portal hypertension
DESCRIPTION
Portal Hypertension. Portal hypertension. Portal hypertension is defined by a portal pressure higher than 5 mm Hg. Type. prehepatic portal hypertension intrahepatic portal hypertension posthepatic portal hypertension. Prehepatic portal hypertension. portal vein thrombosis: the most common - PowerPoint PPT PresentationTRANSCRIPT
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• Portal hypertension is defined by a portal pressure higher than 5 mm Hg.
Portal hypertension
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Type
• prehepatic portal hypertension
• intrahepatic portal hypertension
• posthepatic portal hypertension
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Prehepatic portal hypertension
• portal vein thrombosis: the most common
• Infection in the abdominal cavity
• omphalophlebitis
• A-V fistula between HA and PV
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Intrahepatic portal hypertension
• Type:the presinusoidal levelthe sinusoidal levelthe postsinusoidal level
• Cause:schistosomiasishepatitis B and hepatitis C hepatocellular carcinoma
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Postsinusoidal portal hypertension
• Cause: Budd-Chiari syndrome (hepatic vein thrombos
is) constrictive pericarditis heart failure. massive splenomegaly (idiopathic portal hype
rtension) a splanchnic arteriovenous fistula
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Anatomy of portal hypertension
• The portal vein is formed from the confluence of the superior mesenteric inferior mesenteric and splenic veins
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The extrahepatic portal venous circulation
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Four collateral pathways
• Esophageal and gastric venous plexus
• umbilical vein from the left portal vein to the epigastric venous system
• retroperitoneal collateral vessels
• the hemorrhoidal venous plexus
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Portosystemic collateral pathways
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Pathophysiology of portal hypertension
• The portal vein contributes two thirds of the total hepatic blood flow
• Indirectly regulated by vasoconstriction and vasodilation of the splanchnic arterial bed.
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Pathophysiology of portal hypertension
portal venous resistance portal venous pressure inc
rease hyperdynamic systemic cir
culation splanchnic hyperemia portal hypertension collateral pathways establi
shed
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Clinical manifestation
• Upper gastrointestinal hemorrhage
• Ascite
• Enlarged spleen 、 hypersplenia
• Hepatic coma
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Ascite
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Laboratory tests
• Blood test• Hepatic function: aminotransferase alkaline phosphatase
serum bilirubin level • α-fetoprotein level • CT CTA• Magnetic resonance imaging• ultrasound Doppler ultrasonography
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A three-dimensional reconstruction of a CT angiogram
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Liver Biopsy
• A useful technique for establishing the cause of cirrhosis and for assessing activity of the liver disease.
• Laparoscopic biopsy
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Pressure test
• portal pressure can be indirectly estimated by measurement of hepatic venous wedge pressure (HVWP)
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Child-Pugh criteria for hepatic functional reserve
Clinical and Laboratory Measurement Patient Score for Increasing Abnormality 1 2 3
• Encephalopathy (grade) None 1 or 2 3 or 4• Ascites None Mild Moderate• Bilirubin (mg/dL) 1–2 2.1–3 ≥3.1• Albumin (g/dL) ≥3.5 2.8–3.4 ≤2.7• Prothrombin time (increase, sec) 1–4 4.1–6 ≥6.1
• Grade A, 5 and 6; grade B, 7–9; grade C, 10–15.
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Diagnosis
• History
• Symptom and Physical examination
• Laboratory examination
Hematology exam
CT 、 CTA
USG
Endoscopic examination
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Treatment
• Nonoperative treatments
• operative treatments
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Nonoperative treatments
• Pharmacotherapy
• Endoscopic treatment
• Balloon Tamponade
• Transjugular intrahepatic portosystemic shunt ( TIPS )
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Pharmacotherapy
• Vasopressin: a bolus dose of 20 units over 20 minutes and a continuous infusion of 0.2 to 0.4 unit/minute
• Somatostatin is a250-μg intravenous bolus and a continuous infusion of 250 μg/hour for 2 to 4 days
• Octreotide :an intravenous bolus of 50 μg and an infusion of 25 to 50 μg/hour for a similar length of time
• β-adrenergic blockade
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Endoscopic treatment
• Sclerosis
• Ligation
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Sclerosis
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Ligation
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Balloon Tamponade
• Complications
esophageal perforation
ischemic necrosis of the esophagus
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Transjugular intrahepatic portosystemic shunt ( TIPS )
• Access is gained to a major intrahepatic portal venous branch through puncture through a hepatic vein. A parenchymal tract between hepatic and portal veins is then created with a balloon catheter,and a 10-mm expandable metal stent is inserted, thereby creating the shunt
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Operative treatments
• operative mortality rates for Child-Pugh classes A, B, and C
• patients are in the range of 0 to 5%, 10% to 15%, and greater than 25%, respectively.
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Operative method
• a shunt procedure
• a nonshunt operation
• hepatic transplantation
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Nonselective shunts
• The end-to-side portacaval shunt
• The side-to-side portacaval shunt
• The large-diameter interposition shunts
• The conventional splenorenal shunt
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Nonselective shunts
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Selective shunts
• the distal splenorenal shunt
• the left gastric vena caval shunt
• a vein graft between the left gastric (coronary) vein and the inferior vena cava
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The distal splenorenal shunt
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Partial shunts
• a small-diameter interposition portacaval shunt
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Partial shunts
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Nonshunt Operations
• esophagogastric devascularization procedures
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Hepatic Transplantation
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Removal
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New liver implantation
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Schematic of completed liver
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Piggyback TechniquePiggyback Technique
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Thank you