PORTAL HYPERTENSION

1. PORTAL HYPERTENSION PRESENTER: KRITHIKA KRISHNAN MODERATOR : DR.R.PANDEY www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Mr. Anil Kumar Rai; • 36yrs / male; • Vendor; • New Delhi; • Presenting complaints • Vomiting of blood • Black tarry stools 1 month back • Loss of consciousness

3. History of presenting complaints • Vomiting of blood. • 2 episodes. • 50 ml each. • Dark colour mixed with fresh blood. • Not associated with cough. • Passage of black tarry stools. • 2 episodes.

4. H/O Loss of consciousness. • 1 episode. • Not associated with trauma. • Lasted for 30 seconds. • H/O abdominal distension. • 1 month. • Progressively increasing. • Uniform. • Not associated with abdominal pain.

5. H/O yellowish discolouration of the body and mucous membrane • 1 month. • Progressively deepening. • Not associated with clay stools or dark urine. • H/O fever… 1 month • Low grade. • Intermittent. • Relieved with drugs.

6. H/O wakefulness in night and day time sleepiness. • 15 days back. • Improved with medications. • H/O loss of weight. • 15 kgs over past 2 years. • H/O loss of appetite.

7. No H/O…. • Pedal edema. • Breathlessness on exertion. • Chest pain. • Palpitation. • Decreased urine output. • Bruising/ gum bleed .

8. Personal History • Consumes mixed diet. • Chronic alcoholic since 15 years of age, stopped one year back (8-10 pegs of country liquor/day). • H/O smoking since 15 years of age, stopped one year back – about 15 pack- years. • No H/O drug abuse.

9. Treatment History • H/O upper GI endoscopy and sclerotherapy. • Repeated paracentesis for the ascites. • Antibiotics. • T. Aldactone 100mg OD. • T. Methyl cobalamine1500mg OD. • T. Thiamine 100mg OD. • Syrup. Lactulose 30ml TDS.

10. Past History • H/O similar episodes of hemetemesis present …2 years • 4 such episodes. • UGI endoscopy done….diagnosed as oesophageal varices and sclerotherapy done. • Evaluated and diagnosed as cirrhosis with ESLD. • H/O spontaneous bacterial peritonitis. • 6 months back. • Treated with antibiotics.

11. No H/O any other systemic illness. • No H/O any surgery in the past. Family History • No H/O any similar illness in the family.

12. 55 kg, 5 feet 7 inches. Average built . Pallor +ve. Icteric. No clubbing. No cyanosis. No pedal edema. No other sign of liver cell failure. No significant lymphadenopathy. Venous access - good General examination

13. Vital Signs • Pulse rate • 72 beats/ min, • regular in rhythm, • normal in volume and character. • Blood pressure • 120/60 mm Hg • measured in right upper limb ,in the supine posture. • Jugular venous pulsations visible, pressure not elevated. • Temperature - 37ºC.

14. AirwayExamination • MMP II. • Mouth opening and neck movements adequate. • No loose tooth/ artificial denture. • TMD >3 fingers.

15. Systemic examination Abdomen On inspection • Distended uniformly. • All quadrants moving equally with respiration. • No dilated veins. • Needle prick scars made out in the flanks. • Umbilicus – inverted. • Divarication of recti present.

16. On palpation • Soft. • No tenderness. • Spleen palpable below the left costal margin up to the umbilicus. • Liver – not palpable. On percussion • Shifting dullness present. • Liver span – 7 cm.

17. Cardiovascular System • S1 S2 heard - normal, no murmurs. Respiratory System • B/L vesicular breath sounds present, no added sounds. Central Nervous System • Clinically normal.

18. Provisional diagnosis Decompensated chronic liver disease with portal hypertension with ascites.

19. Investigation: Hemogram Hb :9 g/dl TLC 3700/cumm DLC P 74, L 23, M 2 Platelet 71000/cumm PT 12/16.2

20. Biochemistry Blood sugar (R): 152 mg/dl B.Urea: 103 mg/dl S. Creatinine: 1.9 mg/dl Na+/K+: 141/4.1 meq/L S.Bilirubin: 3 mg/dl 0.8mg/dl 2.2mg/dl SGOT/PT 76/56 ALKPO4 222 T.Proteins/ Albumin/globulin: 7.7/4.0/3.7 Unconjugated Conjugated

21. CXR : WNL • ECG : WNL • Echo : Normal study • USG abdomen: Liver small in size with slightly coarse echotexture. • UGI endoscopy: Grade III esophageal varices. • CECT : atrophy of R lobe of liver , spleen enlarged with infarct. • HBsAg -ve. • Anti HCV antibodies –ve.

22. Final diagnosis Decompensated chronic liver disease, probably alcohol in etiology, with portal hypertension with ascites.

23. Portal hypertension(>10mmHg) and its consequences • Gastroesophageal varices • Ascites • Hepatic encephalopathy • SBP • Hepatorenal syndrome • HCC

24. Laboratory findings (minimal or absent) • Anemia (a frequent finding) • Coagulation abnormalities • Increased AST, ALP, bilirubin, gamma globulins • Decreased albumin

25. Imaging: • Spleen and hepatic enlargment • Barium / endoscopic studies- presence of varices • USG/ CT/ MRI –for liver size, ascitis, hepatic nodules • Doppler- for assessing the patency of splenic, portal & hepatic veins

26. Portal Hypertension: • Hemorrhage from varices. • Splenomegaly with hypersplenism. • Ascites. • Acute and chronic hepatic encephalopathy.

