1. Clinical data
Patient Li, female, 38 years old, hospitalization number 309641, was admitted to the Department of Gastroenterology of the Second Hospital of Heavy Medicine on August 2, 2008 because of “yellowing of the body and eyes for half a month, aggravated by anorexia of oil and weakness for one week”. The patient was in good health and had no history of hepatitis or family history. She took black sesame seeds, walnuts, and Radix et Rhizoma Polygonatum daily with sugar three times a day due to gray hair, and occasionally used Radix et Rhizoma Polygonatum powder in soup and steamed eggs for more than 4 months.
The patient had no history of hepatitis exposure and had not taken any other drugs that could cause liver damage while taking the drug. The patient was admitted with yellow eyes, yellow body, aversion to oil, weakness, poor appetite, physical examination: stable vital signs, acute illness, moderate yellowing of the skin and sclera, no cardiopulmonary peculiarities, flat and soft abdomen, no pressure pain, rebound pain and muscle tension in the whole abdomen, liver and spleen not detected under the ribs, negative mobile turbid sounds, no swelling of both lower limbs.
Liver function: total bilirubin (TB) 219.8μmol/L, direct bilirubin (DB) 146.5μmol/L, ALT 1110u/L, AST 1093u/L; prothrombin time (PT) 20.5 seconds, prothrombin activity (PTA) 45%; hepatitis A antibody (HAV-IgM) negative. Hepatitis B two pairs of half: HBsAg negative, anti-HBs positive, HBeAg negative, anti-HBe negative, anti-HBc positive; hepatitis C antibody (anti-HCV) negative; hepatitis E antibody (HEV-IgM) negative.
The patient was diagnosed as “drug-related hepatitis”, and was advised to stop taking He Shou Wu, and was given liver protection, enzyme lowering, anti-yellowness and symptomatic support for 20 days, but the treatment was not effective, and the condition was progressively aggravated. The patient was transferred to the Infection Department for artificial liver plasma exchange therapy.
When the patient was transferred to the department on August 20, he showed poor mental clarity, indifferent expression, unresponsiveness, decreased calculation power, abnormal orientation and memory, severe yellowing of the skin and sclera, large petechiae at the injection and puncture sites, equal size and roundness of both pupils, dull reflex to light, and disappearance of the pressure orbital reflex. Abdominal examination: abdomen was flat and soft, no pressure pain, rebound pain and muscle tension, hepatic turbinates were narrowed, liver and spleen were not detected, intestinal sounds were not heard, and mobile turbid sounds were negative.
The EEG showed severe abnormal EEG, abnormal EEG topography, and abnormal brain power spectrogram. The abdominal ultrasound showed increased, thickened and extremely heterogeneous echogenicity in the liver; thickened gallbladder wall; no exact abnormalities in the pancreas, spleen and both kidneys. CT scan of the head did not show any significant abnormalities. Liver function: ALT/AST 250/203μ/L, TB/DB 403.5/268.6μmol/L, ALB 25.1g/L. Blood WBC 23.37*109/L, N92.6%.
Re-diagnosed as.
1 drug-induced severe hepatitis.
2 hepatic encephalopathy (degree II-III). He was given a combination of hepatoprotective (acetylcysteine), anti-yellowness (adenosylmethionine powder injection), intensive anti-infection (Tylenol), acid suppression and gastric protection (pantoprazole), anti-hepatic coma (ornithine portal, arginine, branched-chain amino acids), dehydration to prevent and control cerebral edema (mannitol) and symptomatic support with plasma and albumin. A deep vein was placed (a double vena cava catheter was inserted into the femoral vein below the right inguinal ligament to establish circulatory access), and a combination of plasma exchange and hemofiltration was applied four times on August 21, 25, 29, and September 4, respectively.
Plasma exchange (PE) treatment was performed with a Japanese KM-8800 hemodialysis machine. Firstly, arteriovenous channels were established and the patient’s blood was introduced into the hemodilator for plasma exchange under heparin anticoagulation, with a separation rate of 25 ml/min and a plasma exchange flow rate of 100 ml/min, with a plasma exchange volume of 2200-2600 ml each time. 10-20mg.
During the treatment, the clotting time and transmembrane pressure were monitored to adjust the heparin dosage. At the end of the treatment, 10-20mg of fisetin was used to neutralize the residual heparin according to the heparin dosage.
