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 UNIVERSITATEA DE STAT DE EDUCA IE FIZICĂ I SPORT Ț Ș Referat La Fiziologia patologică  Tema: Bolile hepatice  Elao!at Mafteu a Liuba ț  Co"t!olat  Erhan Ecateri  Chi in ău 2015 ș #

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UNIVERSITATEA DE STAT DE EDUCA IE FIZICĂ I SPORTȚ Ș

ReferatLa

Fiziologia patologică Tema:Bolile hepatice

Ela o!at Mafteu a Liubaț Co"t!olat Erhan Ecateri

Chi inău 2015ș

#

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Structura anatomică i func iile ficatuluiș ț

Ficat$l e%te cel mai ma!e o!ga" &i" co!p' O!ga" pli"( &e co"%i%te"ta )e!ma( )icat

c*"ta!e%te la a&$lt + ,## - + .## g c$ /a%ele golite' E%te %it$at 0" lo1a %$ &ia)!agmat pa!tea i"te!"a a 2ipoco"&!$l$i %t*"g'

E%te alcat$it &i" &oi lo i i"egali( cel &!ept )ii"& &e ci!ca %a%e o!i mai ma!e &ec*t cel %

Ficat$l a!e &o$a )ete: $"a %$pe!ioa!a( co"/e3a( %i alta i")e!ioa!a' Fata %$pe!ioa!a e%limitata p!i" &o$a ma!gi"i: $"a po%te!ioa!a( mai g!oa%a( %i alta a"te!ioa!a( mai a%c$tita)ata i")e!ioa!a %e o %e!/a &o$a %a"t$!i %agitale %i $" %a"t t!a"%/e!%al( &e a%pect$l litAce%te %a"t$!i &elimiteaza lo $l &!ept( lo $l %t*"g( lo $l pat!at( /e"t!al lo $l Spiegel( &o!%al' 5eale6 a &e%c!i% 7 %egme"te c$ /a%c$la!izatie %i topog!a)ie i"&epe"&e"te( %egme"te &e%pa!tite p!i"t!-$" te%$t co"1$"cti/ &e"%i)icat'

0" %a"t$l t!a"%/e!%al %e a)la 2il$l )icat$l$i( p!i" ca!e pat!$"& /a%ele %i "e!/ii )icat$l$i %ca"alele ilia!e %i lim)atice o!ga"$l$i'

Ficat$l a!e &o$a 0"/eli%$!i: $" 0"/eli% %e!o%( pe"&i"te &e %e!oa%a pe!ito"eala( ca!e 0"tot )icat$l( c$ e3ceptia $"ei e"zi t!a"%/e!%ale la "i/el$l %$p!a)etei %$pe!ioa!e( $"&e )icae%te a&e!e"t &i!ect la &ia)!agm8 al &oilea 0"/eli% e%te cap%$la 9li%%o"( ca!e acope!a )i"t!a la "i/el$l 2il$l$i 0" i"te!io!$l o!ga"$l$i &e-a l$"g$l /a%elo! %i cailo! ilia!e'

Va%c$la!izatia )icat$l$i e%te a%ig$!ata &e a!te!a 2epatica( ca!e a&$ce %*"gele a!te!ial( /e"a po!ta( ca!e a&$ce %*"ge /e"o% )$"ctio"al' S*"gele pleaca &e la )icat p!i" /e"ele%$p!a2epatice( ca!e colecteaza tot %*"gele &i" ace%t o!ga" %i 0l /a!%a 0" /e"a ca/a i")e!ioVa%ele lim)atice %e a&$"a 0"t!-o !etea %$ %e!oa%a ca!e a1$"ge la ga"glio"ii %tme&ia%ti"ali a"te!io!i( pa"c!eaticolie"ali( c$ lim)a colectata &e pe )ata i")e!ioa!a %i &lim)aticele %ept$!ilo! i"t!a2epatice'

Ne!/ii )icat$l$i p!o/i" &i" ple3$l 2epatic( alcat$it &i" )i !e %impatice ca!e ie% &iga"glio"$l ce0iac %i &i" )i !e pa!a%impatice ca!e %e &e%p!i"& &i" am ii "e!/i /agi'

Ficat$l a!e o ma!e capacitate &e !ege"e!a!e( &emo"%t!ata p!i" )apt$l ca &$pa o 2epatectomie pa!tiala !ege"e!a!ea 0"cepe &$pa , &e o!e( ati"ge ma3im$l 0" - . zile %i %te!mi"a 0" + zile' F$"ctiile l$i %$"t m$ltiple( )ii"& 0"&epli"ite la "i/el$l 2epatocit$l$i' N$/om ami"ti &ec*t )$"ctiile l$i p!i"cipale'

Functiile metabolice %e e3e!cita 0"metabolismul glucidic, p!oteic %i mi"e!al' 0"meta oli%m$l gl$ci&ic( )icat$l i"te!/i"e 0" )o%)o!ila!ea %i polime!iza!ea gl$ci&elo!glicoge"( a%ig$!*"& !eze!/e &e gl$coza %i me"ti"e!ea 2omeo%tazei glicemice' La "e/oi

)a !ica gl$coza &i" p!otei"e %i g!a%imi ;glico"eoge"eza<' =eta oli%m$l gl$ci&ic 2epae%te i"%$li"o&epe"&e"t' 0"metabolismul proteic, )icat$l a!e )$"ctie p!otei"o)o!matoa!e %i &eec2ili !$ p!oteic( )$"ctie $!eoge"a' Si"tetizeaza al $mi"a( >#? &i" cc-glo $li"e( .#? &i"

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p-glo $li"e( p!ot!om i"a %i )i !i"oge"$l( cata olizeaza "$cleop!otei"ele' 0"metabolismul lipidelor i"te!/i"e 0" a %o! tia g!a%imilo! %i 0" )o%)a!ila!ea lo!( 0" %i"teza %i e%te!i-)cole%te!ol$l$i( 0" %i"teza lipop!otei"elo!( )o%)olipi&elo! %i t!iglice!i&elo!' 0"metabolismul mineral actio"eaza p!i" &epozita!ea )ie!$l$i %i a c$p!$l$i %i i"te!/i"e 0" !epa!titia apei %i elect!olitilo! ;io"ii &e Na ( @ %i CF< 0" o!ga"i%m'

Functia biliara compo!ta %ec!etia %i e3c!etia ilei( c$ !ol impo!ta"t 0" &ige%tia %i a %og!a%imilo!( 0" a %o! tia /itami"elo! lipo%ol$ ile ;A( D( E %i @<( 0" a %o! tia )ie!$calci$l$i alime"ta!' ila %e /a!%a 0" i"te%ti" 0" ca"titati &e B## - + ### ml , &e o!e' co"ti"e 7>? apa %i $!mato!ii compo"e"ti p!i"cipali: %a!$!i ilia!e( pigme"ti ilia!i(cole%te!ol( leciti"e %i %a!$!i a"o!ga"ice'

Functia antitoxica co"%ta 0" )apt$l ca )icat$l &i%p$"e &e acti/itati p!i" ca!e %$ %ta"teto3ice &e o!igi"e e3oge"a( ca %i acelea !ez$ltate &i" meta oli%mele e"&oge"e %t!a"%)o!mate 0" %$ %ta"te mai p$ti" to3ice %i elimi"ate ca ata!e' Ne$t!aliza!ea %$ %tato3ice e%te !ealizata &e )icat c$ a1$to!$l p!oce%elo! &e co"1$ga!e a ace%to! %$ %ta%$l)$l &e e3empl$ ;acti$"ea &e %$l)oco"1$ga!e<'

Ficat$l e%te $" impo!ta"t &epozit &e /itami"e A( , ( +,( D( @' El i"te!/i"e 0" co"/e!ti!eaca!ote"ilo! 0" /itami"a A( 0" t!a"%)o!ma!ea /itami"ei t 0" coca! o3ilaza( 0" co"1$ga!ea/itami"ei , pe"t!$ )o!ma!ea )e!me"t$l$i gal e" !e%pi!ato!( 0" p!oce%$l &e %i"tetiza!e p!ot!om i"ei c$ a1$to!$l /itami"ei @'

Sinteza fermentilor "ece%a!i p!oce%elo! /itale e%te 0"&epli"ita 0"t!-o )oa!te ma!e ma%$!a

)icat' Fe!me"tii %$"t comple3e mac!omolec$la!e legate &e g!$pa!i acti/e( ia! %i"teza lo!ep!ezi"ta o acti/itate la o!ioa%a a 2epatocit$l$i %i "ece%ita i"teg!itatea a"atomica %)$"ctio"ala a )icat$l$i'

=ai ami"tim i"te!/e"tia )icat$l$i 0" me"ti"e!ea ec2ili !$l$i aci&o- azic( !ol$l )icat$l$i ca&epozit al apei %i po%i ilitatea l$i &e a ec2ili !a pe!t$! a!ile ci!c$lato!ii'

EC5INOCOCOZA 5EPATICĂ

;c2i%t$l 2i&atic 2epatic< Definitie: ec2i"ococoza 2epatica e%te o oala &ato!ata localiza!ii %i &ez/olta!ii 0" )icat em !io"$l$i &eTaenia echinococus.