27. Diagnosis: • Fibreoptic esophagoscopy -for confirming varices. • MRI and contrast CT- tool for detecting the collateral circulation. • Percutaneous transhepatic catheterisation-Portal venous pressure.

28. Management of acute bleed • Prompt replacement of fluid loss • Replacement of clotting factors with fresh frozen plasma • Monitoring of CVP or cap.wedge pressure • Vasoconstrictors • Balloon tamponade • Endosopic variceal ligation • Sclerotherapy • Gastric devascularisation

29. Pathological feaures in advanced liver disease: 1.Hyperdynamic circulation ↓ peripheral vascular resistance ↑ cardiac output Other CVS changes Increased SV & HR. Normal filling pressures. Decreased sensitivity to vasopressors. Cardiomyopathy.

30. 2. Hypoxemia: • Intrapulmonary shunting • Precapillary sphincter dilatation (HPS I). • AV shunting (HPS II). • V-Q abnormality in the lung. • Exacerbated in the upright position. • Pleural effusion. • Pulmonary infection. • Diaphragmatic dysfunction. • Dysfunction of HPV. • Rightward shift of O2 dissociation curve.

31. 3. Metabolic alkalosis: High aldosterone state. 4. Coagulation abnormalities: Deficiency of plasma clotting factors. ↓ platelet count. ↓ platelet function. Abnormal fibrinolytic factors.

32. 5. Hepatic blood flow • Summation of hepatic arterial & portal venous blood flow • Effect of anesthetic drugs • Ventilation – IPPV, CO2 • Effect of surgery 6. Ascites 7. Renal impairment 8. Hepatic encephalopathy

33. Underfill hypothesis Overflow hypothesis Treatment Spirnolactone Paracentesis, large volume ± albumin Frusemide Peritoneovenous shunt Ascites

34. HPS Presence of chronic disease Absence of intrinsic cardiopulmonary disease Pulmonary gas exchange abnormality Intrapulmonary vascular dilatation PPH PAP >25mmHg PCWP <15mmHg PVR >120 dynes/s/cm5 Hepatopulmonary syndrome

35. Hepatorenal syndrome International ascites club criteria 1. S.creatinine >1.5mg/dl (133 µmol/l), GFR <40ml/min. 2. Absence of on going bact infection, fluid loss, treatment with nephrotoxic drugs. 3. No sustained improvement after diuretic withdrawal and plasma volume expansion. 4. Proteinuria < 0.5g/dl. 5. No USG evidence of parenchymal renal disease. • U. Na+ <10 • U.sediments: N • U.osmolality: exceeds pl osmolality by atleast 100mosm/l • U/Pl cr. ratio >30:1

36. Hepatic encephalopathy

37. Hypoxia. Hypovolemia. Hypoglycemia. Anemia. Infection, pneumonia sepsis. UGI bleed. Increased protein intake. Constipation. Large volume parcentesis. Diarrhea and vomiting. Diuretic. Sedatives. Shunts. Treatment Avoid ppt factors. Lactulose. Neomycin . Metronidazole. Liver transplantation. Precipitating factor

38. Guidelines for anaesthetic management in patients with ESLD Common operative procedures: Surgery for gastric/duodenal ulcer, cholecystectomy, & colon carcinoma Various orthopedic procedures Portocaval shunts, Sclerotherapy, gastric devascularisation surgery

39. Preoperative instructions – • NPO > 8 hours. • High risk consent in the view of perioperative risk of renal and hepatic failure. • Hydration of the patient with IV fluids @100ml/hour. • CM S.electrolytes, PT and platelets. • Premedication with T.Lorazepam 4mg HS & CM and T.Ranitidine 150mg HS & CM.

40. Induction: Mod RSI • Pre oxygenation for 3 minutes. • Titrated dose of propofol (Thio can also be used). • Intubate after giving scoline. • Maintenance :- • Volatile agents: Isoflurane, desflurane or sevoflurane. • NMB: Non depolarizing agents - Altered Vdss.

41. Opioids: Fentanyl. Morphine. Pain: Best controlled with epidural opioids if CNB is not contraindicated.

43. Risk assessment in patients with liver diseaseChild – Pugh score

44. MELD score: MELD = 3.8 x loge(bil ) + 11.2 x loge(INR) + 9.6 x loge(creatinine) Causes of mortality in the periop period: Sepsis, pneumonia. Renal failure. Non mechanical bleeding. Hepatic failure & encephalopathy.

45. Liver transplantation • Indications • Children. • Adults. • Contraindications • Absolute. • Relative.

46. Preoperative preparation • Central nervous system status. • Encephalopathy grade. • ICP. • Coagulation status. • Renal failure. • Cardiopulmonary status.

47. Phases of OLT • Preanhepatic phase • Monitor placement to clamping. • Medications titrated. • Lorazepam, morphine, oxazepam. • Temperature monitoring and maintenance. • Invasive monitoring. • Defibrillator ready. • Rapid infusor. • Thromboelastography. • Periodic blood sampling.

48. Anhepatic phase • Occlusion of vascular supply to old liver to perfusion of new liver. • Metabolic acidosis/ alkalosis. • Hypocalcemia. • Hypokalemia.

49. Postanhepatic phase • After perfusion of the new liver. • Ventricular fibrillation - hyperkalemia. • Hypotension – vasoactive amines. • Air embolism. • Paradox – Hepatic congestion.

50. Jaundice