Portal+hypertension prof GOUDA ELLABBAN
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Transcript of Portal+hypertension prof GOUDA ELLABBAN
Portal Hypertension
ByDr. GOUDA ELLABBAN
Prof. of General and hepatobiliary surgeryfaculty of medcine
Suez canal university - Egypt
Portal vein anatomy
The portal vein is formed in front of IVC and behind the neck of the pancreas ( at the level of 2nd lumber vertebra ) by union of the splenic & SMV.
It is 7-8 cm in length & contains no valves.
It courses in the lesser omentum posterior to both the common hepatic artery & common bile duct.
Portal vein anatomy
It bifurcates into the Lt & Rt trunks in , or just below the hillum of the liver.
Its main tributaries are :The coronary (Lt gastric) vein.Pyloric vein.Cystic vein.Pancreaticodudenal vein.Ligamentum teres (umbilical vein).Ligamentum venosum.
Portal vein anatomy
Portal vein anatomy
The portal venous branches ramify in an arterial like pattern and end in dilated channels called sinusoids, which are equivalent to systemic capillaries. From here blood drains into the hepatic venous system.
The normal portal pressure is 5-7 mmHg (8-12 cm of water).Portal hypertension is present when the portal vein pressure exceeds 12 mmHg
Causes of portal hypertension
Increased resistance to flow A) Pre-hepatic (portal vein obstruction):
1- congenital atresia or stenosis.
2- thrombosis of portal vein.
3- thrombosis of splenic vein.
4- Extrinsic compression (e.g , tumor).
Causes of portal hypertension
B) Intra-hepatic:
1- liver cirrhosis obstruction is sinusoidal & post-sinusoidal.
2- bilharzial periportal fibrosis obstruction is pre-sinusoidal.
Causes of portal hypertension
The causes of portal hypertension in cirrhotic patients are:Diminution of the total vascular bed by obliteration, distortion, & compression of sinusoids.Compression of the tiny radicals of portal & hepatic veins by excessive fibrosis.Development of multiple arteriovenous shunts between the branches of the hepatic artery & portal vein.
Causes of portal hypertension
C) Post-hepatic:1- Budd-Chiari syndrome ( hepatic vein thrombosis ) prominent ascites ,hepatomegaly & abdominal pain.
2- Veno-occlusive disease.
3- Cardiac disease:
a- constrictive pericarditis.
b- valvuar heart disease.
c- right heart failure.
Causes of portal hypertension
Increased portal blood flow A) Arterial-portal venous fistula.
B) Increased splenic flow:
1- Banti’s syndrome
( liver disease secondary to splenic disease, result from cirrhosis & other hepatic disorders)
2- Splenomegaly (e.g tropical splenomegaly ,hematologic diseases).
Sequelae & Clinical picture
1- Porto-systemic collaterals:
In normal conditinos collapsed.
In portal hypertension engorged divert blood away from the portal circulation.
Sequelae & Clinical picture
The important sites of these collaterals are:
a) At the lower end of oesophagus Oesophageal tributaries of Lt gastric vein (portal)
Oesophageal tributaries of hemiazygous vein (systemic).
b) Around the umbilicus
Para umbilical vein (portal)
Superior & inferior epigastric veins (systemic)
Sequelae & Clinical picture
c) Lower rectum & analcanal Superior rectal vein (portal)
Middle & Inferior rectal veins (systemic)
d) At the back of the colon Rt & Lt colic veins (portal)
Rt & Lt renal veins (systemic)
e) Retroperitoneum Tributaries of superior & inferior mesentric veins { Retzius }
(portal)
Posterior abdominal & subdiaphragmatic veins (systemic)
Portal vein collaterals
Sequelae & Clinical picture
2- SplenomegalyThe most constant physical finding.
In 80% of patients regardless the cause.
* In Bilharzial cases :
at 1st due to reticuloendothelial hyperplasia due to absorption of bilharsial toxins.
With progress of portal hypertension due to congestion.
Sequelae & Clinical picture
3- Congestion of the whole GIT Leads to anorexia, dyspepsia, indigestion, and malabsorption.
