358.4 📋 章末速蚘 Summary

358.4.1 🔑 䞀句話瞜結

Cirrhosis = irreversible advanced liver disease with fibrosis + nodular regeneration台灣 etiology: viral hepatitis (HBV + HCV declining with DAAs) + ALD + MASLD/MASH (rising) + autoimmune (AIH, PBC, PSC) + hereditarystagescompensated (asymptomatic) → decompensated (jaundice + ascites + encephalopathy + variceal bleeding)scoringChild-Pugh A/B/C (bilirubin + albumin + INR + ascites + encephalopathy) + MELD-Na (since 2016) + MELD 3.0 (2023) for transplant priority (90-day mortality)portal hypertension definition HVPG > 5 mmHg, clinically significant > 10, variceal bleeding risk > 125 hallmarks of decompensation(1) ascites — SAAG ≥ 1.1 portal HTN; treatment Na < 2 g/d + spironolactone:furosemide 100:40 + large-volume paracentesis (LVP) with 6-8 g/L albumin if > 5 L removed + TIPS for refractory; (2) spontaneous bacterial peritonitis (SBP) — PMN > 250/mm³; E. coli most common; ceftriaxone 2 g daily × 5 days + albumin 1.5 g/kg day 1 + 1 g/kg day 3 (reduces HRS + mortality); norfloxacin/ciprofloxacin prophylaxis; (3) variceal bleeding — HVPG > 12 mmHg risk; acute treatment: cautious resuscitation (Hgb 7-8) + octreotide or terlipressin + ceftriaxone 1 g daily × 7 days + EGD with banding within 12 hours + TIPS for refractory + early TIPS in high-risk (Garcia-Pagan 2010 ↓ rebleeding + mortality); primary prevention β-blocker (propranolol, nadolol, carvedilol) or EVL; secondary β-blocker + EVL; (4) hepatic encephalopathy (HE) — West Haven grading 0-4; precipitants infections (SBP) + GI bleeding + constipation + electrolytes + sedatives; lactulose 25-50 mL TID-QID (target 2-3 soft BMs) + rifaximin 550 mg BID for recurrence; treat precipitants; don’t restrict protein (sarcopenia concerns); (5) hepatorenal syndrome (HRS) — Type 1 acute / Type 2 subacute; terlipressin + albumin (FDA 2022, CONFIRM trial) + norepinephrine + albumin ICU alternative + liver transplant curativeHCC surveillance every 6 months US ± AFP for all cirrhotic + chronic HBV high-riskother complications: coagulopathy (rebalanced), hyponatremia, hyperestrogenic state, sarcopenia, cirrhotic cardiomyopathy, hepatopulmonary syndrome (HPS), portopulmonary HTN (POPH), hepatic hydrothoraxACLF (acute-on-chronic liver failure) new category — high mortality + ICU + transplant evaluation。

358.4.2 💊 治療粟芁

  • ascites: sodium restriction < 2 g/d + spironolactone (100 mg) + furosemide (40 mg) 100:40 ratio (max 400:160) + LVP with albumin 6-8 g/L removed if > 5 L + TIPS for refractory ascites
  • SBP: ceftriaxone 2 g daily × 5 days (community-acquired) + albumin 1.5 g/kg day 1 + 1 g/kg day 3 (reduces HRS + mortality)
  • SBP prophylaxis: norfloxacin or ciprofloxacin (prior SBP, low ascitic protein, GI bleeding, advanced cirrhosis)
  • variceal bleeding acute: cautious resuscitation (Hgb target 7-8 — TRIGGER) + octreotide 50 ÎŒg IV → 50 ÎŒg/h infusion or terlipressin + ceftriaxone 1 g daily × 7 days improves survival + EGD within 12 hours with banding + TIPS for refractory or early TIPS for high-risk (Garcia-Pagan 2010) + balloon tamponade bridge if needed
  • variceal primary prevention: non-selective β-blocker (propranolol, nadolol, carvedilol) for small varices with high-risk features or medium-large varices; EVL alternative
  • variceal secondary prevention: β-blocker + EVL combination; TIPS for refractory
  • HE: lactulose 25-50 mL TID-QID (target 2-3 soft BMs daily) + rifaximin 550 mg BID for recurrence (PROFIT trial) + treat precipitants (infections, GI bleed, electrolytes, sedatives); don’t restrict protein
  • HRS: terlipressin + albumin (FDA 2022, CONFIRM trial) first FDA-approved; norepinephrine + albumin ICU alternative; liver transplant curative; avoid diuretics + NSAIDs
  • HCC surveillance: US ± AFP every 6 months for all cirrhotic + chronic HBV high-risk

358.4.3 🎯 盧醫垫的考前提醒

  1. cirrhosis etiology: HBV + HCV (declining with DAAs + vaccines) + ALD + MASLD/MASH (rising — top transplant indication globally) + autoimmune + hereditary
  2. Child-Pugh A/B/C variables: bilirubin + albumin + INR + ascites + encephalopathy (5 components); A 5-6 (80% 5-yr survival), B 7-9 (50%), C 10-15 (30%)
  3. MELD-Na (2016) + MELD 3.0 (2023) for transplant priority allocation: bilirubin + INR + creatinine + sodium (+ female sex + albumin for 3.0); 90-day mortality predictor
  4. portal hypertension HVPG thresholds: > 5 (definition), > 10 (clinically significant), > 12 (variceal bleeding risk)
  5. SAAG (Serum-Ascites Albumin Gradient) key concept: ≥ 1.1 portal HTN (cirrhosis, HF, BCS) vs < 1.1 non-portal (peritoneal carcinomatosis, TB, pancreatitis)
  6. SBP diagnosis + treatment: PMN > 250/mm³ in ascites; ceftriaxone 2 g × 5 d + albumin 1.5 g/kg day 1 + 1 g/kg day 3 (reduces HRS + mortality)
  7. variceal bleeding management: cautious resuscitation (Hgb 7-8 — TRIGGER trial) + octreotide or terlipressin + ceftriaxone (improves survival) + EGD with banding within 12 hours + early TIPS in high-risk (Garcia-Pagan 2010) for Child B with bleeding or Child C 10-13
  8. TIPS (transjugular intrahepatic portosystemic shunt) indications: refractory ascites + refractory variceal bleeding + HRS (selected) + Budd-Chiari + hepatic hydrothorax; contraindications: HF, severe HE, severe PH, polycystic liver, infection
  9. HE management: lactulose 25-50 mL TID-QID (target 2-3 soft BMs) + rifaximin 550 mg BID for recurrence + treat precipitants (SBP, GI bleed, constipation, electrolytes, sedatives); don’t restrict protein (sarcopenia + nutrition concerns)
  10. HRS treatment breakthrough: terlipressin + albumin (CONFIRM trial, FDA 2022) first FDA-approved; norepinephrine + albumin ICU alternative; liver transplant only curative; avoid diuretics + NSAIDs + hold β-blockers if hemodynamic instability