本文選題：慢性丙肝　切入點(diǎn)：肝硬化　出處：《第四軍醫(yī)大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：丙型肝炎是由丙型肝炎病毒（Hepatitis C virus，HCV）引起的一種隱匿性、持續(xù)性、進(jìn)展性疾病，呈世界性流行。全球約有3.2%丙肝感染率，感染人數(shù)約1.7億，我國達(dá)4000萬以上[1]。由于感染HCV后臨床表現(xiàn)無特異性，多數(shù)患者就診時已發(fā)展為肝硬化，并發(fā)脾臟腫大、脾功能亢進(jìn)、血細(xì)胞下降等臨床綜合癥狀，嚴(yán)重影響了干擾素抗病毒方案的實(shí)施。目前針對脾亢問題，通過非手術(shù)治療難以控制，無特異性藥物有效遏制，極易造成白細(xì)胞和血小板減少，甚至導(dǎo)致的出血現(xiàn)象。結(jié)合外科手術(shù)和介入治療手段，主要包括脾臟切除、脾臟部分切除、介入下脾動脈栓塞治療等，可以解決或部分解決脾大脾亢問題。然而，脾臟作為重要的外周免疫器官具有抗感染免疫功能，國外有學(xué)者提出最大限度保留脾臟功能及脾組織，不主張切脾治療，對此學(xué)界至今仍然存在爭議。 隨著近年來丙肝抗病毒治療有效率的提高，丙肝肝硬化伴脾功能亢進(jìn)患者術(shù)后遠(yuǎn)期生存質(zhì)量和各項(xiàng)指標(biāo)的提高，與是否抗病毒治療有關(guān)成為研究熱點(diǎn)。脾功能亢進(jìn)不僅嚴(yán)重影響白細(xì)胞和血小板下降，出現(xiàn)凝血功能障礙和出血傾向，而且對患者的身心健康產(chǎn)生負(fù)面作用。肝硬化的形成與脾臟復(fù)雜的免疫調(diào)節(jié)機(jī)制有著密切關(guān)系，其免疫因子的變化間接參與了肝纖維化的進(jìn)程[5-6]。門靜脈系統(tǒng)阻力和側(cè)枝分流的增加也是促進(jìn)脾功能亢進(jìn)發(fā)生的重要因素[7]，因此，越來越多的證據(jù)表明脾亢、肝硬化、門靜脈高壓癥三者互為因果，不單純是肝硬化的繼發(fā)病變，且給予肝炎肝硬化脾切除患者抗病毒治療不僅可行，而且將從抗病毒治療中獲得益處[18]。 本課題主要以回顧2000年1月至2012年5月，第四軍醫(yī)大學(xué)和西安交通大學(xué)共四所附屬醫(yī)院收治的丙型肝炎肝硬化伴脾功能亢進(jìn)且是否行脾切除術(shù)治療的患者共155例為研究對象（脾切治療97例、保脾治療58例），其一觀察肝硬化患者脾切除術(shù)后行抗病毒治療（抗病毒治療組42例和未抗病毒治療組33例）對患者凝血指標(biāo)、肝臟儲備功能及門脈高壓的動態(tài)臨床影響；其二以5年為隨訪節(jié)點(diǎn)，采用生存質(zhì)量綜合評定問卷（WHOQOL—BREF）等測定，，對丙型肝炎肝硬化伴脾功能亢進(jìn)患者（脾切除術(shù)組28例和保脾治療組30例）生存質(zhì)量(quality of life，QOL)狀況進(jìn)行調(diào)查，并評價聚乙二醇干擾素α-2a聯(lián)合利巴韋林抗病毒治療對患者QOL的干預(yù)作用。 結(jié)果如下： 1.PT在治療組中的表達(dá)于術(shù)后60個月較抗病毒治療前顯著降低（P＜0.01），延緩了PT時間； APTT治療組和對照組在術(shù)后均即刻出現(xiàn)下降（P＜0.05），但這種下降趨勢于治療組可保持到術(shù)后60個月，而對照組自術(shù)后6個月以后呈上升趨勢；治療組對PTA短期無改善，但術(shù)后60個月時較對照組具有顯著差異（P＜0.01）；術(shù)后6月時治療組和對照組Fib值均為最高點(diǎn)，且治療組與各時間點(diǎn)均無顯著差異；PLT在術(shù)后即刻升高且差異顯著（P0.001），并隨病程延長與ALB水平和A/G比值同樣較術(shù)前均呈降低趨勢。治療組較對照組能夠使術(shù)后降低的門脈寬度值延緩上升。 2．比較患者自身健康狀況的四個方面，包括主觀感覺、生理情況、心理狀態(tài)、社會關(guān)系，發(fā)現(xiàn)脾切組與保脾組整體5年生存質(zhì)量無差異；而單純行脾切組5年生存質(zhì)量較保脾并抗病毒治療組差，但脾切組術(shù)后聯(lián)合抗病毒治療可有效地提高患者術(shù)后5年生存質(zhì)量，其差異均具有統(tǒng)計學(xué)意義。 綜上所述； 脾臟切除后無論是否出現(xiàn)免疫功能變化，仍可間接改善肝臟儲備功能、延緩肝硬化進(jìn)程、促進(jìn)肝細(xì)胞再生，但療效短暫。若能術(shù)后聯(lián)合抗病毒治療對肝硬化患者肝臟儲備功能、出凝血穩(wěn)定/保護(hù)作用、延緩門靜脈寬度擴(kuò)張及更有效改善5年生存質(zhì)量意義更大。
[Abstract]:Hepatitis C is by hepatitis C virus (Hepatitis C, virus, HCV) an occult, caused by persistent, progressive disease is a worldwide epidemic. There are around 3.2% HCV infection rate, the infection number about 170 million, China is more than 40 million [1]. after HCV infection due to lack of specific clinical manifestations, the majority of patients treatment has been developed for concurrent cirrhosis, splenomegaly, hypersplenism, clinical symptoms of blood cells decreased, serious impact on the implementation of the scheme. The antiviral hypersplenism treated by non operative problems, it is difficult to control, no effective containment of specific drugs, extremely easy to cause neutropenia and thrombocytopenia, and even lead to bleeding the phenomenon. The combination of surgical and interventional treatment, including surgical resection, partial resection of the spleen, interventional splenic artery embolization treatment, can solve or partially solve problems of splenomegaly and hypersplenism. However, spleen As an important peripheral immune organ, the spleen has the function of anti infection and immunity. Scholars from abroad have proposed that the spleen function and splenic tissue can be maximally preserved, and no splenic treatment is advocated.
