The Portal Hypertension1

7/29/2019 The Portal Hypertension1

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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

The Portal Hypertension1

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