4- Bleeding varices. 5-Ascites (multifactorial)
Portal hypertension alone cannot cause ascites.Hypoalbuminaemia below 3 gm/100 ml.Salt &water retention high level of aldosterone, oestrogens & anti-duretic hormone.Increased lymphatic transudation from liver surface.
Investigations
1. Assessment of liver function tests
(a) Hypoalbuminaemia.
The liver is the only site of albumin synthesis.
(b) ALT & AST are moderately raised.
(c) Prothrombin time and concentration are disturbed.
This test is the most sensitive liver function.
Investigations
2. Detection of oesophageal varices by:
(a) Fibreoptic upper endoscopy
(b) Barium swallow can visualize varices in 90% of cases.
They appear as multiple, smooth, rounded filling defects (honey-comb appearance)
(c) Duplex scan can show dilated portal vein and collaterals.
Detection of oesophageal varices
Investigations
3. Detection of splenic sequestration and hypersplenism.(a) Blood picture anaemia, leucopenia, thrombocytopenia or pancytopenia.(b) Bone marrow examination hypercellularity.
(c) Radioactive isotope studies : using the patients own RBCs tagged with 51Cr
diminished half life of RBCs & increased radioactivity over the spleen.
Investigations
4. Diagnosis of the aetiology of liver disease is performed by:
(a) Immunological tests for hepatitis markers.
(b) Liver biopsy after assessment of prothrombin time and concentration.
Child Pugh classificationPoints
1 2 3
Bilirubin (mg/dL) < 2 2 – 3 > 3
Albumin (g/dL) > 3.5 2.8 – 3.5 < 2.8
Prothrombin time (seconds) 1 – 3 4 – 6 > 6
Ascites None Slight Moderate
Encephalopathy None Minimal Advanced
Grade A, 5-6 points; Grade B, 7-9 points; Grade C, 10-15 points
Treatment
Management of patients with actively bleeding oesophageal varices
1. Admission. The patient should be admitted to hospital.
2. Resuscitation. A wide bore cannula is inserted. A blood sample is taken. Restoration of blood volume should be rapid.Overexpansion of the circulation should be avoided .Morphine and Pethidine are contraindicated.
Treatment 3. Correct coagulopathy.
Vitamin K is administered intravenously.
4. Prevent encephalopathy. Blood in the intestine will be fermented to ammonia and other
nitrogenous products. Repeated enemas.
Oral lactulose. This is a disaccharide sugar, fermented by the intestinal flora
lactic acid combines with ammonia.
Neomycin 0.5 gm every 4 hours can reduce the bacterial flora.
Treatment
SclerotherapyIntra- or Para- Variceal.
1-3 ml sclerosant (ethanolamine oleate).
Occludes venous channels.
Multiple sessions (2 weekly).
Control bleeding in 80-95 %.
About 50% rebleed.
30% complication rate.
Endoscopic Sclerotherapy
Intra-variceal Para-variceal
Complications of Sclerotherapy
LOCAL
Ulceration.
Stricture.
Perforation.
Retrosternal discomfort
for few days.
SYSTEMIC
Fever
Pneumonitis
CNS
Treatment
Endoscopic Banding
Occludes venous channels
Sessions < sclerotherapy
Same results as sclerotherapy
↓ complications vs sclerotherapy
Endoscopic treatment of choice
Endoscopic Banding
Treatment
Drugs Vasopressin vasoconstriction of the splanchnic circulation.
Dose 0.2 unit/kg wt, dissolved in 200 ml of 5% dextrose, over 20 minutes.
Disadvantages
colicky abdominal pains, & diarrhoea .anginal pains, so it is contraindicated in the elderly.
Produce temporary control of bleeding in about 80% of cases.
To prolong its action it is combined with glycine (Glypressin).
Treatment
Somatostatin
lower the intravariceal pressure without significant side effects.
Initial bolus 100 microgram continuous infusion of 25 microgram/ h for 24 hs.
Beta blockare
↓ bleeding by ↓ cardiac output.
Does 20-60 mg bid 25% ↓ in HR.
Reduces 40% of bleeding episodes
Does not reduce mortality
Treatment
Balloon tamponade by Sengestaken or Linton tube. The gastric balloon is inflated first by 200 ml of air, and pulled upwards to press the gastric fundus. If bleeding continues, the oesophageal balloon is inflated. The pressure in the oesophageal balloon should not exceed 40 mm Hg. This therapy is effective in controlling bleeding in 80-90% of cases.
