酒精性肝硬化并发门静脉性胆道病致慢加急性肝衰竭行肝移植治疗1例

2018-03-11 佚名 临床肝胆病杂志

患者男性,41岁

【一般资料】

患者男性,41岁

【主诉】

因“肝硬化病史3年,腹胀、双下肢水肿1个月,加重伴目黄、尿黄15d”,于2015年12月30日急诊入本院。

【现病史】

患者3年前因呕血、黑便于当地医院诊断为酒精性肝硬化,保肝、对症治疗后好转。1个月前患者出现腹胀、双下肢水肿就诊于当地医院门诊,给予利尿治疗后症状较前略有好转,未进一步系统诊治。15d前患者上述症状加重伴有目黄、尿黄,就诊于当地医院行相关检查提示肝衰竭,前往北京某医院给予血浆置换、保肝、对症支持治疗后,肝功能检查提示TBil进行性增高,患者及其家属为求肝移植转入本院。



【既往史】

否认高血压糖尿病、冠心病病史。否认乙型肝炎、丙型肝炎、结核病史及其他传染病接触史。否认手术、外伤史。海鲜类食物过敏,表现为皮肤瘙痒;青霉素药物过敏,表现为试敏阳性。吸烟史30余年,40支/d,未戒;饮酒史10余年,白酒500g/d,折合酒精量192g/d,未戒。否认家族遗传病史。

【体格检查】

体温36.5℃,脉搏92次/min,呼吸18次/min,血压116mmHg/72mmHg。患者神志清楚,查体配合,慢性肝病面容,皮肤、巩膜重度黄染,可见周身广泛皮下出血,以注射部位瘀斑为主,口唇周围可见泡状皮损,并由破损处向外渗血,无肝掌、蜘蛛痣。全身浅表淋巴结未触及肿大。左侧臂部可见经外周静脉穿刺置入中心静脉导管1枚,双肺呼吸音清,未闻及干、湿音,各瓣膜区未闻及杂音及额外心音。腹部稍膨隆,左下腹可见腹腔引流管1枚,可引出淡黄色腹腔积液,腹软,无压痛、反跳痛及肌紧张,移动性浊音阳性。肝区叩击痛阴性,墨菲征阴性。肝肋下未触及,脾大,脾肋下3cm可触及,右侧大腿前侧可见股静脉置管1枚,双下肢轻度对称性凹陷性水肿。

【辅助检查】

血液生化指标:外科综合均为阴性,肝炎病原学、自身免疫性肝病相关抗体均为阴性。肝功能:AST74.2U/L,ALT51.4U/L,GGT42.1U/L,ALP51.7U/L,TBil536.0μmol/L,DBil293.0μmol/L,IBil243.0μmol/L,总蛋白60.0g/L,白蛋白31.2g/L,白球比1.08,总胆汁酸160.0μmol/L。凝血常规:凝血酶时间35.1s,活化部分凝血活酶时间108.1s,凝血酶原时间55.8s,国际标准化比值测不出,凝血酶原时间比值测不出,凝血酶原活动度测不出,纤维蛋白原0.30g/L。血常规:红细胞计数2.03×1012/L,血红蛋白68g/L,血小板计数45×109/L。生化检查:肌酐(急)50.1μmol/L。尿常规:尿胆红素阳性(+++),尿潜血阳性(++),尿红细胞计数85.30/μL,尿红细胞15.4个每高倍视野,细菌计数2673/μL,细菌481.1个每高倍视野。双侧下肢静脉彩超:右侧股静脉导管声像。双侧上肢静脉彩超:左上肢浅静脉、腋静脉、锁骨下静脉、头臂静脉内导管声像。肝胆脾多排CT平扫+三期增强(图1):(1)肝硬化,腹水,脾大;门静脉高压伴侧支循环开放,并与左肾静脉沟通;肝脏密度不均,建议随访;(2)肝多发囊肿;(3)肝内胆管扩张,考虑增宽的门静脉压迫肝门区胆管所致(PD);胆总管末端囊状扩张,胆总管囊肿(Ⅲ型)可能,必要时行磁共振胰胆管造影检查;(4)胆囊炎;胆囊多发结石;(5)脾多发钙化灶;(6)双肾多发囊肿。

【治疗】

患者入院后第5天获得肝源,顺利进行肝移植受体手术(含全肝切除术),未行磁共振胰胆管造影检查。等待肝移植过程中在积极内科保守治疗的基础上行人工肝支持治疗,过程顺利,术后大体标本及病理见图2~3。肝移植术后第1天患者凝血功能恢复良好,其后间断复查凝血功能趋于正常。术后第3天肝功能检查提示胆红素升高,考虑存在排斥反应,给予他克莫司口服后胆红素呈下降趋势,口服该药物后第4天肝功能再次异常,给予激素冲击治疗后肝功能逐步恢复正常,将激素减量最终改为口服。术后第6天患者出现发热症状,辅助检查提示真菌D葡聚糖升高,痰培养中发现酵母菌,给予米卡芬净抗真菌治疗后未再发热。术后第21天患者恢复良好出院,目前处于移植术后随访中。




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    2018-05-08 丁鹏鹏
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target=_blank style='color:#2F92EE;'>#门静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97149, encryptionId=6d779e14916, topicName=门静脉)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Tue Mar 13 01:51:00 CST 2018, time=2018-03-13, status=1, ipAttribution=)]
    2018-03-13 121832a9m88暂无昵称

    学习了

    0

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