肝硬化并发非创伤性乳糜腹水12例临床特征分析

Clinical features of patients with cirrhosis-related non-traumatic chylous ascites:An analysis of 12 cases

目的探讨肝硬化并发非创伤性乳糜性腹水(CNCA)患者的临床特征,以提高对该病的认识。方法2012年1月~2022年1月成都市第三人民医院诊治的CNCA患者12例,总结病史、肝肾功能、腹水、影像学检查、胃镜、治疗方案和预后等特点。结果在12例患者中,有食管胃底静脉曲张破裂出血史2例,有腹水史10例;血清肌酐为92.4(79.2,101.7)μmol/L,Child-Pugh B级8例,Child-Pugh C级4例;腹水甘油三酯为(3.9±0.9)mmol/L,腹水为漏出液3例,渗出液9例,细菌培养阳性2例,分别为大肠埃希菌和嗜水气单胞菌群,所有腹水未见恶性细胞;腹部CT显示2例合并原发性肝癌,3例存在门静脉血栓,10例轻中度脾肿大,1例巨脾,1例无脾肿大;3例未行胃镜检查,4例轻中度食管静脉曲张,5例重度食管胃底静脉曲张;给予低脂饮食、抗生素、腹水引流、利尿剂等治疗5例,禁食、肠外营养、生长抑素治疗4例,禁食、肠外营养、特利加压素治疗1例,内科治疗无效后行TIPS术治疗2例;治疗后腹水中性粒细胞为(186.9±135.8)个/μl,显著低于治疗前【(377.3±223.5)个/μl,P<0.05】,超声检查显示治疗后腹腔最大液性暗区为2.3(1.4,10.4)cm,显著低于治疗前【(12.0±2.3)cm,P<0.05】;住院期间缓解9例(75.0%),无好转2例(16.7%),死亡1例(8.3%)。结论CNCA应个体化选择治疗方案,经内科治疗无效时可根据病情行TIPS术等治疗,总体预后差。

Objective The aim of this study was to summarize the clinical features of patients with cirrhosis-related nontraumatic chylous ascites(CNCA).Methods 12 patients with CNCA were encountered in our Hospital between January 2012 and January 2022,and the medical histories,serum creatinine,liver function tests,ascites,imaging findings,gastroscopic results,therapeutic strategies and prognoses were analyzed retrospectively.Results Out of the 12 patients,2 patients had experienced esophagogastric variceal bleeding,and 10 patients had ascites before;serum creatinine level was 92.4(79.2,101.7)μmol/L,and Child-Pugh class B was found in 8 cases and Child-Pugh class C in 4 cases;ascitic fluid triglyceride level was(3.9±0.9)mmol/L,and the exudate ascites was found in 9 cases and transudate in 3 cases;the ascites bacteria culture was positive in 2 patients,Escherichia Coli in 1 case and Aeromonas Hydrophila in 1 case,respectively;the ascites cytology showed no malignant;the abdominal CT scan presented with primary liver cancer in 2 cases,portal vein thrombosis in 3 cases,and mild to moderate splenomegaly in 10 cases and megalosplenia in 1 case;the gastroscopy was not performed in 3 persons,and found mild to moderate esophageal varices(EV)in 4 cases and severe EV in 5 cases;the treatment included low-fat diet,combined with conventional therapy such as antibiotics,drainage of ascetic fluid,diuretics in 5 cases,fasting,parenteral nutrition,and somatostatin in 4 cases,fasting,parenteral nutrition,and terlipress in 1 case,and TIPS in 2 cases;the ascites neutrophils count after treatment was(186.9±135.8)/μl,significantly lower than[(377.3±223.5)/μl,P<0.05]before treatment;the ultrasonography showed the maximum liquid dark area in the abdominal cavities was 2.3(1.4,10.4)cm after therapy,significantly smaller than[(12±2.3)cm,P<0.05]before therapy;during hospitalizations,there were 9 patients(75.0%)improved,2 patients(16.7%)didn’t respond to therapy,and 1 patients(8.2%)died of liver failure.Conclusion The patients with CNCA should be dealt with appropriately and individually.Under the circumstance of non-responded to conventional therapy,the TIPS might be the alternative.