Treatment
Disadvantages : Discomfort to the patient.
The patient cannot swallow his saliva
Liability to cause oesophageal ulceration or stricture.
Once the tube is deflated, there is liability to rebleeding in 60-80% of patients.
Balloon tamponade is only used as a temporary measure before sclerotherapy or surgery.
Balloon tamponade
Treatment
Emergency surgery.
If all the previous measures fail to stop bleeding, surgery is recommended.
If the general condition of the patient is satisfactory splenectomy, portoazygos disconnection and stapling of the oesophagus.
If the patient is not very fit stapling alone can be performed.
Treatment
Trans-juguJar Intra-hepatic Porto-Systemic Shunt ( TIPSS )
Treatment
Indications for TIPSS:Refractory bleedingPrior to transplantChild CRefractory ascites
Main early complication:Perforation of liver capsule massive haemorrhage.
Treatment
Treatment of patients with history of bleeding oesophageal varices:
1. Repeated sclerotherapy until the varices are obliterated is the first choice.
2. Elective surgery is mainly indicated if sclerotherapy failed to stop recurrent attacks of bleeding provided that they are fit.
Treatment
Operations for portal hypertension
Shunt operations.
The idea of these operations is to lower the portal pressure by shunting the portal blood away from the liver
Total shunt operations
1- Porta-caval operation
End to side Side to side
Porta-caval operation
very efficient in lowering the portal pressure no bleeding occurs from the varices.
disadvantages:
deprives the liver of portal blood flow accelerates the onset of liver failure.
Recurrent hepatic encephalopathy in 30-50% of patients.
Proximal spleno-renal shunt indicated if the portal vein is thrombosed or if splenectormy is indicated due to hypersplenism .The incidence of encephalopathy is less than after porta caval shunt. it is less effective In preventing further bleeding. If the splenic vein is less than 1 cm the anastmosis is liable to thrombosis.
Mesocaval (Drapanas) shunt
insertion of a a synthetic graft as dacron, or autogenic vein between the superior mesenteric vein and inferior vena cava.
The incidence of thrombosis is high
Selective shunt (Warren shunt)
The Rt and Lt gastric vessels are ligated. The proximal end of splenic vein is ligated while the distal end is anastomosed to the left renal vein. The short gastric veins are preserved and will selectively decompress the lower end of the oesophagus. The incidence of encephalopathy is low, and the liver functions remain normal.
Porta azygos disconnection operations
There are many techniques for performing devascularization.
Hassab Khairy operation splenectomy & ligation of the Rt and Lt gastric vessels, the short gastric vessels and the vascular arcade along the greater curvature of the stomach leaving only the right gastroepiploic vessels.
All vessels surrounding the lower 5-10 cm of the oesophagus are ligated.
There is no encephalopathy following this operation and the portal blood flow is intact.
There is a low incidence of rebleeding following the operation, but it can usually be controlled by sclerotherapy.
Liver Transplant
Indicated for liver failure
Not for variceal bleeding.
24% in USA die on waiting list
Control of Ascites
Sodium / Water Restriction.
Spironolactone.
Loop Diuretic.
Large Volume Paracentesis.
Peritoneal-Venous Shunt .
TIPSS
THANK YOU
TIPS on
Portal Hypertension for Surgeons
ByPROF/ GOUDA ELLABBAN
VARICEAL BLEEDING
Resuscitation
Treat hemorrhagic shockCrystalloid (Limited)
Platelets (Rarely)
Red Cells + FFP
Goal: Tissue Perfusion
Monitor: Urine Output
Caveat: Do NOT overload
VARICEAL BLEEDING
Initial Treatment
Continue Tx hemorrhagic shock
IV therapy
Sandostatin®
INITIATE WHEN Dx SUSPECTED!!!