Etiologie: pa!azit$l e%te $" ce%to& mic( l$"g &e - B mm' 9az&ele &e)i"iti/e ale te"iei %$c*i"ele( pi%ica( l$p$l %i /$lpea' 9az&ele elimi"a o&ata c$ )ecalele( %i em !io)o!ii( ca!e( plip%a &e igie"a alime"ta!a( pot a1$"ge 0" i"te%ti"$l om$l$i' Em !io)o!ii t!a/e!%eaza pe!etei"te%ti"al %i( pe calea /e"ei po!te( a1$"g 0" )icat8 cei mai m$lti !am*" 0" )icat( !e%t$lt!a/e!%eaza %i pot a1$"ge 0" alte o!ga"e: plam*"i( c!eie!( !i"ic2i( %pli"a' Em !io"ii !ama%)icat %e t!a"%)o!ma 0" /ezic$le( )o!m*"& /ezic$la 2i&atica %a$ c2i%t$l 2i&atic'

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Anatomie patologica: c2i%t$l 2i&atic a!e $" pe!ete %i $" co"ti"$t' Pe!etele c2i%t$l$i e%talca$tit &i" &o$a mem !a"e: mem !a"a e3te!"a( c$tic$la!a %a$ c2iti"oa%a( %i mem !

i"te!"a( p!oli)e!ati/a ;ge!mi"ati/a<' 0" 1$!$l mem !a"ei e3te!"e %e ga%e%te o a&/e"-ticapa!$ta ca $!ma!e a mo&i)ica!ii pa!e"c2im$l$i 2epatic'

=em !a"a ge!mi"ati/a &a "a%te!e cat!e i"te!io! /ezic$lelo! p!olige!e( c$ +# - # &e%colec%i' La !*"&$l lo!( ace%tea pot &ez/olta /ezic$le-)iice ;c2i%t$!i< ca!e a$ ace%t!$ct$!a ca %i /ezic$la-mama' C2i%t$l co"ti"e $" lic2i& i"colo!( cla! ca 4apa &e %t*"ca4lic2i& %e ga%e%te "i%ip$l 2i&atic( alcat$it &i" /ezic$le p!olige!e( %colec%i( c*!lige'

Patogenie: c2i%t$l 2i&atic %e &ez/olta cel mai &e% 0" ap!opie!ea cailo! ilia!e i"t!a2e-patel poate comp!ima $" ca"al ilia!'

O %t!$ctiile ca"alic$lelo! ilia!e pot c!ea c!ipte p!opice pe"t!$ &ez/olta!ea $"o! colo"ii acte!ie"e( c!e*"& p!oce%e &e cola"gita %i %$p$!atii' acte!iile pot i")ecta !et!og!a& c2i%ca!e /a %$p$!a' Da!( &e cele mai m$lte o!i( %$p$!atia c2i%t$l$i %e !ealizeaza pe c2ematoge"a %a$ lim)atica'

Simptomatologia apa!e t*!zi$( c2i%t$l &ez/olt*"&$-%e le"t( 0" l$"i &e zile( a1$"g*"&&ime"%i$"ile $"ei ci!e%e'

Debutul t!ece "eo %e!/at' U!meaza o )aza &e late"ta( l$"ga( &e a"i &e zile( 0" timp$l ca!eiapa! cel m$lt %em"ele $"$i %i"&!om &i%peptic 2epatocel$la!' 0" )aza &e late"ta pot apa!e)e"ome"e ale!gice8 p!$!it( !a! %$ icte!( a"emie $%oa!a c$ eozi"o)ilie'

Perioada de stare ;pe!ioa&a t$mo!ala< e%te aceea 0" ca!e apa! p!imele %em"e cli"ice %!a&iologice' 0" c*ti/a a"i ;, - <( c2i%t$l ati"ge ma!imea $"ei po!tocale %a$ c2ia! &e/i"/ol$mi"o% %i /a &ete!mi"a mo&i)ica!i &ecela ile 0" /ol$m$l %i )o!ma )icat$l$i' Sem"ecli"ice( ca %i cele !a&iologice /o! &epi"&e &e localiza!ea %i &e ma!imea c2i%t$l$i'

- Localiza!ea %$pe!ioa!a e%te cea mai )!ec/e"ta %i %e %it$eaza &e !eg$la 0" lo $l &!e)icat$l$i' C*"& /ol$m$l e%te ma!e( c2i%t$l /a )i 0" co"tact c$ &ia)!agm$l %i /o! )i p!eze"%em"ele &e i!itatie &ia)!agmatica: t$%e $%cata( %$g2it( &i%p"ee( &$!e!i 0" $ma!$l &!ep

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Ficat$l /a )i ma!it &e /ol$m( /a p!o/oca &e)o!ma!ea 2emito!acel$i &!ept %i /a 0mpi"ge 0"%$% 2emi&ia)!agm$l &!ept'

- Localiza!ea a"te!o-i")e!ioa!a /a !ealiza( c*"& c2i%t$l e%te ma!e( o om a!e a !egi$"2epatice( c$ 0mpi"ge!ea coa%telo! 0"ai"te' 0" acea%ta localiza!e( ol"a/$l ac$za &$!e!i

epiga%t!$ %a$ 0" 2ipoco"&!$l &!ept( ca o apa%a!e %a$ c$ a%pct$l $"o! colici ilia!e'- Localiza!ea i")e!ioa!a e%te cel mai g!e$ &e &iag"o%ticat( ma"i)e%ta!ile )ii"& &ete!mi"atcomp!e%i$"i a%$p!a o!ga"elo! /eci"e %i 0m !ac*"& ca!acte!ele %$)e!i"telo! ace%to! o!ga"

Examenul radiologie a&$ce &ate p!etioa%e pe"t!$ p!eciza!ea &iag"o%tic$l$i' 0" $"ele caz$!!a&iog!a)ia %impla pe!mite %a %e /a&a calci)ie!ile pe!etel$i c2i%tic %a$ imagi"i 2i-&!oaC*"& c2i%t$l e%te localizat %$pe!io! %e poate o %e!/a o $m !a emi%)e!ica ce om e%$p!a)ata )icat$l$i( 0"%otita &e mo&i)ica!i 0" mi%ca!ile &ia)!agm$l$i'

Sci"tig!a)ia e%te &e a%eme"ea $" e3ame" &e /aloa!e: ea poate p!eciza localiza!ea c2i%t$lma!imea %i )o!ma l$i'

n!estigatiile biologice pe"t!$ &iag"o%tic %$"t: c$ti!eactia( !eactia &e )i3a!e acompleme"t$l$i %i 2emole$cog!ama'

C$ti!eactia Ca%o"i e%te poziti/a 0" 7#? &i" caz$!i' Se )ace c$ a1$to!$l !eacti/$l$i Ca%o" p!epa!at &i" lic2i& &e c2i%t$!i 2i&atice )ilt!at' Se i"1ecteaza i"t!a&e!mic #(+ - #( ml!eacti/ %i %e cite%te !eactia &$pa # &e mi"$te( + o!a %i , &e o!e' Reactia poziti/a co"%apa!itia la loc$l i"1ecta!ii a $"ei pap$le al icioa%e( 0"co"1$!ata &e $" e!item i"te"% 0"%otita &e eozi"o)ilie' Reactia e%te "egati/a &aca a m$!it pa!azit$l %a$ &aca c2i%ta ce&at' Reactia &e )i3a!e a compleme"t$l$i ei" e!g-P*!/$ e%te mai p$ti" %e"%i ila &ec$ti!eactia' Le$cog!ama a!ata eozi"o)ilie( 0" ge"e!al mo&e!ata ;0" me&ie - 7?<'

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0" c2i%t$l 2i&atic ;c2ia! %i "$mai a"$it< e%te co"t!ai"&icata p$"ctia 2epatica e3plo!atoDaca tot$%i acci&e"tal %-a p$"ctio"at $" c2i%t 2i&atic( ac$l "$ %e mai %coate %i ol"a/$%$p$% ime&iat i"te!/e"tiei c2i!$!gicale'

Lapa!o%copia %i lapa!otomia e3ploatoa!e pot p!eciza &e m$lte o!i p!eze"ta c2i%t$l$i'

E!olutia e%te le"ta' U"eo!i c2i%t$l e/ol$eaza %a$ %e elimi"a p!i" caile ilia!e %i oala /i"&eca' Alteo!i( c2i%t$l !am*"e %tatio"a! a"i &e zile' 0" alte caz$!i( c2i%t$l 2i&atic e/ol$tie zgomotoa%a p!i" complicatiile %ale'

"omplicatii: %$p$!atia( !$pt$!a %i comp!e%i$"ile pe o!ga"ele /eci"e'

Diagnosticul poziti! %e p!ecizeaza c$ a1$to!$l e3ame"$l$i cli"ic( mai ale% 0" localiza!ile

g!e$ acce%i ile' P!eze"ta $"$i c*i"e 0" ca%a e%te $" eleme"t ca!e poate 0"ta!i a"$ialE3ame"$l !a&iologie( %ci"tig!a)ia ;la "e/oie lapa!o%copia %i papa!otomia< pot a&$ p!eciza!i' P!o ele iologice( mai ale% c$ti!eactia Ca%o"i( %$"t eleme"te &e aza pe"&iag"o%tic'

Diagnosticul diferential %e )ace 0" !apo!t c$ localiza!ea c2i%t$l$i'

Prognosticul &epi"&e &e "$ma!$l &e localiza!i %i mai ale% &e complicatii' C2i%t$l 2i&"et!atat co"%tit$ie( &e o icei( $" pe!icol pe"t!$ /iito!'

