Transcript Portal Hypertension

Portal Hypertension
portal venous pressure > 5 mmHg
collaterals
> 10 mmHg
bleeding
> 12 mmHg
Portal Hypertension
intrahepatic - sinusoidal / post-sinusoidal (cirrhosis)
pre-sinusoidal (schistosomiasis)
posthepatic - Budd-Chiari syndrome
Veno-occlusive disease
prehepatic - portal vein thrombosis
cavernous transformation of the portal vein
isolated splenic vein thrombosis
left sided portal hypertension (inflammation – tumor)
Cirrhosis
alcohol
viral
cholestatic
hepatitis B & C
primary biliary cirrhosis
secondary biliary cirrhosis
primary sclerosing cholangitis
autoimmune lupoid
metabolic
hemochromatosis
Wilson’s
alpha 1 – antitrypsin deficiency
cryptogenic
Cirrhosis
hepatocellular necrosis - fibrosis & nodular
regeneration
two major phenomena:
loss of cell mass - hepatocellular failure
increased hepatic vascular resistance portal hypertension
Portal Hypertension
splenomegaly
porto-systemic collaterals
- coronary & short gastric veins to azygos vein –
esophageal varices
- recanalized umbilical vein –
caput medusae
- retroperitoneal
- hemorrhoidal venous plexus
Bleeding
esophageal varices
gastric varices
80 %
20 %
portal hypertensive gastropathy
Bleeding
patients with varices – bleeding in 33 - 50 %
acute variceal bleeding – mortality 25 - 30 %
rebleeding - 70 %
Bleeding
chronic liver disease
spider angiomas
palmar erythema
testicular atrophy
gynecomastia
jaundice
ascites
splenomegaly
caput medusae
asterixis (liver flap)
Immediate Management
hemodynamic stabilization
- PT
- platelets
- electrolytes
- creatinine
endoscopy
- diagnostic
- therapeutic
Pharmacotherapy
splanchnic vasoconstrictors
vasopressin
(hypertension, bradycardia, decreased cardiac output,
coronary vasoconstriction) Tx combined with nitroglycerin
glypressin – terlipressin
somatostatin - octreotide
Endoscopic Treatment
variceal sclerosis – sclerotherapy
variceal ligation – banding
control of bleeding – 85 %
Balloon Tamponade
Sengstaken – Blakemore tube
Encephalopathy
neomycin –
suppresses urease containing bacteria
lactulose –
acidifies colonic contents
cathartic effect
Further Treatment
rebleeding – 70 %
options:
pharmacotherapy – propranolol
repeat endoscopic therapy
TIPS
porto-systemic shunt operations
devascularization procedures
liver transplantation
Hepatic Functional Reserve
Child’s classification
A
albumin (g/dl)
bilirubin (mg/dl)
ascites
encephalopathy
nutritional state
> 3.5
<2
none
none
excellent
B
3 – 3.5
2–3
mild
minimal
good
C
<3
>3
moderate
marked
poor
Hepatic Functional Reserve
Child – Pugh classification
points
1
albumin (g/dl)
> 3.5
bilirubin (mg/dl)
<2
PT (sec prolonged) 1 – 4
ascites
none
encephalopathy
none
2
3
2.8 – 3.5
< 2.8
2–3
>3
4–6
>6
mild
moderate
minimal marked
Hepatic Functional Reserve
Pugh score
5–6 =
good hepatic reserve
good operative candidate
Pugh score
7–9 =
Child’s A
< 5 % mortality
Child’s B
moderate hepatic reserve
modest operative candidate 10 – 15 % mortality
Pugh score
10 – 15 =
low hepatic reserve
poor operative candidate
Child’s C
> 25 % mortality
Portosystemic Shunts
effective decompression of portal system
- effective in preventing recurrent bleeding
diversion of portal blood
- accelerated hepatic failure
- encephalopathy
Portal Blood
cerebral toxins - ammonia
bypass of the liver prevents inactivation
hepatotrophic elements – insulin
diversion causes atrophy
Surgical Shunts
nonselective (total)
end-to-side portocaval shunt (Eck’s fistula)
other nonselective shunts
side-to-side
meso-caval
spleno-renal
selective shunts
distal spleno-renal (Warren shunt)
TIPS
Transjugular Intrahepatic Portosystemic Shunt
major advantage – nonoperative
disadvantage nonselective shunt – encephalopathy 30 %
shunt stenosis or occlusion at 1 year 50 %
Devascularization Procedures
transection & reanastomosis
- of esophagus = Sugiura procedure
- of stomach = Tanner procedure