?????? Portal Hypertension

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??????Portal Hypertension
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Portal
hypertension is a pathologic state that the liver
or associated structures obstruct portal blood
flow and result in the portal vein system
hypertension, which clinically presents as
splenomegaly and hypersplenism, hematemesis and
melena from esophageal and gastric varices
rupture, and ascites.
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What is portal hypertension?
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? Anatomy of portal vein system ? Etiology ?
Pathophysiology ? Clinical presentation ?
Diagnosis and differential diagnosis ?
Treatment
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?????????Anatomy of Portal Vein System
??????-??(1)
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? The blood flow of splenic vein is 20-30 of
that of portal vein
??????-??(2)
? The portal vein system is between two
capillary networks
? No valves in portal vein system and the
blood flow can be reversed
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? Four ramus communicans between portal and
systemic circulations
??????-??(3)
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1.??????????????????? ????????????????
??????-??(4)
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2.????????????? ????????? ?????? ?????????
??????-??(5)
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3.????? ?????? ??????? ????? ??????????
??????-??(6)
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4.??????????? ??????? ????
??????-??(7)
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? ?Etiology
??????-??(1)
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Portal hypertension should be divided into three
types as its blood flow obstructed positions
pre-hepatic type
intra-hepatic type post-hepatic
type
??????-??(2)
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pre-hepatic type the portal vein trunk
itself obstructioncongenital deformity
obliteration, stenosisthrombosis infection,
trauma
??????-??(3)
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post-hepatic type hepatic veins or
inferior vena cava in hepatic level obstruction
included congenital deformity or thrombosis,
called Budd-Chiari syndrome
??????-??(4)
??-??????
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intra-hepatic type 95, a classification
is pre-sinusoidal and post-sinusoidal
obstructions by pathology
??????-??(5)
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pre-sinusoidal obstruction The main cause is
schistosomial cirrhosisSchistosomial eggs
deposit in small branches withperipheral
granulation, resulting in obstructionof blood
flow and increaseof portal vein pressure
??????-??(6)
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post-sinusoidal obstructionThe main cause is
post-hepatitis cirrhosis(1)Fibroplasia and
regeneration of hepatic cells compress the
hepatic sinus, reducing in obstructed blood flow
and increased portal vein pressure
??????-??(7)
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(2)The shunts between terminal hepatic arteries
and portal veins open, and the hepatic arteries
blood flow with high-pressure perfuse directly
into low-pressured portal veins, which
contributes to portal hypertension
??????-??(8)
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(3)The high hepatic resistance can affect the
hepatic lymphatic back-flow, which will further
increase the portal pressure
??????-??(9)
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??????-??(10)
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??????-??(11)
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????Pathophysiology
??????-????(1)
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The normal pressure of portal vein
13-24cmH2OPortal hypertension
??????-????(2)
30-50cmH2O
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? congestive splenomegaly? ramus
communicans dilatation? ascites
??????-????(3)
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1. congestive splenomegaly and
hypersplenism
??????-????(4)
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??????-????(5)
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??????-????(6)
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2. ramus communicans dilatation ?esophageal
and gastric veins varices rupture and
gastrointestinal hemorrhage ?inferior
rectal-anal veins hemorrhoid and bleeding
?anterior abdominal wall veins paraumbilical
varices (caput medusae) ?numerous
retroperitoneal veins dilatation and
congestion
??????-????(7)
???
?????? ??????!
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??????-????(8)
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??????-????(9)
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??????-????(10)
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??????-????(11)
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??????-????(12)
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??????-????(13)
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3. ascites ? disordered albumin synthesis
and decreased plasma colloid osmotic
pressure caused by hepatocellular function
damage ? increased capillary filter pressure
due to increased portal hypertension
??????-????(15)
The most important cause for ascites
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? lymph liquid leakage into abdominal
cavity from surface of the liver because of
lymph back-flow obstruction ? salt and water
retention by aldosterone and antidiuretic
hormones deactivation disturbance
??????-????(16)
???
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? portal hypertensive gastropathy? hepatic or
portosystemic encephylopathy
??????-????(17)
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???? Clinical
presentation
??????-????(1)
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?splenomegaly and hypersplenism ? hematemesis
and melena? ascites
??????-????(2)
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??????-????(3)
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??????-????(4)
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??????-????(5)
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??????-????(6)
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??????-????(7)
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???????Diagnosis and Differential
Diagnosis
??????-??(1)
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Diagnosis ?medical history
hepatitis or schistosomiasis?clinical
presentation splenomegaly and
hypersplenism hematemesis and melena
ascites? investigations
??????-??(2)
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? blood routine examinations WBC ? and Ptc
? ? liver function tests albumin?, A/G
ratio reversing, prothrombin time??
markers of hepatitis B or C
??????-??(3)
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??????-??(4)
Childs classification of patient with liver
disease Child grade A
B C
serum bilirubin lt34 35-51
gt68 (µmol/l) albumin (g/l)
gt 35 28-35
lt28 prothrombin 1-4
4-6 gt6 (s prolonged)
SGPT lt100
100-200 gt200
lt40 40-80 gt80
ascites absent
slight moderate encephalopathy
none none or minimal coma
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? esophageal barium swallow multiple
irregular filling defects as string of
beads or earthworm? esophageal endoscopy
white, pink, red, cherry red varices
??????-??(5)
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??????-??(6)
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??????-??(7)
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??????-??(8)
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? ultrasound and Doppler cirrhosis,
splenomegaly, ascites, thrombosis and
occlusion of the portal, superior mesenteric
and splenic vein, enlargement of portal
veingt13mm and of splenic veingt10mm? CT, MRI
and angiography
??????-??(9)
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??????-??(10)
ascites
ascites
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Differential diagnosis ?
peptic ulcer bleeding ? gastritis bleeding ?
gastric cancer bleeding ? biliary tract bleeding