Profilaxia co"%ta 0" !e%pecta!ea ma%$!ilo! &e igie"a: %palat$l m*i"ilo! 0"ai"te &e me%$p!ima!ea o icei$l$i &e a ti"e c*i"i %i pi%ici 0" ca%a %a$ &e a la%a ace%te a"imale m*i"ile'

Tratamentul e%te c2i!$!gical' Pe"t!$ )e"ome"ele ale!gice ;$!tica!ie< %e /o! a&mi"i%t!aRome!ga"( Nil)a"( Fe"i!ami"( A/ii( S6"ope"

CIROZELE HEPATICE

Definitie: ci!ozele 2epatice %$"t %$)e!i"te c!o"ice c$ e/ol$tie p!og!e%i/a(ca!acte!izatemorfologic p!i" &ezo!ga"iza!ea a!2itecto"icii 2epatice &ato!ita metaplazieite%$t$l$i co"1$"tic - ca!e )o!meaza e"zi &e %cle!oza ce 0"co"1$!a %a$ )!agme"teaza lo-( &ete!mi"ata &e &i%t!actia 2epatocita!a %i &e !ege"e!a!ea "o&$la!a8 iologic p!i" alte%e/e!a a %i"&!oamelo! &e acti/a!e meze"c2imala( &e 2ipe!te"%i$"ea po!tala %i i"%$)icie"ta 2epatocita!a %i p!i" po%i ilitatea e3ace! a!ii %i"&!om$l$i e3c!eto ilia! acel$ia &e 2epatocitoliza8 cli"ic( p!i" %ta&ii a/a"%ate &e i"%$)icie"ta 2epatica( 0"%oti%em"ele &e 2ipe!te"%i$"e po!tala'

0" )ieca!e caz pot p!e&omi"a $"$l %a$ mai m$lte %i"&!oame( ci!ozele 0m !ac*"& ma%pecte pa!tic$la!e'

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Etiopatogenie: 0" $ltim$l timp "$ma!$l caz$!ilo! &e ci!oza e%te 0" c!e%te!e' V*!%ta cma3im$l &e i"ci&e"ta e%te 0"t!e . %i B# &e a"i( 0"%a p!imele %em"e apa! 0" mo& o0"t!e . %i .# &e a"i' E3i%ta o p!e&omi"a"ta la %e3$l ma%c$li"'

Ca$zeleinfectioase oc$pa $" loc impo!ta"t 0" etiologia ci!ozelo! i" ta!a "oa%t!a( cele maim$lte &i"t!e ele )ii"& &e "at$!a /i!otica( p!i" /i!$%$l 2epatitic' Celelalte caz$!i apa!ti"/i!$%$!ilo! "e2epatice( %i)ili%$l$i( t$ e!c$lozei %i alto! i")ectii acte!ie"e'

Ci!ozelenutritionale apa! p!i" ca!e"te &e p!otei"e( &e )acto!i lipot!opi %a$ &e /itami"e'

Di"t!e ca$zeletoxice ca!e p!o/oaca ci!oze( alcool - p!i" a)ecti$"ea %a %teatoge"a( la ca!e %ea&a$ga %i ca!e"tele "$t!itio"ale - oc$pa p!im$l loc' =ai %$"t i"c!imi"ate &e%t$l &e !to3icele i"&$%t!iale ;comp$%i o!ga"o)o%)a!ici( 2i&!oge"$l a!%e"iat( tet!aclo!$!a &e ca&e!atiza"tele( i"%ectici&ele< %i( 0" $ltim$l timp( me&icame"tele c$ ag!e%i/itate 2epatica'

Alteo!i( ci!ozele %$"t p!o/ocate &e#nmagazinarea 0" )icat a $"o! %$ %ta"te' Depozita!ea)ie!$l$i 0" )icat %i 0" alte o!ga"e p!o/oaca 2emoc!omatoza( ia! &epozita!ea c$p!$l$i e%!e%po"%a ila &e apa!itia &ege"e!e%ce"tei 2epatole"tic$la!e'

Ci!ozelebiliare a$ &!ept ca$za %tag"a!ea ilei( ca!e poate %a %e &ato!eze $"o! o %tace3t!a2epatice8 %taza ilia!a poate %a )ie p!imiti/a( p!i" 2epatita c!o"ica colo%tatica( $!ma!e a $"ei 2epatite /i!ale %i( p!o a il( c$ i"te!/e"tia $"ei meca"i%m im$"ologic'

0" etiologia ci!ozelo! a$ mai )o%t i"c!imi"ate ca$ze &i%meta olice ;o ezitate( &ia et<ca$ze e"&oc!i"e ;2ipe!)olic$li"emie( 2ipe!ti!oi&ie<'

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4Ci!ozacardiaca$ e%te 0"ca co"t!o/e!%ata' N$ %$"t %$)icie"te &ecompe"%a!ile ca!&i!epetate pe"t!$ a %e a1$"ge la ci!oza %i( p!o a il( ca 0" apa!itia ei i"te!/i" )acto!i ci!oge"mai impo!ta"ti' =ai &eg!a a poate e3i%ta o ci!oza 2epatica la ca!&iaci( c*"& apa! alte!a)$"ctio"ale 2epatice %i %ple"omegalie'

A $z$l &e alcool %i 2epatita /i!ala tip ( !ep!ezi"ta p!i"cipalele ca$ze ale ci!ozei 2epatice'I" $"ele ta!i ca &e e3empl$ F!a"ta( p!e&omi"a etiologia alcoolica( 0" ta!a "oa%t!a p!e&omietiologia /i!otica' Di" p$"ct &e /e&e!e etiopatoge"ie( &eo%e im $!matoa!ele tip$!i &e ci!oz2epatica:

- ciroza alcoolica ;&e"$mita %i ci!oza po!tala %a$ g!a%a<( p!ezi"ta &o$a /a!ia"te: at!o-)ic;Lae""ec< %i ci!oza 2ipe!t!o)ica ;5"ot-9il e!t<'

- ciroza post%necrotica ;po%t-2epatitica<( 0" ca!e !ol$l p!i"cipal 0l &eti"e 2epatita /i!ala ac$ta%i 2epatita c!o"ica acti/a' =ai %$"t i"c!imi"ati 0" etiologia %a $"ele i"to3icatii ;)o%)o!clo!o)o!m<( %i i")ectii ; !$celoza<'

- ciroza biliara, ca!e poate )i p!imiti/a %i %ec$"&a!a

- ciroza din hemocromatoza, %i &i" oala il%o"'

- cirozele cardiaca, carentiala, si ciroza splenogena ; a"ti<

Anatomie patologica: ma1o!itatea ci!ozelo! 0"cep p!i" 2epatomegalie %i %)*!%e%c p!i" at!o2epatica' 5epatomegalia e%te &ato!ita 2ipe!plaziei co"1$"cti/e( pl$% %teato)ei( pl p!oce%elo! &e !ege"e!a!e8 c*"& ace%te p!oce%e 0"ceteaza( %e p!o&$ce at!o)ia 2epatica'

C$loa!e )icat$l$i /a!iaza &$pa tip$l &e ci!oza: gal e"-!$gi"ie &e o icei( /e!&e- !$"a 0ci!ozele ilia!e( !o%iatica 0" 2emoc!omatoza' S$p!a)ata poate )i !eg$lata( )ie g!a"$la!a

>

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;ci!oza mic!o"o&$la!a< %a$ "e!eg$lata( c$ "o&$li &e &ime"%i$"i /a!iate ;ci!oza mac!"o&$la!a<' Cap%$la 9li%%o" e%te 0"g!o%ata %i p!ezi"ta "o&$li'

&icroscopic %e co"%tata comp!omite!ea %t!$ct$!ii 2epatice p!i" e"zi &e te%$t co"1$"cca!e )!agme"teaza lo $lii' Fi !ele &e colage" %$"t mai m$lt %a$ mai p$ti" mat$!e'G Se /

i"%$le &e cel$le pla%mocita!e %i lim)ocite( "eoca"alic$le ilia!e( &ege"e!e%ce"te %i "eale 2epatocitelo!( "o&$li &e !ege"e!a!e'

