2018年 · 第38卷第02期

Cirrhosis has a systemic hyperdynamic circulatory state characterized by increased cardiac output and decreased peripheral resistance. Cirrhosis can lead to redistribution of circulating blood volume, decrease in effective circulating blood volume, arterial blood pressure, and changes in volume and pressure load activate the sympathetic nervous system, further exacerbating the hyperdynamic circulatory state and myocardial tone. Cirrhosis can cause abnormalities in cardiac systolic function, diastolic function and electrophysiology of cardiomyocytes, namely cirrhotic cardiomyopathy. In addition, heart failure can also cause congestive liver disease, and long-term congestion will further lead to cardiogenic cirrhosis. Liver function indexes, such as bilirubin, GGT, albumin, etc., are also important indicators to predict death in patients with heart failure. The interaction between liver disease and heart disease is discussed from the perspective of integrative medicine.

IBD is a group of chronic recurrent intestinal diseases with unknown etiology, non-specific immune mediation, and difficult to self-limit. UC and CD are the main disease types. In the past, this disease was rare in my country. In the past 10 years, IBD has changed from a rare disease to a common disease in my country, and the ability of Chinese clinicians to diagnose and treat IBD is also improving rapidly. 30% of IBD patients have liver function abnormalities^[1]Its accompanying liver disease is common in clinical practice, but it has not attracted the attention of most doctors.

Since Marshall's introduction of the "intestinal-hepatic axis" in 1998, its important role in the pathogenesis and treatment of a variety of liver and intestinal diseases has been demonstrated^[1]。 Previous studies have found that the course of many liver diseases is accompanied by changes in intestinal microecology, but there are still certain limitations in their understanding, such as the lack of large sample clinical controlled studies, which only describe the differences in intestinal microecology at the phylum level, and do not conduct a deeper classification of bacterial flora. And there is still a lack of research on new intestinal microecological agents to improve liver disease. At present, the research in this field is progressing rapidly, and some new findings suggest that clinicians should not only pay attention to intestinal microecology, but also pay attention to the influence of metabolites of intestinal microecology on liver diseases and the influence of intestinal immunity on liver immunity when studying "intestinal-liver dialogue", so as to have a more comprehensive and deep understanding of "intestinal-liver dialogue" and provide new ideas for the diagnosis and treatment of liver diseases.

Liver and stomach are important organs of human digestive system, and there is a natural connection between them in anatomy. The liver and stomach together originate from the embryonic foregut. The left lobe of the liver and the anterior wall of the stomach are adjacent, and together form part of the small omental sac. The liver is connected with the gastric blood vessel, part of the blood supply of the liver comes from the left gastric artery, and part of the blood supply of the stomach comes from the common hepatic artery or the intrinsic hepatic artery; The gastric vein merges into the portal vein. The liver communicates with the gastric cavity through the biliopancreaticoduodenum. The primary function of the stomach is the reception, storage, and transport of food; The liver is the center of human metabolism, involved in the metabolism of sugar, protein, fat, vitamins and hormones, and has powerful detoxification, phagocytosis and defense functions. The liver and stomach work synergistically to maintain important physiological functions of the body. In the disease state, due to the anatomical and functional connection between the liver and the stomach, the disease of the liver and the stomach brings mutual influence, that is, the disease of one organ may induce or aggravate the damage of another organ, and the treatment of the disease of one organ may also affect the other organ. At the same time, liver and stomach diseases have similar clinical symptoms, complicating the diagnosis and treatment of the disease. This paper reviews the integrated diagnosis and treatment of liver and stomach diseases, aiming at helping clinicians to improve the diagnosis and treatment level of liver and stomach diseases.

The spleen and the liver are separated on the left and right sides of the human abdominal cavity, and the splenic vein merges with the superior mesenteric vein to form a portal vein that enters the liver. Because of the anatomical connection of the portal vein, portal hypertension in cirrhosis is often accompanied by splenomegaly and hypersplenism. At the same time, the liver and spleen have the same function in the physiological processes such as hematopoiesis and hemofiltration of the body, and the related systemic changes often affect the liver and spleen at the same time, such as malaria and leukemia. In recent years, a series of important studies have gradually elucidated the mechanism of common physiological functions of liver and spleen in hematopoiesis and iron metabolism regulation, and also found that spleen, as an important immune organ, participates in the occurrence and development of liver disease. It can be seen that there is an extensive direct or indirect dialogue between the liver and the spleen. From the perspective of integrative medicine, it is of great significance to understand and manage liver diseases to clarify the relationship between liver and spleen around physiological connections and interactions in disease processes.

