何婷婷+王伽伯+柏兆方+郭玉明+牛明+朱云+景婧+宫嫚+肖小河

[摘要] 近年，中草药相关肝损伤（herb-induced liver injury， HILI）问题备受关注，HILI因具有联合用药复杂、组成成分多样及体质、遗传、基础疾病等特点，导致其临床诊断比西药肝损伤诊断更加困难。中华中医药学会在2016年发布国内外首个专门针对HILI的诊疗技术标准——《中草药相关肝损伤临床诊断指南》（以下简称《指南》）。为便于广大临床医师特别是肝病专科医师在诊断HILI时对《指南》的操作应用，该文将不同诊断结果的病例诊断流程予以解析。

[关键词] 药物性肝损伤； 诊断； 中草药； 病例

[Abstract] In recent years， the issues related to herb-induced liver injury （HILI） have received much concern. Its clinical diagnosis is much difficult than that of Western medicine-induced liver injury due to its complicated drug combination and multiple constituents. Moreover， it is also correlated with physiques， inheritance and basic diseases. China Association of Chinese Medicine has released the first standards for HILI diagnosis and treatment technology in 2016， namely Guidelines for clinical diagnosis of herb-induced liver injury （hereinafter referred to as the Guidelines）. The diagnostic processes with different diagnostic results were explained in this paper to help clinicians， particularly liver specialists， in diagnosing liver diseases by applying the operation of the Guidelines.

[Key words] drug-induced liver injury （DILI）； diagnosis； Chinese herbal； case

近年，中草药相关肝损伤（herb-induced liver injury， HILI）问题备受关注，有关报道呈升高趋势，由于缺少特异性临床指标、临床表现特征存在差异等，目前药物性肝损伤缺少统一、规范的诊断标准，成为国际性诊断难点[1]。HILI因具有联合用药复杂、组成成分多样及体质、遗传、基础疾病等特点，导致其临床诊断比西药肝损伤诊断更加困难。开展中草药肝损伤研究，客观、准确诊断是基础前提，为此，中华中医药学会在2016年发布国内外首个专门针对HILI的诊疗技术标准——《中草药相关肝损伤临床诊断指南》（以下简称《指南》）[2]。为便于广大临床医师特别是肝病专科医师在诊断HILI时对《指南》的操作应用，本文将不同诊断结果的病例诊断流程，见图1。

1 基于整合证据链（integrated evidencechain-based causality identification algorithm，iEC）的中草药相关肝损伤诊断流程

《指南》首次提出采用整合证据链（iEC）的诊断策略，将主观排除法诊断思路转变为客观证据链法，将相关性诊断转变为确定性诊断[3-4]。……