Tabloul clinic: debutul, poate %a )ie a%imptomatic %a$ "eca!acte!i%tic' P!imele %em"e %$a%pecte &e %i"&!om a%te"o-"e/!otic ;)atiga ilitate( a"3ietate( %om"ole"ta( i"%om"ie<&i%pep%ie ilia!a ;4g$!a !ea4( i"apete"ta( g!et$!i( alo"a!i po%tp!a"&iale( i"tole!a"taalcool( &i%colie<( o!i )e"ome"e 2emo!agipa!e ;epi%ta3i%( gi"gi/o!agii( me"omet!o!age!$ptii p$!p$!ice<' U"eo!i( oala e/ol$eaza timp 0"&el$"gat )a!a "ici $" %em"( p!imama"i)e%ta!e )ii"& o 2emo!agie &ige%ti/a %$pe!ioa!a( %a$ &iag"o%tic$l e%te p$% c$ ocai"te!/e"tii c2i!$!gicale'

#n perioada de stare, pe l*"ga ma"i)e%ta!ile ami"tite mai %$%( %e co"%tata p!eze"ta $"%em"e la "i/el$l m$coa%elo! %i al teg$me"telo!( mo&i)ica!i 2epatice %i %ple"ice( mo&ie"&oc!i"e %i "e!/oa%e( a%cita( e&eme( 2i&!oto!a3( p!ec$m %i pe!t$! a!i ca!&io/a%c!e"ale %i 2ematologice'

cterul %$!/i"e epi%o&ic 0" $"ele ci!oze( ca %em" &e p!a $%i!e p!i" "ec!oza 2epato-cita!aaltele - c$m %$"t ci!ozele ilia!e - a!e $" ca!acte! pe!ma"e"t'

Stel$tele /a%c$la!e apa! 0" pa!tea %$pe!ioa!a a to!acel$i ;&ecolte$<( mai )!ec/e"t la cei c2ipe!te"%i$"e po!tala' =$coa%a li"g$ala %i cea 1$gala %$"t ca!mi"ate' Teg$me"telemi"e"telo! te"a!e %i 2ipote"a!e %$"t !o%ii( &*"& a%pect$l &e e!it!oza palma!a' Se pot 0"%i e!$ptii p$!p$!ice'

Ficatul e%te ma!it &e /ol$m 0" #? &i" caz$!i( &e co"%i%te"ta c!e%c$ta( p*"a la &$!itatema!gi"ea a%c$tita( c$ %$p!a)ata !eg$lata %a$ )i" g!a"$loa%a( mai !a! c$ mac!o"o-&$li' C2%i 0" caz$!ile at!o)ice )icat$l e%te ma!e la 0"cep$t( pe"t!$ ca $lte!io! %a %e mic%o!eze( p*&i%pa!itie %$ !e o!&$l co%tal'

Splenomegalia e%te p!eze"tata 0" # - 7#? &i" caz$!i( &e /ol$m /a!ia il &e g!a&ele II-III( &e co"%i%te"ta c!e%c$ta( &e !eg$la "e&$!e!oa%a' De%eo!i %ple"omegalia e%te 0"%em"e 2ematologice &e 2ipe!%ple"i%m: a"emie( le$cope"ie( t!om ocitope"ie'

'ipertensiunea portala %e ma"i)e%ta la 0"cep$t p!i" meteo!i%m ;4/*"t$l &i"ai"tea ploii4<( % p!i" apa!itia ci!c$latiei colate!ale e3te!"e %i i"te!"e ;/a!ice e%o)agie"e<'

Ascita apa!e )oa!te )!ec/e"t ca %em" &e 0"%oti!e a olii( ea p$t*"& )i 0"t*l"ita 0" o!ice )o!m&e ci!oza' E%te p!eze"ta &e !eg$la 0" ci!oza at!o)ica Lae""ec( &e o!igi"e etilica( c*"&

!e)ace( )oa!te $%o!'

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E&emele apa! 0" )aze mai a/a"%ate( &e o icei ca 0"%otitoa!e ale a%citei' S$"t al e( moc*"& %$"t "ei")l$e"tate &e t!atame"t( co"%tit$ie $" eleme"t %$m !$ pe"t!$ p!og"o%t5i&!ato!a3$l &!ept poate )i 0"t*l"it 0" - ? &i" ci!oze'

&odificarile endocrine %$"t tot&ea$"a p!eze"te' De ami"tit !ol$l 2o!mo"$l$i a"ti-&i$!etic

!et!o2ipo)iza! %i al al&o%te!o"$l$i' 0" ci!oze %e i"%taleaza &e%t$l &e !epe&e o i"%$go"a&ica: %ca&e!a li i&o$l$i( impote"ta %e3$ala( gi"ecoma%tie( at!o)ie te%tic$ame"o!ee( i")e!tilitate'

Tulburari ner!oase %e 0"t*l"e%c 0" tot c$!%$l e/ol$tiei ci!ozei( $"eo!i( &$pa c$m am /az$c2ia! ca )e"ome" &e &e $t' Pe pa!c$!% pot %a !e/i"a %a$ %a capete o i"te"%itate mai ma!m$lte o!i( p!eze"ta $"ei %om"ole"te( a $"ei a%te"ii e3ce%i/e %a$ o %ta!e &e "eli"i%tei"%om"ie pot )i %em"e p!emo"ito!ii pe"t!$ &!ama 2epatica ce /a $!ma' Ele pot )i tempo!a!!e/e!%i ile'

Tulburarile cardio!asculare: 2ipe!/olemia &i" ci!oze poate %a &$ca la &e%c2i&e!ea $"oa"a%tomoze a!te!io-/e"oa%e ;%$"t$!i<( p!o/oc*"& %tel$te /a%c$la!e %i e!it!oza' Acelci!c$ite a!te!io/e"oa%e( la ca!e %e a&a$ga t$l $!a!i &e /e"tilatie %i 2ipe!te"%i$"e p$lmo"%ec$"&a!a( %$"t !e%po"%a ile &e i"%tala!ea cia"ozei'

Perturbarile renale: 0" %ta&iile a/a"%ate( &i$!eza %ca&e8 i"%$)icie"ta !e"ala e%te 0"t*0"t!-o p!opo!tie p*"a la ++?'

&odificarile hematologice: a"emia e%te $" %em" ca!e "$ lip%e%te 0" c$!%$l e/ol$tie

ci!ozelo!' Le$cope"ia e%te p!o/ocata &e 2ipe!%ple"i%m' T!om ocitope"ia a!e la o!igi"e at2ipe!%ple"i%m$l( c*t %i $" &e)icit &e megaco!ioge"eza' T$l $!a!ile &e coag$la!e %e &aat*t %i"tezei &e)icita!e a )acto!ilo! &e coag$la!e( c*t %i e3ce%$l$i &e )i !i"olizi"a' E3plim$"ologice'

Febra, c*"& apa!e( e%te e3p!e%ia "ec!ozei %a$ a i")lamatiei 2epatice o!i a $"o! a)ecti$%$p!aa&a$gate ;ate"tie la pe!i)le itaH<'

Examenul radiologie poate p$"e 0" e/i&e"ta /a!icele ga%t!oe%o)agie"e %i( $"eo!i( $m !a2epatica ma!ita8 coleci%tog!a)ia e%te i"&icata 0" ci!ozele ilia!e'

Explorarile morfologice ca!e %e pot )ace %$"t: lapa!o%copia( $tila 0" 2epatomegalii ;mai alec$ icte!< %i la &iag"o%tic$l &i)e!e"tial c$ "eopla%m$l8 p$"ctia- iop%ie( ca eleme"te &e&iag"o%tica8 %ci"tig!ama 2epatica'

Explorarile functionale % at*t pe"t!$ pa!e"c2im( c*t %i pe"t!$ meze"c2im - %$"t a %ol$t"ece%a!e( ele i"&ic*"& %em"e &e i"%$)icie"ta 2epatica: ili!$ i"a %i $!o ili"a %$"t c!ete%tele )$"ctio"ale %$"t i"te"% poziti/e8 %i&e!emia e%te c!e%c$ta8 p!otei"ele pla%matic%caz$te pe %eama al $mi"elo!8 6-glo $li"ele %$"t c!e%c$te( !apo!t$l %e!i-"e glo $li"

i"/e!%at8 te%t$l c$ SP a!ata /alo!i %$ B - >?( c$ timp$l &e 0"1$ma-tati!e &e pe%tmi"$te'

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Explorarile !asculare: !a&ioma"omet!ia e%te $" e3ame" "ece%a!( mai ale% 0" ci!oza ilia!aSple"opo!tog!a)ia poate )$!"iza &ate &e%p!e /a%c$la!izatia i"t!a2epatica %i poate &ecelt!om oza %ple"opo!tala'

0" e/ol$tia ci!ozei 2epatice e3i%ta &o$a %ta&ii( stadiul compensat, %a!ac 0" %imptome

