358.2 🩺 國考版

358.2.1 高頻考點

358.2.1.1 Etiology

  • HBV + HCV + ALD + MASLD top globally
  • Autoimmune + hereditary + drugs + vascular other

358.2.1.2 Child-Pugh Score

  • Bilirubin + albumin + INR + ascites + encephalopathy
  • A 5-6 (80% 5-yr), B 7-9 (50%), C 10-15 (30%)

358.2.1.3 MELD Score

  • Bilirubin + INR + creatinine
  • 90-day mortality
  • Transplant priority
  • MELD-Na (2016) + MELD 3.0 (2023) refinements

358.2.1.4 HVPG (Hepatic Venous Pressure Gradient)

  • 5: portal HTN

  • 10: clinically significant

  • 12: variceal bleeding risk

358.2.1.5 Ascites

  • SAAG ≥ 1.1: portal HTN
  • SAAG < 1.1: peritoneal carcinomatosis, TB, pancreatitis
  • Treatment: Na < 2 g/d + spironolactone:furosemide 100:40 + LVP + TIPS

358.2.1.6 LVP + Albumin

  • 6-8 g/L removed if > 5 L
  • Reduces post-paracentesis circulatory dysfunction

358.2.1.7 SBP

  • PMN > 250/mm³
  • E. coli, Klebsiella, S. pneumoniae
  • Ceftriaxone 2 g daily × 5 d + albumin 1.5 g/kg day 1 + 1 g/kg day 3
  • Prophylaxis: norfloxacin / ciprofloxacin

358.2.1.8 Variceal Bleeding

  • Octreotide / terlipressin
  • Ceftriaxone (improves survival)
  • EGD with banding within 12 hours
  • TIPS rescue or early
  • Hgb target 7-8 (conservative)

358.2.1.9 Variceal Prophylaxis

  • Primary: β-blocker (propranolol, nadolol, carvedilol) or EVL
  • Secondary: β-blocker + EVL
  • TIPS for refractory

358.2.1.10 Hepatic Encephalopathy

  • Lactulose (target 2-3 soft BMs)
  • Rifaximin for recurrence
  • Treat precipitants
  • Don’t restrict protein

358.2.1.11 HRS

  • HRS-AKI (Type 1): rapid; SBP/bleed precipitate
  • HRS-NAKI: subacute
  • Terlipressin + albumin (FDA 2022)
  • Norepinephrine + albumin alternative
  • Liver transplant curative

358.2.1.12 HE Precipitants

  • Infections (especially SBP)
  • GI bleeding
  • Constipation
  • Hyponatremia, hypokalemia, alkalosis
  • Sedatives
  • TIPS

358.2.1.13 HCC Surveillance

  • All cirrhotic
  • Chronic HBV high-risk (Asian male > 40, female > 50)
  • US ± AFP every 6 months

358.2.1.14 Key Trials

  • CONFIRM: terlipressin for HRS (FDA 2022)
  • PROFIT: rifaximin for HE
  • Early TIPS Garcia-Pagan 2010: early TIPS for high-risk variceal bleeding

358.2.2 易混淆比范

Complication Diagnosis Treatment
Ascites SAAG ≥ 1.1 Na restriction, diuretics, LVP, TIPS
SBP PMN > 250 Ceftriaxone + albumin
Variceal bleeding EGD Octreotide + ceftriaxone + banding + TIPS
HE Clinical + ammonia Lactulose + rifaximin
HRS AKI in cirrhosis Terlipressin + albumin
HCC Imaging + AFP Ch359

358.2.3 Special Topics

358.2.3.1 Conservative Transfusion in Variceal Bleeding

  • TRIGGER trial: restrictive (Hgb 7) better than liberal
  • Avoid over-transfusion + worsening portal pressure

358.2.3.2 Antibiotic Prophylaxis in Cirrhotic Bleeding

  • Reduces SBP + mortality
  • Even without ascites
  • Ceftriaxone 1 g daily × 7 days

358.2.3.3 Early TIPS for Variceal Bleeding (Pre-Emptive)

  • High-risk patients (Child B with bleeding, Child C 10-13)
  • Within 72 hours
  • Improved survival (Garcia-Pagan trial)

358.2.3.4 Albumin Dialysis (MARS, Prometheus)

  • Limited evidence
  • Bridge in select patients