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Portal hypertension DR/ Walid Elshazly. Portal hypertension. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system Normal portal pressure is generally defined between 5 and 10 mm Hg. Portal hypertension.
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Portal hypertension DR/ Walid Elshazly
Portal hypertension • Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system • Normal portal pressure is generally defined between 5 and 10 mm Hg.
Portal hypertension The portal vein drains blood from the small and large intestines, stomach, spleen, pancreas, and gallbladder.
Portal hypertension The superior mesenteric vein and the splenic vein unite behind the neck of the pancreas to form the portal vein.
Etiology • Functional • Organic • Pre-sinusoidal extra-hepatic • Pre-sinusoidal intra-hepatic ( Fibrosis) • Post-sinusoidal intra-hepatic ( Cirrhosis) • Post-sinusoidal extra-hepatic
Etiology • Presinusoidal • Extrahepatic • Cavernomatous malformation • Malignant portal & splenic vein obstruction • Intrahepatic • Schistosomiasis • Congenital hepatic Fibrosis • Sarcoidosis
Etiology • Post sinusoidal • Intrahepatic • Cirrhosis • Venoocclusive disease • Extra hepatic • Hepatic vein obstruction • Budd Chiari syndrome • Constrictive pericadritis
Pathogenesis • Backward resistance theory (to initiate) • It denotes increase resistance in the liver bed through a • constant component (liver fibrosis and regenerating nodules) • variable component through the action of humoral substances (endothelin, prostaglandins, adrenergic sububstances, and serotonin)
Pathogenesis • Forward flow theory (to maintain) • It denotes increase in inflow to the liver through the action of humoral substances that cause • hyperdynamic and • hypervolemic circulation (nitric oxide, glucagon and, prostacylin)
Mechanism of portal hypertension In Shistosomiasis • Peri-portal fibrosis • Portal hyper-volaemia • Release of vaso-spastic substances • Angiomatous mass • Endo- arterial obstruction
Complication of portal hypertension • Spleno-megally • GIT congestion • Ascites • Opening of porto-systemic collaterals • Hepatocelluar failure • Portosystemic encephalopathy
Splenomegally • Mechanisms • RES hyper-plasia • Opening of A/V shunts • Venous congestion • hypersplenism
Splenomegally • Clinical picture • Pressure manifestations • Splenic pain • Hypersplenism • Psychic trauma
GIT congestion • Gastric dyspepsia related to type of food • Haematemesis dt gastropathy which cause sever form of bleeding
Ascites • etiology of ascites • Hormonal factors lead to salt and water retention • Hypo-proteinaemia • Portal hypertension • Lymphorrhoea • Disturbed renal function
Ascites ( treatment) • Bed rest • Diet • Albumin infusion • Fresh frozen plasma • Diuretics • Refractory ascites require • Therapeutic para-centesis • Recirculation therapy • Peritoneo-venous shunt • Sapheno-peritoneal shunt
Porto-systemic Collaterals • Cephalic • Lower end of esophagus • Bare area of liver • Caudal • Around umbilicus • Rectal • Retro-peritoneal
Portal Vein Collaterals • Five Principle Routes • EsophagealVarices • Umbilical Vein • Hemorrhoids • Veins of Retzius • Adhesions
1 4 2 3
Lower end of esophagus There is four rather than three plexuses of veins (intraepithelial, superficial, sub mucus and periesophageal) with the intraepithelial plexus in excess
Lower end of esophagus In the palisade zone the veins are oriented in a special way, different from the gastric, perforator or truncal zones
Lower end of esophagus The veins are condensed in the superficial plexus, rather than in the submucosal plexus opposite to the distribution in other zones