Gastric cancer is one of the common tumors of digestive tract, which seriously threatens human life and health. In recent decades, with the improvement of people's living conditions, the formation of good eating habits,H.pyloriThe incidence rate of gastric cancer has decreased overall, but its incidence rate is still the fourth highest in the world among male tumors, and the mortality rate is the third highest, and the incidence rate of men is twice that of women^[1,2]。 China is a country with a high incidence of gastric cancer. According to the 2015 China Cancer Data Report, the estimated number of new cases of gastric cancer in China is 679,000 and the number of deaths is 498,000 every year. Its incidence and mortality rate rank second among malignant tumors. New cases and deaths of gastric cancer in China account for about 42.6% and 45.0% of the global total^[3]。 Therefore, reducing the incidence and mortality of gastric cancer in China is a major public health problem that needs to be solved urgently, and it is also in line with the growing needs of our people for a better life.

tumor necrosis factor superfamily 15 (TNFSF15) binds to death receptor 3 to activate NF-κ B and promote the proliferation and activation of various immune cells. mankindTNFSFThe gene 15 is located at 9q32 and contains a variety of single nucleotide polymorphism (SNP), among which rs3810936 is located at exon 4, and the C→T mutation at this site is synonymous^[1]。 Both rs4263839 and rs4979462 are located in the first intron. The G→A mutation in the former can lead to peripheral blood and intestinal tissuesTNFSF15 mRNA down-regulated expression; C→T mutation in the latter will be upregulatedTNFSF15 mRNA expression of^[2]。 This study is intended to explore the Han population in Zhejiang ProvinceTNFSFThe relationship between 15 (rs3810936, rs4263839, rs4979462) gene polymorphisms and CD susceptibility provides clues for further interpretation of the genetic immunological pathogenesis of CD.

In the field of diagnosis of chronic liver diseases, fibro scan (FS) is one of the most promising non-invasive techniques in recent years. liver stiffness measurement (LSM) using FS has been applied to assess the severity and prognosis of liver disease^[1]。 However, there is no sufficient clinical evidence to prove that LSM can accurately predict the presence and degree of cirrhotic esophageal varices (EV)^[2]。 Portal hypertension and EV are important complications in patients with liver cirrhosis. EV hemorrhage can endanger the life of patients, and the mortality rate is 10% ~20%. The latest guidelines recommend that all patients with cirrhosis should undergo endoscopic screening to determine the presence of EV^[3]。 Gastroscopy is the gold standard for EV diagnosis, but it also has limitations. It not only increases the burden of endoscopic screening, but repeated examinations also require high patient compliance. Studies have shown that spleen stiffness measurement (SSM) can be used to assess portal pressure and varicose veins in patients with liver cirrhosis^[4,5]。 Related studies have also found that the measurement of spleen stiffness using FS or acoustic radiation force impulse (ARFI) is closely related to portal hypertension and EV^[4,5]。 The purpose of this study was to evaluate the relationship between liver stiffness and spleen stiffness and the degree of EV in patients with liver cirrhosis by using FS for LSM and SSM, so as to provide a basis for the non-invasive diagnosis of EV in liver cirrhosis.

autoimmune pancreatitis (AIP) is a special type of chronic pancreatitis, characterized by diffuse pancreatic enlargement, exudation, fibrosis with tissue IgG4-positive cell infiltration, which can involve multiple organs in the body, and responds well to glucocorticoid therapy. The onset of AIP lacks specificity, and obstructive jaundice is often the clinical manifestation. Serum IgG4 level and CT imaging findings are very important for the diagnosis of AIP. Because the onset and imaging findings of AIP are very similar to those of biliary and pancreatic system tumors, if the understanding of AIP is insufficient, patients may suffer unnecessary surgical treatment. A case of AIP with multiple cystic changes of the pancreas admitted to Shanghai Ruijin Hospital in May 2013 was reviewed, and the diagnosis and treatment process was discussed.

