Portal Hypertension - PowerPoint PPT Presentation

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Portal Hypertension

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  1. Portal Hypertension

  2. Portal hypertension • Portal hypertension is defined by a portal pressure higher than 5 mm Hg.

  3. Type • prehepatic portal hypertension • intrahepatic portal hypertension • posthepatic portal hypertension

  4. Prehepatic portal hypertension • portal vein thrombosis: the most common • Infection in the abdominal cavity • omphalophlebitis • A-V fistula between HA and PV

  5. Intrahepatic portal hypertension • Type: • the presinusoidal level • the sinusoidal level • the postsinusoidal level • Cause: • schistosomiasis • hepatitis B and hepatitis C • hepatocellular carcinoma

  6. Postsinusoidal portal hypertension • Cause: • Budd-Chiari syndrome (hepatic vein thrombosis) • constrictive pericarditis • heart failure. • massive splenomegaly (idiopathic portal hypertension) • a splanchnic arteriovenous fistula

  7. Anatomy of portal hypertension • The portal vein is formed from the confluence of the superior mesenteric inferior mesenteric and splenic veins

  8. The extrahepatic portal venous circulation

  9. 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

  10. Portosystemic collateral pathways

  11. 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.

  12. Pathophysiology of portal hypertension portal venous resistance portal venous pressure increase hyperdynamic systemic circulation splanchnic hyperemia portal hypertension collateral pathways established

  13. Clinical manifestation • Upper gastrointestinal hemorrhage • Ascite • Enlarged spleen 、 hypersplenia • Hepatic coma

  14. Ascite

  15. Laboratory tests • Blood test • Hepatic function: aminotransferase alkaline phosphatase serum bilirubin level • α-fetoprotein level • CT CTA • Magnetic resonance imaging • ultrasound Doppler ultrasonography

  16. A three-dimensional reconstruction of a CT angiogram

  17. Liver Biopsy • A useful technique for establishing the cause of cirrhosis and for assessing activity of the liver disease. • Laparoscopic biopsy

  18. Pressure test • portal pressure can be indirectly estimated by measurement of hepatic venous wedge pressure (HVWP)

  19. 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.

  20. Diagnosis • History • Symptom and Physical examination • Laboratory examination Hematology exam CT、CTA USG Endoscopic examination

  21. Treatment • Nonoperative treatments • operative treatments

  22. Nonoperative treatments • Pharmacotherapy • Endoscopic treatment • Balloon Tamponade • Transjugular intrahepatic portosystemic shunt (TIPS)

  23. 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

  24. Endoscopic treatment • Sclerosis • Ligation

  25. Sclerosis

  26. Ligation

  27. Balloon Tamponade • Complications esophageal perforation ischemic necrosis of the esophagus

  28. 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

  29. 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.

  30. Operative method • a shunt procedure • a nonshunt operation • hepatic transplantation

  31. Nonselective shunts • The end-to-side portacaval shunt • The side-to-side portacaval shunt • The large-diameter interposition shunts • The conventional splenorenal shunt

  32. Nonselective shunts

  33. 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

  34. The distal splenorenal shunt

  35. Partial shunts • a small-diameter interposition portacaval shunt

  36. Partial shunts

  37. Nonshunt Operations • esophagogastric devascularization procedures

  38. Hepatic Transplantation

  39. Removal

  40. Newliver implantation

  41. Schematic of completed liver

  42. Piggyback Technique

  43. Thank you