%i stadiul decompensat, c*"& %imptomatologia e%te e/i&e"ta( zgomotoa%a' Decompe"%a!ci!ozei poate )i /a%c$la!a %i pa!e"c2imatoa%a'

Decompensarea !asculara %e ma"i)e%ta p!i" i"%tala!ea a%citei %i acce"t$a!ea %ple"megaliei %i a cic$latiei a"a%tomotice po!to-ca/e' ;/a!ice( e%o)agie"e %i ga%t!ice<' C!e%t !$tala a 2ipe!te"%i$"ii po!tale( poate &ecla"%a o 2emo!agie &ige%ti/a %$pe!ioa!a !$pe!ea $"o! /a!ice e%o)agie"e %a$ ga%t!ice( co"%eci"ta ci!c$latiei a"a%tomotice'

Decompensarea parenchimatoasa e/i&e"tiaza &e)icit$l cel$la! 2epatic 0" e3c!etia pigme"tilo! ilia!i c$ apa!itia icte!$l$i( &ete!mi"a %i"teza e3ce%i/a &e %e!i"e c$ apa!ie&emelo! %i a%citei( %i"teza &e )acto!i ai coag$la!ii c$ apa!itia &e 2emo!agii &i)$ze( &e0" "e$t!aliza!ea $"o! p!o&$%i to3ici( ca!e a!e &!ept co"%eci"ta apa!itia e"ce)alopatiei po!ta%i a comei 2epatice' Decompe"%a!ea pa!e"c2imatoa%a 2epatica p!o/oaca %i meta- oliza$"o! 2o!mo"i a/*"& &!ept co"%eci"ta t$l $!a!i e"&oc!i"e' Deci %imptomele p!i"cipale al&ecompe"%a!ii pa!e"c2imatoa%e %$"t: icte!$l( e&emele %i a%cita( 2emo!agiile &e"ce)alopatia po!tala %i coma 2epatica' F!ec/e"t apa! %ta!e &e %la ici$"e( )atiga ilitata%te"ie( i"apete"ta( pie!&e!e 0" g!e$tate %i %$ )e !ilitate' Di"t!e cele mai impo!ta"te %e)izice me"tio"am 2epatomegalia c$ co"%i%te"ta c!e%c$ta( 2ipot!o)ia m$%c$la!a la mem !%$pe!ioa!e %i to!acice( 0" &eo%e i( $zele ca!mi"ate( %tel$te /a%c$la!e pe pa!tea %$peco!p$l$i ;a! o!izatii 0" %tea( 0" 1$!$l $"ei a!te!iole &ilatate<' =ai me"tio"am e!it!oz palma!a %i pla"ta!a ca!e %e &ato!e%te ca %i %tel$tele /a%c$la!e( imp!eg"a!ii e%t!og&ato!ita i"%$)icie"tei &e i"acti/a!e 2epatica8 U"ele t$l $!a!i e"&oc!i"e ;gi"ecoma%tie at!o)ie te%tic$la!a la a! at( at!o)ie mama!a %i $te-!i"a( %te!ilitate %i t$l $!a!i me"%t!$a)emei( ia! la am ele %e3e ca&e!ea pa!$l$i a3ila! %i p$ ia"<' Sple"omegalia e%te palpaci!c$latia a &omi"ala colate!ala 0" !egi$"ea me&ia"a %$p!aom ilicala %i 0" )la"c$!i e p!eze"ta' A%cita( 2emo!oizii( e&emele mem !elo! i")e!ioa!e ;moi( al e %i i"&olo!e<(&ato!e%c 2ipo%e!i"emiei( c!e%te!ii %ec!etiei &e al&o%te!o" %i comp!e%iei /e"ei ca/e i")&e cat!e lic2i&$l &e a%cita' F!ec/e"t apa! ma"i)e%ta!i 2emo!agice &i)$ze: ec2imoze( p$!p$

gi"gi/o!agii( epi%ta3i%( 2emo!agii &ige%ti/e ;2emateleza %i mele"a<( la apa!itia ca!co"t!i $ie 2ipe!te"%i$"ea po!tala ;/a!icele e%o)agie"e ca!e %e !$p<( %i %ca&e!ea )acto!ilcoag$la!e 0" %*"ge ;p!otom- i"a( )i !i"oge"$l( t!om ope"ia etc<' D$pa c$m %-a mai %picte!$l %i mai ale% %$ icte!$l e%te )!ec/e"t 0"t*l"it'

Forme clinice: ciroza ascitogena a!e &!ept p!ototip ci!oza at!o)ica Lae""ec( ca!e %eca!acte!izeaza p!i" etiologia p!e&omi"a"t alcoolica %i /i!ala( p!i"t!-$" %ta&i$ p!eci!otic mal$"g( c$ o pe!ioa&a p!eme!gatoa!e &e %teatoza 2epatica' Cli"ic( e3i%ta la 0"cep$t $" )ic"o!mal %a$ ma!it( apoi $" )icat !e&$% la /ol$m( o %pli"a ma!e( c$ ca!acte! )i !oco"-ge%e%te i"te!e%at %i pa"c!ea%$l' 5ipe!te"%i$"ea po!tala %i a%cita %$"t ma"i)e%tate( icte!$l$" ca!acte! epi%o&ic'

+#

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"iroza post%necrotica, ;po%t-2epatitica< apa!e &e o icei la ti"e!i ca!e a$ a/$t 2epatita /i!ala(&a! %i la a&$lti( &e o icei "eco"%$mato!i a $zi/i &e alcool' 0" acea%ta )o!ma 2ipo-tm$%c$la!a e%te !e&$%a( 2epatomegalia e%te mac!omo&$la!a( ia! icte!$l e%te mai i pe!%i%te"t %i p!ecoce %p!e &eo%e i!e &e ci!oza Lae""ec ;a%citoge"a %i po%talcooli-)!ec/e"te polia!t!algii( p!$!it$l %i te"&i"ta la malig"iza!e ;+. ?<' De o icei apa!e

2epatom$l' 5ipe! ili!$ i"emia e%te p!eze"ta( la )el 2ipe!t!a"%ami"azemia( 2ipe!-gamaglo $li"emia' P$"ctia ioptica %ta ile%te &iag"o%tic$l( p$"*"& 0" e/i&e"ta i")iltlim)opla%mocita!e %i "ec!oze cel$la!e' I"&i)e!e"t &e t!atame"t >. ? &i" caz$!i( e/ol$eazacat!e e3it$% 0" + - . a"i'

Fo!mahipersplenomegalica %e ca!acte!izeaza p!i" p!e&omi"a"ta %i"&!om$l$i &e 2i- pe!%ple"i%m'

O )o!ma c$ e/ol$tie apa!te e%teciroza bantiana, c$ o pe!ioa&a p!eme!gatoa!e 0" ca!e e%te p!eze"ta "$mai %ple"omegalia8 apoi apa! %em"e &e 2ipe!%ple"i%m %i mai t*!zi$( &$pa a"i( %$!/i" %em"ele ci!ozei at!o)ice a3citoge"e'

E/ol$tia ci!ozei a%citoge"e e%te p!og!e%i/a( c$ o &$!ata &e B l$"i p*"a la , a"i' S)*!%it$l p!o&$ce p!i" 2emo!agie &ige%ti/a( coma %a$ i")ectie i"te!c$!e"ta ;p"e$mo"ie( e!izipel etc'<

"iroza biliara primiti!a, apa!$ta p!i" o %tacol i"t!a2epatic e%te /a!ia"ta colo%tatica a2epatitelo! t!ec$te 0" c!o"iciza!e: %e mai "$me%te %iciroza 'anot. F!ec/e"ta e%te mica'Ficat$l e%te ma!e( c$ a%pect &e %taza ilia!a( )i"( "e!eg$lat8 e3i%ta %ple"omegalie( icte! pe!ma"e"t( teg$me"tele a$ o "$a"ta "eg!icioa%a( ia! p!$!it$l e%te p!eze"t' Pot apa!ea &eget

2ipoc!atice' ili!$ i"emia c!e%c$ta( %i $!o ili"oge"$!ia %$"t pe!ma"e"te8 %ca$"ele %2ipocolice' Fo%)ataza alcali"a e%te c!e%c$ta' E/ol$tia e%te le"ta: .-+#-+. a"i: %)*!%it$l p!o&$ce p!i" 2ipe!te"%i$"e po!tala %a$ coma 2epatica'