A 56-year-old female was admitted to the hospital on 14 February 2015 due to anorexia for 2 years and nausea for 10 days. The patient had no obvious trigger for anorexia 2 years before admission, and no formal diagnosis and treatment was given. 10 days before admission, nausea symptoms, no vomiting, abdominal pain, diarrhea, no skin itching, no white clay-like stools, etc., were seen for a definite diagnosis. His grandmother suffers from rheumatoid arthritis and denies a history of drinking alcohol, special medication, and hepatitis and tuberculosis. Physical examination at admission: sclera was yellow stained, and the superficial lymph nodes of the whole body were unpalpable and enlarged. Post-admission check ALT 569 U/L, AST 277 U/L, ALP 198 U/L, GGT 183 U/L, TBil 15.2 μ mol/L, DBil 11.1 μ mol/L. Immune indexes anti-nuclear antibody, anti-smooth muscle antibody, anti-liver and kidney microsomal 1 antibody, anti-mitochondrial antibody, anti-mitochondrial antibody type M2, anti-nuclear membrane glycoprotein 210, anti-soluble acid phosphorylated protein 100 antibody, anti-double stranded DNA antibody and anti-SM antibody were all negative; Immunoglobulin G (IgG) 22.0 g/L (normal<15.6 g/L), IgG4 6.27 g/L (normal 0.03-2.01 g/L); Five indexes of hepatitis B and hepatitis C antibody were all negative; Both cytomegalovirus and parvovirus antibodies were negative. Upper abdominal enhanced CT examination showed no obvious abnormalities. The pathology of liver puncture biopsy showed that the structure of liver lobules still existed, some hepatocyte edema, punctate necrosis and detrital necrosis, portal inflammation and boundary laminitis (a large number of lymphocytes and plasma cells were positive for CD38 and CD138, and a few neutrophils infiltrated), no rose knot structure, interstitial fibrous tissue proliferation, and a trend of pseudolobule formation, seeFIG. 1A、FIG. 1B。 Immunohistochemical staining showed CD38 and CD138 positive, IgG4 positive plasma cells>10/high power field, IgG4 positive cells to IgG positive cells ratio>0.4, IgG4 related diseases were not excluded, seeFigure 1C、Figure 1D。 The patient met the diagnostic criteria for immunoglobulin G4-related disease (IgG4-RD)^[1], diagnosed as IgG4-RD. After treatment with ursodeoxycholic acid for more than 1 month, the liver function improved but did not return to normal. The patient was given 60 mg/d of prednisone and gradually reduced to 10 mg/d. The patient's symptoms improved compared with before, and the liver function, serum IgG and IgG4 levels all returned to normal. The patient spontaneously stopped treatment with prednisone and hepatoprotective drugs, and after about 3 months, the liver function index was abnormal again. The patient was given prednisone 60 mg/d and gradually reduced to 5 mg/d, and the liver function gradually returned to normal. After 2 years of follow-up, the patient's liver function continued to be normal, and no progression of liver fibrosis was found on abdominal ultrasound.

Since the concept of natural orifice transluminal endoscopic surgery (NOTES) was introduced in the late 1990s, NOTES has revolutionized the development of minimally invasive therapy. In recent years, with the development of endoscopic submucosal dissection (ESD) and endoscopic ultrasound techniques, new NOTES techniques have been emerging^[1]: ESD-related NOTES are mainly represented by peroral endoscopic myotomy (POEM), peroral endoscopic pyloromyotomy (POP), endoscopic submucosal tunneling endoscopic resection (STER), endoscopic full-thickness resection (EFTR), etc. endoscopic ultrasound-related NOTES mainly include endoscopic ultrasound-guided drainage debridement of infectious pancreatic necrosis, pancreatic pseudocyst drainage, biliopancreatic duct drainage, gallbladder drainage lithotomy, gastrointestinal anastomosis, etc. Endoscopic ultrasound has the advantages of guiding the surgical approach and reducing complications such as bleeding, and its related NOTES occupies an important position in the new NOTES technology. The progress of clinical application of NOTES related to endoscopic ultrasound is reviewed.

acute kidney injury (AKI) is a common complication in patients with advanced cirrhosis, accounting for about 19% of all hospitalized patients with cirrhosis^[1]。 AKI in patients with liver cirrhosis can be caused by different causes, and the treatment options for AKI caused by different causes are also different. The etiology of AKI is mainly classified into structural renal diseases (acute tubular necrosis, glomerulonephritis), interstitial nephritis and functional renal failure associated with hemodynamic changes, especially progressive cirrhosis^[2]。 In clinical practice, it is difficult to accurately judge the etiology of AKI to formulate a reasonable treatment plan. At present, the formulation of relevant diagnostic criteria and treatment guidelines has refined the diagnosis and treatment plan of cirrhotic AKI for clinicians. Now, the new progress in the etiology, diagnosis, management, prevention and treatment of cirrhotic AKI in recent years is analyzed, in order to provide clinicians with new ideas for diagnosing and treating cirrhotic AKI.