VARICEAL BLEEDING Diagnosis
50% UGI bleeds not variceal
(MW Tear, Gastritis, Gastric/Duodenal Ulcer)
Early endoscopy mandatory
Variceal bleeding Dx’d:
Active bleeding
Stigmata
Varices and NO other source
VARICEAL BLEEDING
Initial Therapy
Continue I.V. Sandostatin®
Endoscopic Therapy
Sengstaaken-Blakemore tube
TIPS
Emergency operation
VARICEAL BLEEDING
Supportive Therapy
Correct coagulopathyFFP, vitamin K, +/- platelets
Pulmonary
Other infection
Encephalopathy
Nutrition
VARICEAL BLEEDING
Evaluation
Child class
History
Hepatitis profile
Angiography
Transplant evaluation
Child-Pugh Classification
Points
1 2 3
Bilirubin (mg/dL) < 2 2 – 3 > 3
Albumin (g/dL) > 3.5 2.8 – 3.5 < 2.8
Prothrombin time (seconds ↑) 1 – 3 4 – 6 > 6
Ascites None Slight Moderate
EncephalopathyNone Minimal
Advanced
Grade A, 5-6 points; Grade B, 7-9 points; Grade C, 10-15 points
VARICEAL BLEEDING
Definitive Therapy
Rationale: 67% rebleed
Most rebleed < 6 weeks
Definitive Tx during initial stay
VARICEAL BLEEDING
Definitive Therapy
Medical
Endoscopic
Surgical
Radiological
VARICEAL BLEEDING
Medical Therapy
Beta blockade
↓ bleeding by ↓ cardiac output
Goal: 25% ↓ in heart rate
Reduces # bleeding episodes
Does not reduce mortality
Use as adjunct
Endoscopic Banding
Occludes venous channels
Multiple sessions + surveillance
>60% rebleed
1/3 fail treatment
↓ complications vs scleroTx
= / ↑ efficacy vs scleroTx
ENDOSCOPIC Tx OF CHOICE
Endoscopic Banding
VARICEAL BLEEDING
SURGICAL OPTIONS
Total Shunt
Selective Shunt
Partial Shunt
Non-Shunt
Total ShuntsEnd to Side Portocaval Side to Side Portocaval
Interposition Shunts Central Splenorenal
Total Shunt Results
Prevent rebleed > 90%
Thrombosis with graft
Encephalopathy rate 40%
Selective Shunts
Goals:
Prevent variceal bleeding and encephalopathy
Mechanism:
Decompress Varices
Maintain Portal Perfusion
Maintain Portal Hypertension
Key:
Decompress only gastrosplenic compartment
Distal Splenorenal Shunt
DSRS vs Total Shunts
Six randomized trials in N.A.
Mean follow-up 39 mos (1-8 yrs)
Partial Shunts
Ease of portocaval
Limited portal diversion
Maintain some liver perfusion
Short, straight PTFE graft
Partial Shunts
Sarfeh Ann Surg 200:706,1986
Partial ShuntsRandomized trial in ETOH cirrhotics
Follow-up @ 20 +/- 11 mos
Non-Shunt Operations
Options
Esophageal transection
Variceal ligation
Devascularize +/-
splenectomy
Very limited role
Liver Transplant
Indicated for liver failure
Not for variceal bleeding
Number ↑ > 3,500/yr in U.S.
20,000 potential recipients in U.S.
5,000 listed for transplant
24% die on waiting list
TIPSTransjugular Intrahepatic Portocaval Shunt
TIPS
TIPS
Technically feasible
Complications 9 - 50%
Infection Intraperitoneal Bleeding
Congestive Failure Subcapsular Hematoma
Acute Renal Failure Hemobilia
Mortality (30 day) 3 - 13%
(1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884, (3) LaBerge Radiology 1993;187:913.
Problems With TIPS
Encephalopathy minimum 15%
Occlusion 33 - 73% @ one year
Rebleeding
18% @ one year (1)
19% @ 4.7 months (3)
(1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884, (3) LaBerge Radiology 1993;187:913.
The Role For Tips
Refractory bleeding
Bridge to transplant
Child C
(all or only “D→Z” ?)