As to improve the efficiency of antiviral therapy for hepatitis C in recent years, patients with hepatitis C cirrhosis with hypersplenism after long-term survival and quality indicators improved, and whether the antiviral therapy has become a research hotspot. Hypersplenism not only affects white blood cells and platelets decreased, coagulation dysfunction and bleeding tendency, but also have a negative effect on patients the physical and mental health. The formation of spleen and liver cirrhosis complicated immune regulation mechanism is closely related to the changes of immune factors indirectly involved in the process of liver fibrosis [5-6]. portal system shunt resistance and collateral increase is an important factor for the occurrence of hypersplenism [7], therefore, more and more evidence of liver cirrhosis, hypersplenism and portal portal hypertension is not only the three reciprocal causation of cirrhosis, secondary lesions, and give the patients resistant hepatitis cirrhosis splenectomy Drug treatment is not only feasible, but will benefit from antiviral treatment, [18].
This paper focuses on a review from January 2000 to May 2012, a total of four hepatitis C cirrhosis from the Affiliated Hospital of The Fourth Military Medical University and the Xi'an Jiao Tong University with hypersplenism and whether splenectomy in the treatment of patients with a total of 155 cases as the research object (spleen resection in the treatment of 97 cases, 58 cases of the treatment, the observation of spleen preserving) in patients with liver cirrhosis after splenectomy (antiviral therapy the antiviral treatment group of 42 cases and no antiviral treatment group 33 cases) on blood coagulation indexes of patients with clinical effect, dynamic liver function and portal hypertension; second in 5 years of follow-up by the node, the quality of life assessment questionnaires (WHOQOL - BREF) were of hepatitis C patients with cirrhosis and hypersplenism (splenectomy group and 28 cases of spleen preserving treatment group 30 cases (quality of life) quality of life, QOL) to investigate the situation, and evaluation of pegylated interferon alpha -2a combined with ribavirin The intervention of treatment on patients with QOL.
The results are as follows:
The expression of 1.PT in the treatment group after 60 months compared with before antiviral therapy significantly decreased (P < 0.01), the PT time delay; APTT treatment group and control group after operation were immediately decreased (P < 0.05), but the decline in the treatment group can be maintained up to 60 months after operation, while the control group after 6 months later showed an upward trend; the treatment group had no improvement on PTA in the short term, but 60 months after operation compared with the control group with significant difference (P < 0.01); after June when the value was the highest point of the treatment group and the control group Fib, and there was no significant difference the treatment group and each time point; PLT in the immediate postoperative period significantly increased (P0.001), and with the extension of the course and the level of ALB and A/G ratio as compared with the preoperative decreased. The treatment group than the control group to the postoperative portal vein width decreased slow rise.
Four aspects of 2. patients with their own health status, including subjective feeling, physiological, psychological status, social relations, found that splenectomy and spleen preserving group overall 5 year survival quality has no difference; and underwent splenectomy group 5 years survival quality and spleen preserving antiviral therapy group, but splenectomy group after antiviral therapy can effectively improve the quality of life of patients after 5 years, the differences were statistically significant.
In summary錛

本文編號：1608719