"iroza biliara secundara, p!i" o %tacol e3t!a2epatic( e%te p!ece&ata &e ma"i)e%ta!i "i/el$l cailo! ilia!e e3t!a2epatice ca!e &$c la icte! meca"ic: litiaza &e cole&oc( cole&o-cit%cle!oat!o)ica( papilita %te"oza"ta( comp!e%i$"i a%$p!a 2epatocole&oc$l$i( "eopla%mcailo! ilia!e' Pe"t!$ apa!itia ci!ozei e%te "ece%a!a p!eze"ta icte!$l$i meca"ic pe o l$"ga pe!ioa&a ;ceea ce "$ %e 0"t*mpla &ec*t )oa!te !a! 0" "eopla%m<' Ficat$l e%te ma!eco"%i%te"ta c!e%c$ta( c$ %$p!a)ata "ete&a %a$ )i" "e!eg$lata( &e c$loa!e 0"c2i%a' ge"e!ala %e me"ti"e $"a m$lt timp' Icte!$l e%te pe!ma"e"t %i ia o "$a"ta !$"a-/e!z$ie'

ili!$ i"emia e%te mo&e!at c!e%c$ta8 )o%)ataz alcali"a( c!e%c$ta8 p!$!it$l e%te %$pa!ato!' E3i%ta %ple"omegalie' A%cita apa!e 0" )aza )i"ala'

'emocromatoza, co"%ta"ta %i %$ "$mele &e 2emo%i&e!oza %i( mai &em$lt(diabet bronzat, e%te o t$l $!a!e &e meta oli%m( ca!acte!izata p!i" &epozita!ea )ie!$l$i 0" )icat %alte o!ga"e: pa"c!ea%( %pli"a( teg$me"te( mioca!&( gla"&e e"&oc!i"e etc' E3i%ta %a %o! tie c!e%c$ta &e )ie!( %i o elimi"a!e &e)icita!a a ace%t$i metal' Ficat$l e%te maco"%i%te"ta c!e%c$ta( &e c$loa!e !o%iatica' Lezi$"i &ege"e!ati/e "ec!otice %i )i !oza ap)icat %i 0" o!ga"ele ami"tite8 !eactia pe"t!$ pigme"t )e!ic ;Pe!l%< e%te poziti/a 0" toate aceo!ga"e' Sta!ea ge"e!ala e%te alte!ata( e3i%t*"& %i a%te"ie acce"t$ata' Teg$me"tele %

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pigme"tate 0" !$"-ce"$%i$ ; !o"zate<( mai ale% pe )ata %i a"te !ate' 5epatomegalia e%0"%otita &e %pleo"omegalie' E3i%ta at!o)ie te%tic$la!a %a$ ame"o!ee' Dia et$l( &e g!ami1locie %a$ $%oa!a( e%te p!eze"t 0" ma!ea ma1o!itate a caz$!ilo!'

E/ol$tia e%te c!o"ica( p!og!e%i/a( c$ %)*!%it$l o i%"$it al ci!ozelo!'

Degenerescenta hepatolenticulara ;%i"&!om$l il%o"< a!e la aza t$l $!a!i &e meta oli%male c$p!$l$il$i %i ale $"o! acizi ami"titi' oala apa!e 0" a&ole%ce"ta %a$ la a&$lt$l t*"a!' ma"i)e%ta p!i" t$l $!a!i "e$!ologice &e tip e3t!api!ami&al ;%im$l*"& pa! i"%o-"i%m$ p!i" alte!a!i p%i2ice' Simptomele 2epatice %$"t cele ale ci!ozei( c$ e/ol$tie ca!acte!i%tica ace%teia' La oc2i apa!e 0" 1$!$l co!"eei i"el$l @a6%e!-Flei%c2e!( &e c$loa!e !$"a-ce"$%

Diagnosticul poziti! %e azeaza pe a"am"eza( ta lo$l cli"ic %i pe i"/e%tigatiile pa!a-cli"ice'Diag"o%tic$l ci!ozelo! t!e $ie %a p!ecizeze at*t )o!ma cli"ica a olii( c*t %i %ta&i$e/ol$ti/( &e ace%tea &epi"z*"& 0" ma!e ma%$!a atit$&i"ea te!ape$tica'

Diagnosticul diferential /a )i &eo%e it &e la caz la caz( &$pa p!e&omi"a"ta %impto-melo!'

0" caz$!ile &e a%cita( &iag"o%tic$l &i)e!e"tial /a )i )ac$t c$ pe!ito"ita t$ e!c$loa%a pe!ito"ita ca!ci"omatoa%a( c$ a%cita &i" &ecompe"%a!ile ca!&iace !epetate %a$ c$ a%c%im)iza pe!ica!&iaca'C*"& e3i%ta "$mai 2epatomegalie( &iag"o%tic$l &i)e!e"tial %e )a"eopla%m$l 2epatic( c$ c2i%t$l 2i&atic( c$ %i)ili%$l 2epatic'U" &iag"o%tic &i)e!e"tiat!e $ie )ac$t c$ ate"tie( e%te acela c$ 2epatita c!o"ica ag!e%i/a %i c$ 2epatita c!o"icci!oge"a' I" 2epatita c!o"ica e3i%ta %em"e &e !eze!/e )$"ctio"ale 2epatice: al $mi"e"ia

!am*"e pe%te (. g?( i"&icele &e p!ot!om i"a pe%te .#?( SP pe%te B?( c$ timp$l &0"1$matati!e %$ +# mi"$te( 2ipe!te"%i$"ea po!tala e%te )a!a !e)l$3' P!eciza!ea o /a )ace 0 p$"ctia 2epatica( a!at*"& 0" 2epatite pa%t!a!ea a!2itecto"icii 2epatice'

E!olutia ci!ozelo! e%te p!og!e%i/a' Ci!ozele a%citoge"e e/ol$eaza mai !api& ;+-, a"i<Ci!ozele ilia!e a$ o e/ol$tie mai 0"&el$"gata ;. - +# - +. a"i<' 9!e%elile &e !egimalime"ta!( a&mi"i%t!a!ea $"o! me&icame"te 0" mo& i"tempe%ti/( pa!ace"tezele !epetate p)i ca$ze ca!e g!a e%c e/ol$tia p!i" i"%tala!ea e"ce)alopatiei po!tale( a comei 2epatice %a p!i" &ecla"%a!ea $"o! 2emo!agii &ige%ti/e'S)*!%it$l letal %$!/i"e p!i" 2emo!agii &ige%ma%i/e( p!i" e"ce)alopatie po!tala( coma 2epatica( i"%$)icie"ta !e"ala %a$ i")ectii"te!c$!e"te( 0"&eo%e i p"e$mo"ie'

"omplicatiile ci!ozelo! %$"t:

'emoragia digesti!a superioara, ca!e apa!e )!ec/e"t( )ii"& p!o/ocata &e !$pe!ea /e"elo! a)late %$ o p!e%i$"e c!e%c$ta 0" co"&itiile 2ipe!te"%i$"ii po!tale( &e !eg$la la "i/e/a!icelo! e%o)agie"e' S$!/i"e %$ a%pect$l 2ematemezei %i al mele"ei' Apa!itia 2emo!agiilimp!ima $" p!og"o%tic !eze!/at( at*t ime&iat( legat &e 2emo!agia 0" %i"e( c*t %i &e /iito!'

Encefalopatia hepatoportala, ca!e %e ca!acte!izeaza p!i" t$l $!a!ea %ta!ii &e co"%tie"ta8agitatie p%i2omoto!ie( t$l $!a!i &e /o! i!e( i"%om"ie $!mata &e %om"ole"ta p*"a pie!&e!ea c$"o%ti"tei( &eli! ;4&eme"ta 2epatica4<' Co"comite"t co"%tatam t!em$!at$!i(

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ataile &e a!ipi(flapping tremor). Se i"%taleaza &e o icei !api&( 0" c*te/a o!e( %i e%t&ecla"%ata &e 2emo!agii &ige%ti/e( &e o alime"tatie c$ p!otei"e 0" e3ce%( &e &i%i"te%ti"ale %a$ &e a&mi"i%t!a!ea $"o! me&icame"te c$m %$"t clo!$!a &e amo"i$( metio"i"a(%al$!eticele %i &i$!eticele me!c$!iale' Ca$za e"ce)alopatiei o co"%ti$ie i"to3ica!e%i%tem$l$i "e!/o% ce"t!al c$ %$ %ta"te ca!e !ez$lta &i" &eg!a&a!ea p!otei"elo! i"te%ti"

ca!e "$ a$ p$t$t )i meta olizate &e )icat8 !ol$l impo!ta"t 0l &eti"e amo"iac$l' De a%eme"ei"te!/i" pie!&e!ile &e elect!oliti ;Na %i @ <'