??????-??(11)
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? ?
Treatment
??????-??(1)
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The purposes of surgical treatment of
portal hypertension ? treatment or prevention
of upper gastrointestinal hemorrhage ?
decrease the pressure of the portal vein ?
elimination of splenomegaly and
hypersplenism ? treatment of hard ascites
??????-??(2)
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Treatment during Massive
Variceal Bleeding1. anti-shock 2.
pharmacotherapy and control of bleeding
vasopressin 20 u, in 200ml, over 20min.
q4-6h 160u/500ml, 20drops/min. , 0.4
u/min. sandostatin 0.1mg ? or ?
q6h. general hemostatic drugs PAMBA
??????-??(3)
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3. local treatment endoscopic variceal
sclerosis or banding hemostatic drugs
injection per oral or stomach tube
8mg noradrenaline ice saline 5-10
Monsell liquid balloon tamponade
??????-??(4)
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??????-??(5)
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balloon tamponade
(life-saving procedure)
Sengstaken-Blakemore tube ? esophageal balloon
(100-150ml) ? gastric balloon (150-200ml) ?
lumen to gastric balloon ? lumen for gastric
aspiration ? lumen to esophageal balloon
??????-??(6)
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Attention! ? check the
balloons for air leakage before use of the
tube ? 24-72 h of placement and 10-20min. /12h.
removal of air ? filling the air firstly
to the gastric balloon and removing the air
firstly from esophageal balloon ?
observation of the patients breath and
enhancing the respiratory tract nursing
??????-??(7)
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4. emergency operation Childs
classification A or B ? ligation of lower
esophageal variceal veins ?
disconnection of para-cardiac portal
systemic venous shunt
??????-??(8)
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Elective Operations?
splenectomy ? portosystemic shunt or bypass?
disconnection operation? liver transplantation
??????-??(9)
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1. splenectomy reduction of portal blood flow
??????-??(10)
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2. portosystemic shunt or bypass Principle
anastomose the portal vein or its main branches
(splenic vein and superior mesenteric vein) to
vena cava or its main branches(renal vein)by use
of operative procedures, and put the hypertensive
portal blood flow into the low-pressured inferior
vena cava.
??????-??(11)
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Objective To reduce the portal vein pressure and
thus decrease the blood flow through collateral
venous beds
??????-??(12)
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Indications liver function Childs A or
B ? with serious esophageal and gastric
varices or with the history of rupture of
esophageal and gastric varices ? without
ascites, or previous with ascites but
rapidly disappeared after treatments ?
albumin gt30g/L, serum bilirubin lt17 µmol/L
??????-??(13)
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Ways ? total shunts splenorenal
shunt portacaval shunt
end-to-side, side-to side, H-graft
mesocaval shunt ? selective shunts
distal splenorenal shunt (Warrens
operation) ? TIPSS
??????-??(14)
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??????-??(15)
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??????-??(16)
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??????-??(17)
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??????-??(18)
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??????-??(19)
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transjugular intrahepatic
portasystemic shunt (TIPSS)
??????-??(21)
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??????-??(22)
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??????-??(23)
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??????-??(24)
stent
stent
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3. devascularization operationsPrinciple
disconnection of the venous circulation of the
distal esophagus and cardiac from the
hypertensive portal circulation by division of
all the feeding vessels
??????-??(25)
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Ways ? ligation of lower esophageal and
gastric variceal veins ? disconnection of
cardiac portal systemic venous shunt ?
resection of lower esophagus and gastric
fundusesophagogastrostomy
??????-??(26)
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??????-??(27)
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??????-??(28)
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Comparing the shunt with disconnection

Shunt disconnectiondecrease
pressure clear, obvious none or
increaseencephalopathy maybe
nonehepatic perfusion
decrease increaseoperative procedure
difficult
simpleanastomotic obstruction maybe
none
??????-??(29)
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Management of Ascites ?
salt restriction ? diuretic therapy ?
paracentesis ? peritoneal venous shunt
??????-??(30)
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Budd-Chiari syndrome
a group of disorders caused by obstruction of
hepatic vein or inferior vena cava in hepatic
level
??????-?-?????(1)
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Etiology ?
congenital dysplasia ? thrombosis ?
tumor compression or invasion
??????-?-?????(2)
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??????-?-?????(3)
normal hepatic vein
obstructed hepatic vein
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??????-?-?????(4)
thrombosis
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??????-?-?????(5)
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Clinical Presentation ?
hepatosplenomegaly ? hard ascites ? rupture of
esophageal and gastric varices ? others
pain in right upper quadrant
paraumbilical varices lower extremity
edema
??????-?-?????(6)
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Diagnosis
? clinical presentation ? Doppler
ultrasound ? CT, MRI ? hepatic
venography
??????-?-?????(7)
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??????-?-?????(8)
obstructed hepatic vein
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??????-?-?????(9)
hepatomegaly
ascites
obstructed hepatic vein
splenomegaly
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??????-?-?????(10)
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Treatment 1. intervening
therapy catheterizing, membrane perforation
with needle, dilatation with balloon,
or with stents
??????-?-?????(11)
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2. operative treatment ? membrane perforation
with finger through right auricle ?
inferior vena cava membranectomy ? artificial
vessel bridge of right auricle to inferior
vena cava or superior mesenteric vein
? liver transplantation
??????-?-?????(12)
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??????-?-?????(13)
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3.?????????????? 4.???????????