PORTAL HYPERTENSION

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PORTAL HYPERTENSION

• Jose Macario V. Faylona, MD, FPCS
• Division of Gastrointestinal Surgery
• Department of Surgery
• Philippine General Hospital

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DEFINITION
PORTAL PRESSURE GRADIENT OF 12 mm Hg OR
GREATER ASSOCIATED WITH VARICES AND ASCITES
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DEFINITION (RADIOLOGIC)
PORTAL VEIN gt 13 mm (57 SENSITIVITY, 100
SPECIFICITY) CORONARY VEIN gt 4mm RECANALIZED
UMBILICAL VEIN gt 3mm
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ANATOMY
PORTAL VEIN DRAINAGE SMV SPLENIC VEIN
CORONARY VEIN

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PATHOPHYSIOLOGY

• VASCULAR RESISTANCE
• BLOOD FLOW

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MEDICAL HISTORY

• DETERMINE THE CAUSE OF PORTAL HPN
• DETECT PRESENCE OF COMPLICATIONS

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PHYSICAL EXAM

• SIGNS OF LIVER DISEASE
• SIGNS OF PORTOSYSTEMIC COLLATERAL FORMATION
• SIGNS OF HYPERDYNAMIC CIRCULATORY STATE

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ETIOLOGY

PREHEPATIC INTRAHEPATIC PRE-SINUSOIDAL
SINUSOIDAL POST-SINUSOIDAL POSTHEPATIC
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DIAGNOSTICS

• INVESTIGATE ETIOLOGY OF CIRRHOSIS
• IMAGING STUDIES
• ANGIOGRAPHY PROCEDURES
• ENDOSCOPY
• LIVER BIOPSY

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TREATMENT CONCERNS

VARICES ASCITES LIVER FAILURE
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ESOPHAGEAL VARICES
TYPE I - IV NOTE SEVERITY SIGNS OF BLEED
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ACUTE VARICEAL BLEED

MORTALITY RATE 30-50 FAILURE TO CONTROL
BLEED RECURRENT BLEED
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VARICEAL BLEED (1ST EPISODE)

RISK OF BLEED 4.4/100 per YEAR MORTALITY 25
50 PV PRESSURE gt 12 mm Hg
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VARICEAL BLEED (1ST EPISODE)

RISK FACTORS 1. SEVERITY OF LIVER FUNCTION 2.
LARGE VARICES 3. PRESENCE OF RCS
SHUNT SURGERY NO ROLE TREATMENT OF CHOICE BETA
BLOCKERS
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BLEEDING GASTRIC VARIX
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GASTRIC VARICES

• INCIDENCE OF BLEEDING 3-30
• HIGH RISK OF REBLEEDING
• DECREASED SURVIVAL

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DUODENAL VARIX

• MAYBE MISTAKEN FOR PROMINENT DUODENAL FOLDS
• BEST WAY TO DIAGNOSE IS THROUGH EUS

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ACUTE VARICEAL BLEED

• PHARMACOLOGICAL TREATMENT
• SCLEROTHERAPHY
• VARICEAL LIGATION
• TISSUE ADHESIVES
• SURGERY

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ACUTE VARICEAL BLEED

VASOPRESSIN SOMATOSTATIN OCTREOTIDE
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LIGATING DEVICES
10 SHOOTER
DETACHABLE SNARE
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SCLEROTHERAPY VS. VARICEAL LIGATION

• NO BASIC DIFFERENCE BETWEEN THE TWO
  INTERVENTIONS
• LIGATION HAS FEWER COMPLICATIONS

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TISSUE ADHESIVES
HISTOACRYL BUCRYLATE
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HISTOACRYL GLUE
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HISTOACRYL GLUE

• 96-100 IMMEDIATE HEMOSTASIS RATE
• 9-25 CHANCE OF REBLEED
• GOOD OPTION FOR LARGE ESOPHAGEAL VARICES AND
  BLEEDING GASTRIC VARICES

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ENDOSCOPIC ULTRASOUND

• DETECTING VARICES
• RESIDUAL VARIX
• POST GLUE
• INJECTION

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SURGICAL TREATMENT
SHUNT SURGERY NON- SHUNT SURGERY LIVER TRANSPLANT
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CHILDS PUGH SCORING
A B C
BILIRUBIN lt2 2-3 gt3
ALBUMIN gt3.5 3-3.5 lt3
ASCITES ABSENT EASILY CONTROLLED REFRACTORY
ENCEPHALOPATHY ABSENT MINIMAL SEVERE
MALNUTRITION ABSENT MILD SEVERE
OPERATIVE MORTALITY RATE 2 10 50
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N0N-SHUNT SURGERY
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SHUNT SURGERY
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LIVER TRANSPLANT
THE ULTIMATE SHUNT RESTORES LIVER
FUNCTION CHILDS C PATIENTS
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TIPS (Transjugular Intrahepatic Portosystemic
Shunt)

• FOR CHILDS C CASES
• MEDICAL AND ENDOSCOPIC FAILURE
• PORTAL HYPERTENSION OF HEPATIC IN ORIGIN
• ASSOC. WITH 30 INCIDENCE OF HEPATIC
  ENCEPHALOPATHY

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PREVENTION OF RECURRENT BLEEDING
BETA BLOCKERS SCLEROTHERAPY SCLEROTHERAPY VS.
VASOACTIVE DRUGS SCLEROTHERAPY VS. VARICEAL
LIGATION SURGICAL SHUNTS
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THANK YOU