Immediately after the plasma exchange treatment, hemofiltration treatment was performed (the instrument was a continuous hemodialysis system, model 7106505, Beltran, Germany) with 250-280 ml/min of circulating blood, 4000 ml/min of exchange fluid flow, 5 mg/h of extracorporeal heparin anticoagulation, and neutralization of sodium heparin with fisetin in equal amounts for 6-8 h. During the combined treatment of plasma exchange and hemofiltration Patients’ symptoms were observed before and after, and patients’ routine blood, liver (TB, DB, ALT, ASTALB, GLB, ALB/ GLB) renal function, electrolytes and prothrombin activity (PTA) were monitored.
After treatment, serum TB, ALT, AST and GLB were significantly lower than before treatment, and serum ALB, ALB/GLB and PTA were significantly higher than before treatment. After treatment, the patient’s consciousness became clear, calculation power, orientation power and memory were completely restored to normal, he ate and defecated on his own, his vital signs were stable, there was no edema in both conjunctivae, the muscle strength of the limbs was normal, fluttering tremor was negative, the heart and lungs were normal, the abdomen was flat and soft, there was no pressure pain, rebound pain and muscle tension, and the mobile turbid sound was negative.
Both lower limbs were not swollen. He was treated with liver-protective and anti-yellowness medications. On October 5, PT was detected for 18 seconds, PTA 57%, liver function ALB 31.4 g/L, ALT/AST 37/93μ/L, TB/DB 117.6/84.3μmol/L. Since then, liver care treatment was continued and the patient recovered completely. Chen Xinyu, Department of Hepatology, Chongqing Hospital of Traditional Chinese Medicine
2. Discussion
The patient developed moderate yellow sclera and general skin mucosa with anorexia and weakness after taking He Shou Wu continuously for more than 4 months because of white hair, and the examination was negative for hepatitis virus serum index, so it was mostly considered to be caused by taking He Shou Wu for a long time, and the patient did not know whether it was raw He Shou Wu or made He Shou Wu.
The Chinese medicine He Shou Wu, also known as mountain shou Wu, red shou Wu, earth essence, mountain essence, Chen Zhi Bai, red within the elimination, horse liver stone, small unique root, etc., was first published in the “Kai Bao Ben Cao”, as Polygonum multiflorumThunb Polygonum dried tuberous root, “Kai Guo Ben Cao” records, Shou Wu has “benefit qi and blood, black moustache temples, pleasing color, long service long tendons and bones, and It also treats women after childbirth and all kinds of illnesses of the belt”.
According to the Compendium of Materia Medica, Shou Wu “can nourish the blood and benefit the liver, strengthen the kidneys, strengthen the muscles and bones, darken the moustache hair, is a good tonic, not cold and not dry, above the function of Di Huang and Tian Men Dong”, is a common Chinese medicine to nourish the liver and kidneys, its nature is slightly warm, taste bitter, sweet, astringent, mainly into the liver, kidney, heart meridian. It is slightly warm, bitter, sweet and astringent, and is mainly used in the liver, kidney and heart meridians. There is a difference between raw and prepared radix. Raw Shou Wu is the raw product of the dried tuberous root of He Shou Wu, with a dosage of 6-12g, taken by decoction. It is used to treat scrofulous sores and carbuncles, itchy rash and constipation.
Because of its laxative effect, raw Radix et Rhizoma Polygoni is often used clinically to treat blood deficiency and constipation in the elderly, maternity or the weak. Prepared shouwu can nourish the liver and kidney, benefit the essence and blood, augment the hair and strengthen the muscles and bones, and is used to treat blood deficiency and yellowing, dizziness and tinnitus, premature graying of the hair, soreness and weakness of the waist and knees, numbness of the extremities, collapse and leakage, and prolonged malaria. The dosage of Radix et Rhizoma Polygoni is 1O-30g, taken by decoction. Raw Radix et Rhizoma Polygoni and Radix et Rhizoma Polygoni are identical in taste, but different in efficacy and main treatment. Experiments have shown that there are differences in their composition, action and toxicity.
The combined anthraquinone contained in raw Radix et Rhizoma can be transformed into free type after concoction, which can reduce the toxicity and increase the content of reducing sugar, so Radix et Rhizoma can be used for black hair; while Radix et Rhizoma has a mild laxative effect and Radix et Rhizoma has none; Radix et Rhizoma has obvious toxicity and Radix et Rhizoma has very little toxicity.
