Post on 04-Apr-2018
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The portal hypertension
by Dr.M.Pandidurai
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Portal vein
Spleenic vein and superior mesentric vein
Behind the head of pancreas at L2
5.5 to 8 cm to the right of midline to porta
hepatis
Portal vein flow 1000-1200ml/min
72% of O2 supply to liver
Streamline flow-not consistent , but not turbulentPortal pressure 7mmHg
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Hepatic circulation
Low resistant high compliance circulation
30% of cardiac output
75% from portal flow
Hepatic arterial buffer response
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Tributeries
Superior mesentric vein small intestine,
colon, head of pancreas, stomach
Spleenic vein left gastro epiploic vein,
tributeries from neck of pancreas, inferior
mesentric vein( left part of colon and
rectum)
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Pathology of portal Hypertension
Hepatic Stellate Cell
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Endothelial cells
eNOS
ET-1 bind to ET-A HSC contraction
HSC ET-1 autocrine loop
ET-1 binds to ET-B in endothelial cell
vaso dialation
Increased sympathetic activiey-Angiotensin HSC contraction
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mechanics
Mechanical obstruction fibrosis, regenerating
nodules
Vascular resistance HSC contraction-increased
intra hepatic resistance, splanchnicvasodilatation- hyper dynamic circulation
Plama conc of ET-1 increased
TNF-alpha intestinal decontaminationShear dependant and independent eNOS
expression
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Forward flow theory of portal hypertension
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Sites of collaterals
Group Portal system Systemic system
I a (gastriccardia)
left, posterior and shortgastric
Intercostal, diaphragmo-esophageal, minor azygos
I b (anus) Superior hemorrohoidal Middle and inferiorhemorrhoidal vein
II Para umbilical vein Subcutaneous abdominalvein
III Veins from liver(portal) todiaphragm (sys)
Splenorenal lig(sys) toomentum (portal)
IV Splenic vein, pancreatic,gastric, adrenal,
diaphragmatic
Left renal vein
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Portal hypertension classification
Extra hepatic
Post hepatic
Intra hepaticPre sinusoidal schisto somiasis
Sinusoidal - cirrhosis
Post sinusoidal-
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Portal hypertension clinical features
Hematamesis- commonest presentation
malena
Abdominal wall veins caput medusae
Extrahepatic portal vein obstruction-dilated vein in left flank
Murmurs( HCC, alcoholic hepatitis) -
venous hum thrillCirrhosis jaundice, palmar erythema,
spider neavei,anaemia, ascites, precoma
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Dialated veins
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Portal hypertension clinical features..
Spleenomegaly firm edge, single most
important diagnostic sign of PoHT
Secondary hyperspleenism hypertrophy
of reticulo endothelial system
Liver consistancy, tenderness, nodularity
soft EHPVO, firm- cirrhosis
Ascites- always indicates liver failure
Rectum- anorectal varices 44% in
cirrhosis
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investigations
USG abdomen
endoscopy
LFT
CT abdomen
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PoHT gastropathy
Common in fundus
Mosaic like pattern
Polygonal areas
Lined by yellowish whitedepression
Cherry red spot, redpointleison high risk ofbleeding
Sclerotherapy- incresesintensity of leison
PoHT-should be reduced
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Cherry red spot
Dialated sub epithelial
veins
Increased risk of
bleeding
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Hematocystic spots
4 mm diameter
Represents blood
from deeper veins
communicating veins-superficial
submucosal veins
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Oesophageal grading of varices
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Variables predict bleed
Size
Red sign
Liver function
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management
Childs grade recorded
Treated in ICU
Central vein pressure monitor
BP >90mmHgFFP, vit K1
PPI
LFT monitoring, electrolyte balanceShot term antiboitic course- cipro
Sedatives oxacepam, chlordiazepoxide
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Therapeutic options
Vasoactive drugs
Endoscopic sclrotherapy
EVBLSengstaken tube
TIPS
Emergency surgery
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Vasoactive drugs
Constricts splanchnic vessels
Decrease flow from gut to portal vein
Decrease portal pressureVasopressin coronary vaso constriction,
coliky abdomen,facial pallor, intestinal
ischmiaTelepressin- stable, longer half life 2mg
6th hrly for 48 hrs,1mg 4-6th hrly for 3 days
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Cont..
Somatostatin-250 microgram iv push f/b
infusion 6mg/24hr for 5 days
Octreotide- long half life
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Sengstaken blackemore tube
Replaced by vasoactive drugs, TIPS
Gastric ballon 250 ml air
Oesophageal tube 40mmHg
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Endoscopic sclerotherapy and banding
Gold standard for acute bleeding
91% -contol of bleeding
Sclerosant -1%sodium tetredecyl sulphate5%ethanalomine oleate 100% alcohol
4ml to one varix , above GE junction
Transient fever, dysphagia, chest pain
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EVBL
Superior to sclerotherapy
Spurting varix rathar than oozing
Application of small elastic O ringsComplication aspiration pneumonia, large
esophageal ulcers
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Emergency surgery
Need for surgery reduced by
sclerotherapy, banding, vasoactive drugs,
particularly TIPS
Emergency end to side portocaval shunt
effective in stopping bleeding
Mortality high grade C pt,
encephalopathy- high
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TIPS
Side to side portocaval shunt
Torrential bleeding
Bleeding not controlled after 2 sclerotherapy sessions
Other indications- hepatorenal syn,refractory
ascites,BuddchiariDone as bridge to liver transplantation
Palliation
Reduces portal venous pressure by 50%
Survival not increased25% risk of encephalopathy
Ascites is also controlled
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TIPPS
tipps.wmv
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Hepatic transplantation
Uncontrolled variceal bleeding
End stage liver disease
Spleeno renal, meso caval ,TIPS notcontra indicatd
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Thank you