tailieunhanh - Hepatobiliary Surgery - part 4

Cổ trướng thể hiện như là kết quả của: giữ natri 1) suy giảm albumin và protein tổng hợp, 2) áp lực thủy tĩnh trong hình sin gan tăng lên và các mao mạch nội tạng, 3) trong sản xuất, và transudation thấp của bạch huyết tái hấp thu vào không gian phúc mạc, 4) và thận , 5) suy thận bài tiết nước | 78 Hepatobiliary Surgery 5 Ascites Ascites manifests as a result of 1 impaired albumin and protein synthesis 2 increased hydrostatic pressure in hepatic sinusoids and splanchnic capillaries 3 over-production transudation and low reabsorption of lymph into the peritoneal space 4 renal sodium retention and 5 impaired renal water excretion partially due to increased concentrations of antidiuretic hormone ADH . Albumin infusion has no beneficial effect even in the presence of severe hypoalbuminemia. The treatment of ascites underscores bed rest and sodium restriction to be followed by spironolactone if a spontaneous diuresis is not restored. If life threatening complications such as cardiac or respiratory compromise occur these patients require hemodynamic monitoring. Paracentesis should be attempted in case ascites persists. Renal Failure Following hepatobiliary surgery rapidly progressive renal failure may occur. The differential diagnosis includes acute tubular necrosis prerenal azotemia and hepatorenal syndrome. Hepatorenal syndrome is the development of otherwise unexplained renal failure with urine sodium 10 meq l hyperosmolar urine oliguria 400 ml 24hrs fractional excretion of sodium FeNa 1 and urine creatinine to plasma creatinine ratio 30 1 in patients with advanced liver disease. The pathophysiology of hepatorenal syndrome is based on the pooling of blood in the splanchnic bed and the resultant decrease in plasma volume. The kidney perceives a decreased glomerular filtration rate and causes a vasoconstriction that shunts blood away from the renal cortex. There is no specific treatment for hepatorenal syndrome. Dopamine mcg kg min may help maintain urine output. Although spontaneous recovery has been reported mortality is very high. These patients generally cirrhotic may benefit from liver transplant. Pulmonary Care Hepatopulmonary syndrome is defined by liver disease increased alveolar arterial gradients and evidence of reduced intrapulmonary vascular .