经开腹胆囊造瘘引流成功救治致命鹅膏中毒致肝衰竭1例

A case of liver failure caused by fatal amanita poisoning was successfully treated by open cholecystostomy drainage

致命鹅膏中毒引起的肝衰竭致死率高,国内尚无有效解毒药物。2020年7月30日云南省第一人民医院感染性疾病及肝病科收治1例67岁女性致命鹅膏中毒致肝衰竭患者。患者因"进食鹅膏蕈350~400 g后腹痛、呕吐、腹泻2 d伴乏力1 d"于急诊科就诊。查体无异常;实验室指标显示丙氨酸转氨酶(ALT)4798 U/L,天冬氨酸转氨酶(AST)10030 U/L,活化部分凝血活酶时间(APTT)57.5 s,凝血酶原时间(PT)72.1 s,国际标准化比值(INR)8.66,凝血酶原活动度(PA)10%。结合患者病史、临床表现及实验室结果诊断为鹅膏毒肽类蕈中毒、急性肝衰竭。依据鹅膏毒肽中毒机制为肠肝循环,拟行内镜下逆行胰胆管造影及超声引导下胆囊穿刺术引流胆汁排出毒素,以中断毒素的肠肝循环,但尝试两种方法后均失败,故行开腹胆囊造瘘术。由于患者凝血功能极差,故先给予人工肝血浆置换,改善凝血功能后再行开腹胆囊造瘘术,最终成功引流出胆汁。经过综合内科治疗19 d后患者痊愈出院,随访1年未发现后遗症。对于该类患者需早期识别病情,针对毒素的特点及毒理机制尽早阻断毒素的肠肝循环,可能是抢救含鹅膏毒肽类蕈中毒致肝衰竭患者的关键,同时需结合积极补液、血液净化等综合治疗进一步提高存活率。

The fatality rate of liver failure caused by fatal amanita poisoning is high,and there are no effective antidote drugs in China.On July 30,2020,the department of infectious diseases and liver diseases of the First People's Hospital of Yunnan Province admitted a 67-year-old female patient with liver failure caused by fatal amanita poisoning.The patient went to the emergency department for treatment due to abdominal pain,vomiting and diarrhea after eating 350-400 g of amanita mushroom for 2 days,accompanied by fatigue for 1 day.There was no abnormality in physical examination.Laboratory indexes:alanine aminotransferase(ALT)4798 U/L,aspartate aminotransferase(AST)10030 U/L,activated partial thromboplastin time(APTT)57.5 s,prothrombin time(PT)72.1 s,international normalized ratio(INR)8.66,prothrombinactivity(PA)10%.Based on the patient's medical history,clinical manifestations and laboratory data,the diagnosis was amanita peptide mushroom poisoning and acute liver failure.According to the mechanism of amanita toxin poisoning as enterohepatic circulation,endoscopic retrograde cholangiopancreatography and ultrasound-guided gallbladder puncture and drainage for drainage of bile to discharge toxins were performed to interrupt the enterohepatic circulation of toxins.However,both methods failed,so open cholecystostomy was performed.Because the patient's coagulation function was very poor,artificial hepatic plasma exchange was given to improve coagulation function before open cholecystostomy,and eventually bile was drained successfully.After a total of 19 days of comprehensive medical treatment,the patient was cured and discharged from the hospital,and no sequelae was found after 1 year of follow-up.For such patients,early identification of the disease is required,and blocking the enterohepatic circulation of toxins as soon as possible according to the characteristics and toxicological mechanism of toxins may be the key treatment for rescuing patients with liver failure poisoned by amanita toxin,and it is necessary to combine comprehensive treatments such as active fluid replacement and blood purification to further improve the survival rate.