"oma hepatica &i" ci!oze poate apa!ea 0" ca&!$l i"%$)icie"tei 2epatice c!o"ice te!mi"ale( 0"e"ce)alopatia 2epatopo!tala %i 0" caz$!ile c$ 2ipe!al&o%te!o"i%m %ec$"&a! ;c$ t$l $2i&!oelect!olitice<'0" i"%$)icie"ta 2epatica c!o"ica( coma poate )i &ecla"%ata ;!a!< &e a"$)acto!i: e)o!t )izic( a $z &e alcool( i")ectii i"te!c$!e"te( me&icame"te( 2emo!agii &ige%ti/i"te!/e"tii c2i!$!gicale' 0"ai"te &e apa!itia comei %e acce"t$eaza !api& %i"&!om$l c$ta"aapa!e %om"ole"ta( %ca&e &i$!eza( apa! t$l $!a!i p%i2ice( apoi %e i"%taleaza coma' 0" comei %e co"%tata 2emo!agii( &i$!eza %caz$ta a&e%ea )e !a %i icte!( t$l $!a!i "e$!oe3t!api!ami&ale( t$l $!a!i p%i2ice polimo!)e' E/ol$tia e%te )!ec/e"t )atala'

nfectiile intercurente %$"t complicatii )!ec/e"te %i &e o g!a/itate &eo%e ita 0" ci!oze( elco"%tit$i"& &e m$lte o!i ca$za %)*!%it$l$i( &e o icei p!i" t!ece!ea %p!e coma 2epatica'mai )!ec/e"te %$"t p"e$mo"iile ac$te8 mai pot %$!/e"i %ta)ilococii( e!izipel etc'

P!o lema ca"ce!iza!ii ci!ozei "$ %e p$"e ca o complicatie' A&e"oca"ce!$l c$ ci!oza!ep!ezi"ta coe3i%te"ta celo! &o$a a)ecti$"i( i"&i)e!e"t ca apa!e 0"t*i ca"ce!$l %a$ 0"t*i ci!o%a$ ca apa! co"comite"t'

Prognosticul 0"&epa!tat al ci!ozelo! e%te tot&ea$"a %e/e!' 0" ceea ce p!i/e%te p!og"o%ticime&iat( el e%te mai $" 0" caz$!ile 0" ca!e a%cita ce&eaza !api& la !epa$%( &ieta %a$ &%i c*"& al $mi"emia &epa%e%te g?'

Profilaxia ci!ozelo! co"%ta 0" t!atame"t$l co!ect al 2epatitelo! epi&emice %i al 2epatiteloc!o"ice( c$ &i%pe"%a!iza!e 0"&el$"gata: 0" com ate!ea )acto!ilo! %$%cepti il0m ol"a/ea%ca )icat$l: alime"tatie &ezec2ili !ata( alcooli%m( a $z$!i me&icame"toa%t!ata!ea la timp %i co!ecta a olilo! ca!e )a/o!izeaza 2epatopatiile c!o"ice: litiaza ilia!a(a)ecti$"ile o %t!$cti/e ale cailo! ilia!e e3t!a2epatice( %i)ili%$l( &ia et$l( !ectocolita( $lcei")ectiile' P!o)ila3ia complicatiilo! e%te &e a%eme"ea impo!ta"ta( ea )ii"& !ealizata p!icom ate!ea ca$zelo! &ecla"%atoa!e &e complicatii: &ieta "e!atio"ala( me&icati"tempe%ti/a( i"te!/e"tii c2i!$!gicale "ei"&icate( &i% acte!ii i"te%ti"ale'

Tratamentul ci!ozelo! $!ma!e%te %$p!ima!ea ca$zelo!( com ate!ea p!oce%$l$i i")lamato! %!eactiilo! im$"ologice 0" e3ce%( %tim$la!ea !ege"e!a!ii 2epatice %i p!e/e"i!ecomplicatiilo!'T!atame"t$l t!e $ie %a )ie i"&i/i&$alizat( comple3( meto&ic %i %i%temaSe !ecoma"&a %pitaliza!i la - . l$"i %i 0" c$!%$l &ecompe"%a!ilo!'

*epausul e%te o ligato!i$ 0" pat 0" ci!ozele &ecompe"%ate' 0" cele compe"%ate( !epa$%$)i !elati/( p*"a la + o!e pe zi %i c*te o l$"a &e !epa$% complet la pat' Vo! )i i"te!zi%e)o!t$!ile )izice %i cele i"telect$ale'

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Dieta t!e $ie %a a%ig$!e $" !egim alime"ta! complet %i ogat 0" /itami"e' P!otei"ele /o! )&ate 0" p!opo!tie &e +(. g iloco!p zi( apo!t$l )ii"& !e&$% 0" caz$!ile c$ e"ce)alop po!tala' 9l$ci&ele %e !ecoma"&a 0" ca"titate &e ## g zi' Lipi&ele /o! )i limitate la B# - g zi( )ii"& p!e)e!ate cele &e o!igi"e /egetala8 0" ci!oza ilia!a pot c!e%te c2ia! p*"a la +g zi( %$ )o!ma &e $lei' Re%t!ictiile /o! p!i/i alcool$l( co"%e!/ele( a)$mat$!ile( mezel$!i

!*"zet$!ile )e!me"tate' Dieta ci!oticilo! /a ti"e %eama %i &e t$l $!a!ile &ige%ti/e 0"%oti!e( )ii"& a&aptata )ieca!$i caz 0" pa!te' 0" mo&$l &e p!epa!a!e c$li"a!a %e /o! i"te! p!a1elile( %o%$!ile c$ !*"ta%( co"&ime"ta!ile i!ita"te' 0" caz &e 2emoc!omatoza( !egialime"ta! /a ti"e %eama &e &ia et$l coe3i%te"t' 0" caz$!ile c$ a%cita %e /a !e&$ce apo!t$lic2i&e( ia! !egim$l /a )i 2ipo%o&at

Tratamentul etiologic %e /a a&!e%a a)ecti$"ilo! !e%po"%a ile &e apa!itia ci!ozelo! %a$ aceca!e co"%tit$ie eleme"te &e ag!e%i/itate 2epatica' A%t)el( 0" ci!ozele ilia!e c$ o %tae3t!a2epatic %e /a p!oce&a la 0"&epa!ta!ea o %tacol$l$i' 0" i")ectiile cailo! ilia!e %e )ace t!atame"te c$ a"ti iotice %$ i"&icatia a"ti iog!amei' Si)ili%$l /a )i t!atat c$ pe"icili"ac$ 2emoc!omatoza %e /a 0"ce!ca elimi"a!ea )ie!$l$i 0" e3ce% p!i" emi%i$"i !epetate &%*"ge8 0" &ege"e!e%ce"ta 2epatole"tic$la!a %e /a )ace t!atame"t c$ EDTA'

Tratamentul patogenic /izeaza com ate!ea i")lamatiei %i a p!oce%elo! im$"ologice %i%tim$la!ea !ege"e!a!ii 2epatice'

Co!ticote!apia( c$ acti$"e a"tii")lamato!ie( im$"o&ep!e%oa!e( &i$!etica %i &e %tim$laapetit$l$i( a!e i"&icatii 0" ci!ozele c$ 2ipe!%ple"i%m( a%cita %i colo%taza' N$ %e co!tizo" 0" caz$!ile c$ t!om oza po!tala' Te!apia im$"o%$p!e%i/a "$ e%te !ecoma"&a ila ci!oze'Pe"t!$ %tim$la!ea !ege"e!a!ii 2epatocita!e %e p!e%c!i$ e3t!acte 2epatice co"ce"t!ate( i" p$!i)icate( c$ /itami"a + , , ( I, ( C( E %i p!epa!ate ca =ecopa!( P$!i"o!( Lit!i%o"' Pe"t!$%teatoza 2epatica %e !ecoma"&a )acto!ii lipot!opi'

Daca apa! t$l $!a!i 0" %ec!etia ilia!a( %e !ecoma"&a colagoge' 0" %i"&!oamele 2emo!ag%e a&mi"i%t!eaza Vit' @J %$ co"t!ol$l i"&icel$i &e p!ot!om i"a' 0" 2ipe!%ple"i%m %co!ticote!apie( %e a&mi"i%t!eaza ma%a t!om ocita!a %i( la "e/oie( c$ m$lt &i%ce!"am* p!oce&eaza la %ple"ectomie' 0" ci!ozele ilia!e %e !ecoma"&a( 0" pl$%( /itami"lipo%ol$ ile A'D'@' p!epa!ate c$ calci$ %i )e!me"ti pa"c!eatici'

Tratamentul ascitei: &ieta /a )i 2ipo%o&ata( ogata 0" pota%i$( p!i" %$c$!i &e )!$cte( )!$$%cate %i c$ $%oa!a !e%t!ictie &e lic2i&e' Cli"o%tati%m$l e%te $" )acto! impo!ta"t 0m $"atati!ea &i$!ezei' Di"t!e &i$!eticele )olo%ite 0" t!atame"t$l a%citei %$"t &e p!e)T!iamte!e" ; ## mg zi<( Amilo!i& ; # mg zi<( Etac!i"( F$!o%emi&( Ne)!i3( U)!i3)olo%e%c c$ m$lt %$cce% %pi!olacto"ele ;Al&acto"e<' Pe"t!$ a o ti"e o $"a &i$!eza t!co!ectata 2ipo/olemia p!i" pe!)$zii c$ %ol$tii 2ipe!to"ice &e gl$coza( c$ al $mi"a $ma"a(c$ ma%a e!it!ocita!a( c$ =a"itol8 la "e/oie( %e pot )ace t!a"%)$zii c$ %*"ge total( ci!otic%$po!t*"& i"e %*"gele %i g!e$ a"emia'

