2013酒精性肝炎的诊断与处理（天坛）课件

曾留学日本4年.在国内外发表论文170余篇，其中1篇文章被Am J gastroenterol 推荐为2010年CME教材。主编或参编了消化病手册、脂肪性肝病、消化内科门诊手册等8部著作 兼任实用肝脏杂志共同主编,中国实用乡村医学杂志副主编，Hepatobiliary & Pancreatic Diseases International、WJG、国际消化病杂志等十数家杂志的编委,王炳元教授,中国医大一院消化科 主任医师、教授、博士生导师 主要从事胃肠疾病和肝胆胰疾病的临床诊断和治疗，尤其重视慢性病毒性肝病、脂肪肝、酒精性肝病的基础和临床研究 获辽宁省科技成果2等奖1项、3等奖2项，沈阳市科技成果1等奖1项、3等奖1项 中国医师协会脂肪肝专业委员会副主任委员，中华肝病学会脂肪肝和酒精性肝病学组副组长，中华消化学会肝胆协作组委员，辽宁省消化分会和辽宁省中西医结合肝病学会副主委，辽宁省肝病分会常委,王炳元（中国医大第一医院消化科）,ALCOHOLIC HEPATITIS DIAGNOSIS and TREATMENT,,Main Point：,1. Excessive alcohol intake 2. Spectrum of ALD 3. Who develop ALD? 4. Whats the clinical diagnosis of alcoholic hepatitis? 5. Prognostic assessment 6. 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 2009,2. 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, brosis, 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 Association).,3. Who develop ALD?,4. Whats 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 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 Decompensated alcoholic cirrhosis including sepsis-induced cholestasis Alcoholic foamy degeneration Zieves syndrome Non-alcoholic liver disease Malignant inltrative disease Drug-induced liver injury Viral hepatitis (including acute hepatitis E) Hereditary hemochromatosis Autoimmune liver disease,The Alcoholic Liver Disease/Nonalcoholic Fatty Liver Disease Index (ANI),/gi-rst/mayomodel10.html,5. Prognostic assessment,Novel histological grading systems for alcoholic hepatitis,Ballooning and inammatory score No ballooning; no inammation: 0 510% ballooning; no/mild inammation: 2 1020% ballooning; mild inammation: 3 2050% ballooning; mild inammation: 4 50% ballooning; mild/moderate inammation: 5 Histological grade Score 01: Grade 0, no significant evidence of histological AH Score 23: Mild/moderate AH, Grade 1 Score 45: Moderately severe/severe AH,Mookerjee et al. 2011,Fibrosis stage None/portal: 1 Expansive fibrosis: 2 Bridging brosis or cirrhosis: 3 Bilirubinostasis None: 1 Hepatocellular bilirubinostasis: 2 Canalicular/ductular: 3 Hepatocellular and canalicular/ductular: 4 Neutrophil inltration None/mild: 0 Severe: 1 Megamitochondria None: 0 Present: 1,Histological grade Score 02: Mild AH Score 35: Moderate AH Score 67: Severe AH,Novel histological grading systems for alcoholic 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 GAHS, Glasgow Alcoholic Hepatitis Score ABIC score, age, serum Bilirubin, INR, and serum Creatinine MELD score, Model-for-End-Stage-Liver-Disease score,,6. Major therapeutic measures,（1） Abstinence,Abstinence from alcohol reduces the risks of complications and mortality in patients with alcoholic cirrhosis and represents a major therapeutic goal (Recommendation A1),A specic analysis of fatality and its causes in alcoholic 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, including 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 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),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 biochemical 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 diagnosis and management of alcoholic liver disease: Update 2010. Journal of Digestive Diseases 2011; 12; 4550,（4） Detection and treatment of SAH,Liver transplantation confers a survival benefit in patients with ALD classified 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 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 (Recommendation B1),（5）Liver transplantation,Kaplan-Meier survival curves comparing patient su