臨牀消化器内科 Vol.29 No.4(6-1)


特集名 肝硬変―診断と治療の進歩
題名 肝硬変治療の進歩 (1) 脳症の診断・治療
発刊年月 2014年 04月
著者 福井 博 奈良県立医科大学消化器・内分泌代謝内科
【 要旨 】 近年,肝性脳症の病態は脳内の星状膠細胞(astrocyte)に対するアンモニアと炎症の影響から論じられてきている.高アンモニア血症と炎症は相まって活性酸素種,活性窒素種,ベンゾジアゼピン受容体などを巻き込み,星状膠細胞の浮腫を引き起こす.肝性脳症は顕性脳症とミニマル脳症に分類されるが,ミニマル脳症を早期に診断するために,神経心理測定テストが種々工夫されており,今後コンピューターを用いる客観的かつ迅速な評価法がさらに進歩すると思われる.肝性脳症治療はラクツロースなどの二糖類と分岐鎖アミノ酸製剤を基本とするが,難吸収性抗菌薬の投与は新しい病態理論に立脚したもので,rifaximinの効果が期待される.
Theme Cirrhosis -- Recent Progress in Diagnosis and Treatmen
Title Diagnosis and Treatment of Hepatic Encephalopathy
Author Hiroshi Fukui Third Department of Internal Medicine, Nara Medical University
[ Summary ] The development of hepatic encephalopathy in patients with liver cirrhosis has been explained by the effects of hyperammonemia and inflammation on the astrocytes, the only cells in the brain that can metabolize ammonia. An accumulation of ammonia and inflammatory cytokines induces swelling of the astrocytes and stimulates reactive oxygen species, reactive nitrogen species and the benzodiazepine receptors. This may in turn exaggerate brain edema and encephalopathy. Hepatic encephalopathy is frequently associated with systemic inflammatory response syndrome (SIRS), which may be attributable to bacterial translocation and endotoxemia.
To make an early diagnosis of minimal encephalopathy several neuropsychometric tests including those assisted by computers have been developed. Computerized psychometric tests uploaded into these handy devices have the potential to provide objective and prompt assessment of patients with hepatic encephalopathy. Lactulose and branched-chain amino acids are basic treatment modalities for encephalopathy in Japan. Oral administration of non-absorbable antibiotic rifaximin is a promising new adjunctive therapy based on control of blood ammonia levels and gut-derived infections in patients with decompensated cirrhosis.
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