Modern pharmacological studies have found that its main active ingredients are anthraquinones, which have a wide range of effects such as anti-aging, immune regulation, lipid-lowering, and promotion of adrenocortical function, but anthraquinone derivatives have toxic effects on the liver, and insecure quinone derivatives have similar adrenocortical hormone-like effects, which may have certain toxic effects on the liver. The cause of hepatic damage from He Shou Wu is still unclear, and it has been reported that it may be related to idiosyncratic body allergy.
In the present case, the time from the administration of the drug to the onset of the disease was more than 4 months. Whether the liver damage was caused by improper use (Shou Wu was not concocted or not properly concocted), excessive dosage of the drug, or the accumulation of the drug due to prolonged use of the drug, and the pathogenesis of liver damage induced by He Shou Wu (whether the body’s immune response to the drug and its metabolites or the covalently bound complexes of the drug and metabolites with macromolecules in the body) is relevant, remains to be further studied. Further studies are needed.
If the dosage and contraindications of this product are well grasped, no adverse reactions will occur without overdose, but adverse reactions do occur in clinical practice, which may be related to the specific constitution, and the mechanism is not clear. The mechanism is not clear. It means that He Shou Wu is not absolutely safe in clinical application and clinicians should pay attention to it. In conclusion, to prevent liver damage caused by He Shou Wu, clinicians should first raise awareness of liver damage caused by He Shou Wu, distinguish between raw and prepared He Shou Wu, and pay attention to the rational use of He Shou Wu (applied in appropriate amounts and at appropriate times);
The medical and family histories should be repeatedly followed before the use of Radix Polygoni and its preparations; secondly, liver function should be monitored during the use of the drug, with a view to early detection and treatment of adverse drug reactions. The preparation of drugs must follow scientific methods, only in this way can the therapeutic effect of drugs be better played, while avoiding the occurrence of toxic side effects.
Through the treatment of this patient, I also learned that with the improvement of the level of comprehensive medical treatment, the death rate of liver failure due to various causes has decreased, but it is still as high as 6O-8O ％. Liver transplantation is the most effective and ultimate treatment for liver failure, but it is not widely available due to the high technical requirements, shortage of liver sources and high costs.
By temporarily replacing the detoxification and filtration functions of the liver, ALSS purifies the blood and improves the body’s internal environment, thus creating conditions for hepatocyte regeneration. Plasma exchange (PE) combined with hemofiltration therapy is a proven method of artificial liver treatment. Plasma exchange mainly removes large molecules and plasma protein-bound toxic substances, including endotoxin, bilirubin, bile acids, TNF-a, IL-6 and other substances, to reduce or avoid further damage to the liver from drugs.
The fresh homogeneous plasma as replacement is supplemented with plasma proteins, coagulation factors, regulators and other bioactive substances, which both reduce the patient’s edema and bleeding, and reduce the chance of infection in the organism. It facilitates the repair and regeneration of liver cells.
Hemofiltration can remove medium and small molecules, including cytokines and inflammatory mediators, and each has its own unique removal characteristics. The combined treatment can remove large, medium and small toxins of different molecular weights in the body, and the subsequent hemofiltration can alleviate the side effects of plasma replacement, such as water and sodium retention and metabolic alkalosis.
PE can shorten the course of drug-related liver failure, reduce hepatocyte necrosis, and promote hepatocyte repair and regeneration, thus reducing or avoiding the occurrence of chronic liver damage. Plasma replacement, as a safe and effective method for treating drug-related liver failure, is applied promptly at the early stage of liver failure to help reduce the morbidity and mortality rate and improve the prognosis. Artificial liver can also be used as a means of prognostic assessment in severe hepatitis liver failure.
The rebound curve of serum bilirubin in patients after an average of 3 treatments is extremely closely related to the prognosis of patients. Shortly after the artificial liver treatment, aspartate aminotransferase (AST) and total bilirubin (TBIL) were significantly decreased and prothrombin time (PT) was shortened in patients. The rebound of bilirubin did not exceed more than 80% of the first time and the rebound was slow, indicating that the patient’s liver function was gradually recovering and the prognosis was good.
Because of the wide variety of drugs that may induce liver failure and the fact that most drug-related liver failure occurs within the therapeutic dose of the drug, prevention is more difficult and the key to treatment lies in timely detection and discontinuation of drugs that cause liver damage and timely administration of effective treatment.
In summary, the clinical application of He Shou Wu is not very safe, especially when used for a long time as a tonic to prolong life. When taking He Shou Wu, one should follow the instructions of physicians and pharmacists and pay attention to the adverse effects of He Shou Wu, especially liver damage.