??? refractory ascites
Relative contraindication: Poor f/u
Special Cases of Portal Hypertension
Splenic Vein Thrombosis
Etiology: Pancreatitis - Acute or Chronic
Pancreatic Carcinoma
Hallmark:
Isolated Gastric Varices
Treatment:
Splenectomy (if bleeding)
Portal Vein Thrombosis
Etiology:
Congenital - “Cavernous Transformation”
Hallmark:
Normal Liver Function W/ Varices
Treatment:
Endo Tx OR DSRS
Budd-Chiari SyndromeEtiologyHypercoagulable: Estrogens, XRT, Myeloprolif, PNH
IVC Occlusion: RA Myxoma, Pericarditis, Membrane
Liver Mass
High Dose ChemoTx
Presentation: Classic TriadAbdominal Pain
Ascites
Hepatomegaly
Budd-Chiari Syndrome
Diagnosis– U/S, CT, Angio
Treatment– NOT a static disease
– If NO necrosis → Symptomatic Tx
– If necrosis → Shunt (PCS or MAS) or Transplant
Some Take Home Points
Child A better than Child C
Start Sandostatin when Dx suspected
β blockade ↓ bleeding by ↓ C.O
Banding safer than scleroTx
TIPS: Encephalopathy & occlusion rate
Some Take Home Points
Selective shunt: ↓ encephalopathy
SV Thrombosis: Presentation & Tx
Budd-Chiari: Classic triad
Transplant for liver failure
Portal Hypertension
Etiology
PRE-HEPATIC
Portal Vein or Splenic Vein Thrombosis
INTRA-HEPATIC
Cirrhosis (ETOH, Hepatitis, Other Toxins)
POST-HEPATIC
Budd-Chiari
Complications of Portal Hypertension
Ascites
Encephalopathy
Variceal bleeding– Initial management– Evaluation– Definitive therapy– Special cases
Encephalopathy
Etiology: ? Nitrogen compounds
Induced by:
Infection Dehydration
Constipation Blood in gut
No test is diagnostic
Therapy:
Hydrate Cleanse gut
↓ protein Find and treat cause
AscitesOrigin:Sinusoidal pressure > colloid oncotic pressure
Induced by:Physiologic Stress
IV Fluids
Complications:Spontaneous Bacterial Peritonitis
“Hepatorenal Syndrome”
Control of Ascites
Sodium / Water Restriction
Spironolactone
Loop Diuretic
Large Volume Paracentesis
Peritoneal-Venous Shunt
(?) TIPS
VARICEAL BLEEDING General Approach
Resuscitation
Initial treatment
Support
Evaluation
Definitive therapy
Vasopressin
8-Arginine Vasopressin (ADH)Intense constriction (all beds)
+’s ↓ Mesenteric Flow ↓ Portal Pressure Stops Bleeding in >80%
-’s Peripheral Ischemia Myocardial Ischemia
NTG ↓’s adverse effects
Sandostatin®
Long acting STS analogue
+’s ↓ Mesenteric Flow
↓ Portal Pressure
Stops bleeding in > 85%
Good as VP but ↓ side effects
-’s Cost
DRUG OF CHOICE
Portal Vein Anatomy
Portal Vein Collaterals
Five Principle Routes
Veins of Retzius
Umbilical Vein
Hemorrhoids
Adhesions
Esophageal Varices
VARICEAL BLEEDING
Sclerotherapy
Intra- or Para- Variceal
Occludes venous channels
Multiple sessions + surveillance
>60% rebleed
1/3 fail treatment
30% complication rate
Endoscopic Sclerotherapy
Intravariceal Paravariceal
Complications of ScleroTx
LOCAL
Ulceration
Stricture
Perforation
SYSTEMIC
Fever
Pneumonitis
CNS
Total Shunts
Divert most (all?) portal flow
Options
Portocaval Shunt (E-S or S-S; +/- Graft)
Interposition Shunt
Central Splenorenal Shunt
TIPS
Child’s Classification
A B C
Bilirubin < 2 2 – 3 > 3
Albumin > 3.5 2.8 – 3.5 < 2.8
Ascites None Controlled Uncontrolled
Enceph None Minimal Advanced
Nutrition Excellent Good Poor
SclTx vs TIPS
Five Randomized Trials - 360 patients
Mean Follow-up 15 mos (1-36)
* p < 0.05 in all but one study ** p < 0.05 in all studies*** n.s. in all but one study where survival ↑ w/ SclTx