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Pa!ace"teza "$ %e !ecoma"&a' Se /a )ace "$mai &e "ece%itate( &aca a%cita 1e"eaza )$"ctca!&io!e%pi!ato!ii8 %e %cot ca"titati &e ma3im$m ,- +'

Tratamentul chirurgical e%te $" t!atame"t &e "ece%itate8 "$ %e )ace p!o)ilactic( ei")l$e"t*"& "e)a/o!a il e/ol$tia olii'Sple"ectomia e%te i"&icata 0" p!im$l %ta&i$ al ci!oz

&e tip a"tia" %i 0" 2ipe!%ple-"i%m$l %e/e!'A"a%tomozele po!to-ca/e ca$ta %a %$p2ipe!te"%i$"ea po!tala'Ligat$!i /a%c$la!e &e /a!ice e%o)agie"e( &e /a!ice ga%t!ice %e )ac&e "ece%itate %i c*"& %ta!ea ol"a/$l$i "$ pe!mite i"te!e"tii &e amploa!e'

Tratamentul cirozei hepatice compensate. Se /o! e/ita e)o!t$!ile )izice ma!i( alime"tatiat!e $ie %a )ie ogata ;,.## - ### calo!ii<( ec2ili !ata( c$ apo!t &e p!otei"e +(. - , g g co!;0" a %e"ta e"ce)alopatiei po!tale<( %i c$ apo!t "o!mal &e gl$ci&e %i lipi&e c$ acizi g!a"e%at$!ati' Alcool$l /a )i %$p!imat &e)i"iti/' Se /o! a&mi"i%t!a %$plime"te /itami"ice ;C %

<( o!al %a$ pa!e"te!al( a"a oliza"te ;Napo%im( =a&iol<' 0" ci!oza po%t-"ec!otica ei"&icata co!ticote!apia ;P!e&"i%o" #(. - + mg g co!p( mic%o!*"&$-%e &ozele t!eptaim$"o%$p!e%oa!e ;Azat2iop!i"a-Im$!a"( +## - ,## mg zi<( %a$ Clo!am $-cil( toate )oloc$ p!$&e"ta' A%ocie!ea p!e&"i%o" ;#(,. mg g co!p< c$ cito%tatice ; mg 0" , &e oma!e%te e)ect$l )a/o!a il %i !e&$ce !i%c$l'

Tratamentul cirozei hepatice decompensate. Decompe"%a!ea apa!e &$pa oli i"te!c$!e"te(i"te!/e"tii c2i!$!gicale( 2emo!agii &ige%ti/e( oli i")ectioa%e' T!atame"t$l /izeaza

%i"&!om$l e&emato%( %i"&!om$l &e i"%$)icie"ta 2epatica( a"emia( 2emo!agiile &ige"ce)alopatia po!tala %i coma 2epatica'

- t!atame"t$l %i"&!om$l$i e&emato%( %e )ace p!i" !epao% la pat( !egim &e%o&at(cote!apie # - # mg zi ;!ealizeaza o &i$!eza apoa%a<( %i &i$!etice tiazi&ice comp!imate zi ;Ne)!i3<( F$!o%emi& # mg %a$ E&e!e" .# mg( ,- comp!imate zi( &i$o%motice ;ma"itol 0" pe!)$zie<( T!iamte!e" ,- comp!imate zi( Spi!o"a lacto"a ;Altacto"a

-B comp!imate zi etc' Di$!eticele %e a&mi"i%t!eaza 0" c$!e &e , - zile pe %aptam*0"tot&ea$"a %$ co"t!ol' P$"ctia e/ac$atoa!e( %e p!actica "$mai 0" caz &e "ece%itate( t!e%a )ie mo&e!ata ;,- +<' U"eo!i %e p!actica !epe!)$za!ea lic2i&$l$i &e a%cita'

- t!atame"t$l %i"&!om$l$i &e i"%$)icie"ta 2epatica( p!e%$p$"e !epa$% la pat( &ec2ili !ata c$ apo!t p!oteic %$)icie"t( a"a oliza"te &e %i"teza ;=a&iol( Napo%im/itami"e B %i +,( aci& )olie' Co!ticote!apia %e !ecoma"&a "$mai 0" p!eze"ta )e"ome"elo! i")lamato!ii' Sple"ectomia %e p!actica 0" ci!oza 1$/e"ila c$ 2ipe!%ple"i%m' Se maa&mi"i%t!eaza &$pa caz( /itami"a @( )i !i"oge"( pla%ma 0" 2emo!agii &i)$ze( %i 0" c%peciale aci& ep%ilo"-ami"o-cap!oic'

- t!atame"t$l a"emiei %e !ealizeaza c$ pe!)$zii &e %*"ge( aci& )olie( /iami"a K,( )ie! ;9l$ i)e!<( co!ticote!apie( %i $"eo!i c2ia! %ple"ectomie'

- t!atame"t$l 2emo!agiei &ige%ti/e %e )ace c$ pe!)$zii &e %*"ge izog!$p( %$ %tit pla%matici ;De3t!a"<( $"eo!i aplica!ea %o"&ei c$ aloa"e Seg%to e"- lac mo!e(2emo%tatice( !et!o2ipo)iza( ia! pe"t!$ p!e/e"i!ea e"ce)aliei p!otale( %ec$"&a!a 2emo!agie

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%e !ecoma"&a cli%ma e/ac$atoa!e( a&mi"i%t!a!ea &e Neomici"a -B g zi' 0" caz$!ile e3t%e )ace ligat$!a /a!icelo!'

- t!atame"t$l e"ce)alopatiei po!tale' Se !e&$c p!otei"ele %$ + g g co!p( %e a&mi"i%t!a"ti iotice 0" caz &e i")ectii ;Tet!acicli"a %a$ Ampicili"a , g zi( Neomici"a - g zi( la ca

%e a&a$ga =ico%tati"<' 0"tot&ea$"a %e com ate co"%tipatia c$ la3ati/e' 0" caz$!i %peciaa&mi"i%t!eaza al)acetogl$ta!at &e o!"iti"a( # - B# g 0" , &e o!e'

- t!atame"t$l comei 2epatice( p!o/ocata &e 2ipe!amo"iemie( t$l $!a!i 2i&!oelect!olitice%e/e!e %a$ i"%$)icie"ta 2epatica g!a/a( p!e%$p$"e $" a"%am l$ &e ma%$!i ca!e %e a&!)acto!$l$i etiologic' Pe"t!$ mic%o!a!ea amo"ioge"ezei( %e com ate co"%tipatic$ la3ati/e( )lo!a p!oteolitica c$ Neomici"a - g zi %a$ Tet!acicli"a ,- g zi' Regim$lt!e $ie %a )ie 2ipop!oteic' 0" caz$!i &eo%e ite %e a&mi"i%t!eaza Lact$loza( Al)acetogl&e O!"iti"a( Aci& 9l$tamic( %a$ Clo!2i&!at &e A!gi"i"a 0" pe!)$zie' Pe"t!$ !eec2ili !ameta olica %e !ecoma"&a pe!)$zii &e gl$coza( a"&!oge"i a"a oliza"ti ;Te%to%te!co!ticoizi ;5emi%$c-ci"at &e 2i&!oco!tizo" ## mg 0" , &e o!e<( Clo!$!a &e pota%i$ -B%i Clo!$!a &e calci$'

Tratamentul comei hepatice "ece%ita 0" p!im$l !*"& ma%$!i &e co"t!ol %i igie"o-&ie-tetic0"!egi%t!a!ea tempe!at$!ii %i a p$l%$l$i la - B o!e8 e3ame" zil"ic ge"e!al8 &oza!ea la +zile a Na ( CI4 %i @ 0" %*"ge %i $!i"a( a !eze!/ei alclali"e( a $!eei8 &oza!ea la zil ili!$ i"emiei'

Foa!te impo!ta"te %$"t ma%$!ile &e 0"g!i1i!e: ae!i%i!ea came!ei( igie"a ol"a/$l$i %

!$)a!iei( %c2im a!ea )!ec/e"ta a pozitiei ol"a/$l$i'Regim$l alime"ta! p!e/e&e $" apo!t ec2ili !at &e lic2i&e ;e3c!etia zilei p!ece&e"te .##ml<( %$p!ima!ea p!otei"elo! %i !ei"t!o&$ce!ea lo! &$pa !e/e"i!ea c$"o%ti"tei ;c*te +# -g zi( p*"a la cel m$lt # g<8 &aca ol"a/$l 0"g2ite( %e &a$ %$c$!i 0"&$lcite( &aca "$( g,#? pe %o"&a %a$ ? pe catete! i"t!a/e"o%( p*"a la ,## ml zi' Se /o! a&a$ga #(, p*"a la#(. g %o&i$ zi %i c*te +(. g pota%i$ la )ieca!e lit!$ &e %ol$tie gl$cozata'

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