Cirrhosis Childs-Pugh Classification System Endoscopy No Varices Varices b-blocker Parameter 1 Point 2 Points 3 Points Bilirubin <2 2-3 >3 Albumin >3.5 2.8-3.5 <2.8 D PTT 1-3 4-6 >6 Ascites None Slight Moderate Encepha- None 1-2 3-4 lopathy 1st Variceal Bleed Endoscopy q 2 years Banding Evaluation Medical Tx Banding Rebleeding Childs A or B Childs C / Liver Failure Surgical Shunt / TIPS Transplant 5 – 6 Class A 7 – 9 Class B > 10 Class C
Hepato-cellular failure ( etiology) • Infection • Bleeding • Drugs • Anesthesia • surgery
Hepato-cellular failure (C/P) • Weakness • Jaundice • Fetor hepaticus • Palmer erytems • Spider angioma • Gynaecomastia • Loss of axially and pubic hair • Testicular atrophy • Acute liver failure
Hepato-cellular failure (R) • Treat precipitating factors • Diet • Drugs • Renal failure • Correct clotting abnormalites • If no response • Exchange transfusion • Cross circulation between donor and patient • Extra-corporeal perfusion through pigs liver
Porto-systemic encephalopathy • Due to materials that by pass the liver with its toxic effect over the brain (GABA, ammonia, methionine & short chain FA ) • Clinically • Personality changes • Disorientation • Slurring speech • Flappy tremors • Cogwheel rigidity • Ankle clonus • coma
Porto-systemic encephalopathy • Treatment • Chemical • Intestinal antiseptic • Lactulose • Mechnical • Liver support • Nerve cell support glutamic acid
Investigations • Laboratory • Stool • Urine • CBC • Kidney function • Liver function • Synthesis (proteins, prothrombin) • Excretory ( bilirubin, dye excretion) • Cell insult (SGOT, SGPT, alk phospatase, LDH)
Investigations • Radiological • U/S • Doppler • B swallow • B enema • Portography • CT scan • MRI • Radio-isotope • Instrumental • Upper endoscopy • Laparscopy • Laparscopic U/S
Child-Pugh Classification Grade A, 5-6 points; Grade B, 7-9 points; Grade C, 10-15 points
Angio-graphy • Indirect trans-femoral porto-grapgy • Direct portigraphy • Per-cutaneous trans-splenic • Per-cutaneous trans-hepatic • Umbilical catherization • Direct operative • Wedged hepatic venograpgy
Active bleeder Resusitation Specific measures Non-operative Naso-gastric Tr-iluminal tube Edo-scopic injection Operative Measures to prevent encephalopathy Cold case Child C injection sclerotherapy liver transplantation Child A&B Non shunt Hassab Sugura Tanner Shunt Non selective selective Treatment (Bleeder)
Huge splenomegally or hyper-splenism Decongestion Small spleen No varices conserve Varices Sclerotherapy Decongestion prophylactic ?? Treatment (Non-Bleeder)
Active bleeder Resusitation Specific measures Non-operative Naso-gastric Tr-iluminal tube Edo-scopic injection Operative Measures to prevent encephalopathy Treatment (Bleeder)
Active bleederResusitation On patient admission and after clinical evaluation three lines are installed • I.V. line for blood sample, blood and fluid replacement • Urinary catheter for monitoring tissue perfusion together with pulse and BP • Nasogastric tube or Sangestaken Blackmore tube for monitoring the bleeding, and doing gastric lavage to prepare for endoscopy
Active bleederResusitation Resuscitation with transfusion of • Colloids (blood) and • Crystalloids (Ringer, or lactated Ringer or saline solutions) at the same time with monitoring the blood pressure, pulse and urinary output.
Active bleederResusitation • Sandostatin infusion (0.25 microg in 500 ml glucose over 4 to 8 hours, with or without an intramuscularly administered shot) • Sangestaken tube to arrest the bleeding • Sclerotherapy • can be done immediately, however, • it is better to be postponed until the hemodynamics of the patient are corrected and the stomach is washed from the retained blood which obscure the procedure and make it very difficult
Endoscopic Sclerotherapy Intravariceal Paravariceal