙酶只反映一时的炎症活动性,不能完全以谷丙酶升高的幅度来衡量病情。慢性肝炎从轻到重,主要是由肝纤维化决定的,严重的纤维化就是肝硬化。你如果不相信,可以看下面的事实:急性肝炎病人的谷丙酶常常上千,绝大多数几个月就好了;许多肝硬化病人的谷丙酶只有100上下,能说急性肝炎的病情比肝硬化还重吗?

很多慢性肝炎病人的谷丙酶只有小幅度波动,病情却在持续中缓慢进展,所以系列的定期检查比一时升高的幅度更为重要。

谷丙酶与谷草酶的比值倒置是不是肝硬化了?

有可能,但要结合其他指标综合分析,单项检查结果难以判定。也可能有其他因素:比如用了降酶药,谷丙酶对降酶药比较敏感就降低了,谷草酶不易受降酶药的影响,这样比值就倒置了;又比如你喝了酒、或服用了损肝的药物,谷草酶升高会比谷丙酶明显,比率也就倒置了。附带说一句:你得了乙型肝炎还酗酒,肝硬化可能离你不远了。

球蛋白升高是不是病情加重了?

血清球蛋白增高,只反映感染的长期性,可能因为此时产生多种抗体,而抗体都是球蛋白,只是球蛋白增高不说明病变的重度。慢性乙肝病毒携带也可球蛋白增高,此时肝炎还没有发病呢。球蛋白增高(不是白蛋白减少)所致的白/球比率降低,与病变程度的关系甚小;如果球蛋白升高、同时白蛋白降低,要结合其他检查考虑肝硬化的可能。

血清纤维标志的数值升高,是不是肝硬化了?

检查的是纤维分子,肝内成分只是整个体内含量的小部分。如果一个吸烟重瘾者的血清纤维标志增高了,这些纤维分子应该来自肺部,这一检查不能将来自肝脏的与来自其它脏器的区别。血清纤维标志反映所有细胞外纤维分子代谢的异常,不是肝纤维的特有指标,不一定表示肝纤维化的程度。

检查的纤维分子是原肽,血清中的原肽可能反映细胞外的纤维分子裂解,不一定是从沉积的纤维分子中释放。当肝内有广泛炎症时,纤维分子降解的活性可能很高,因而原肽的血清水平可能也很高。所以谷丙酶升高常有血清纤维检查的异常;而不活动的肝硬化反而血清纤维检查正常。

甲胎蛋白升高是不是发生肝癌了?

甲胎蛋白是肝癌的标志物,肝病的病人出现甲胎蛋白升高,当然要警惕去做进一步的检查。

甲胎蛋白是胎儿时期肝细胞的正常产物,为什么会出现在肝病的病人呢?慢性肝病病人的肝脏如有广泛纤维化,有功能的肝细胞数已大大减少;这时如又有较重的炎症破坏,只有大量再生肝细胞来挽救厄运。肝脏是再生能力很强的脏器,为代偿其必需的功能,是能够大量再生肝细胞的。许多新生的肝细胞可能很幼稚,接近胚胎期的肝细胞,就能分泌甲胎蛋白。所以,有较重纤维化的肝炎、尤其是炎症活动较强的肝硬化病人也可甲胎蛋白升高,少数病人甚至可以升几百和几千,经过治疗,炎症破坏控制了,甲胎蛋白会较快降下来。

能吃能喝、自我感觉良好,是不是没有问题?

严重的病变,一般都会有些感觉,但不尽然。肝脏是一个“沉默”的器官,病变常在“无症状”中进展,如果不定期检查,严重的病变也可能漏诊。有些晚期失代偿性肝硬化病人来医院时自诉发病才几个月;实际病变是在几十年中逐渐累积的。从慢性携带、肝炎、肝硬化发展到肝癌得有许多年,但有些病人来医院时肿块很大已经不能手术了。现在社会竞争很激烈,工作很忙,有些不舒服误以为是劳累所致,可能被疏忽。所以不能跟着感觉走,要紧的是定期检查。

是不是症状越多病情越重?

一般是这样,有症状需去医院做详细的检查。慢性乙肝病毒携带者是基本健康的,但可能从不同渠道不自觉的接受一些暗示,于是忧心忡忡,夜不成眠,抚肝怵然,隐痛不已。各人对疾病的敏感性不同,关注程度也不同,症状未必一定与病情一致。

尿黄是不是有黄疸,病情重了?

要注意观察尿液,如果颜色加深了,是要警惕发生黄疸。正常尿液排泄废物尿胆原,早晨的尿颜色较深,如果喝水少、或出汗多,尿液浓缩颜色就更深了。可以把尿液放在玻璃瓶里晃动,如果泡沫是黄的就有黄疸了。较重的黄疸尿液像浓茶一样,病情确是重了。

有“蜘蛛痣”是不是有肝硬化?

典型的“蜘蛛痣”常标志肝病慢性化的程度或病变的进展,肝硬化病人常有“蜘蛛痣”;但有“蜘蛛痣”却未必都是肝硬化。“蜘蛛痣”是血清雌性素(动情素)增高的缘故,青春期的妇女、尤其是孕妇,血清雌性素水平较高,常能找到小而不典型的“蜘蛛痣”。男人的肾上腺也分泌少量的雌激素,健康人在肝脏被分解了;肝硬化病人不能分解,就出现了“蜘蛛痣”。健康的男人也可出现小而不典型的“蜘蛛痣”,说明你是感情丰富的人呢。

总之,对慢性乙肝病毒感染既难凭一时的表现判定当前的病情,也难凭一时的表现评估以后的发展。重要的是要定期检查,要注意保存所有的验单和检查报告,自己的健康档案对判断病情最有用。

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    2018-06-24 小小远志草

    学习参考

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    2018-06-24 131****1460

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    2018-06-24 1ddf0692m34(暂无匿称)

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    2018-06-24 医者仁心5538

    学习了

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