Portal Hypertension

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This presentation is made by Dr Ashok Jaisingani

This presentation is made by Dr Ashok Jaisingani

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  • 1. Dr. Ashok Jaisingani
  • 2.  The hepatic portal circulation carries blood from GI tract (i.e. from the distil esophagus to anorectal junction) to the liver. Porto – systemic anastomosis occurs in junctional areas of venous drainage. Portal venous blood drain into liver venous sinusoids and hence in to the hepatic veins.
  • 3.  Portal hypertension develop when there is elevation of portal pressure is greater than 12 mmHg, while normal portal pressure is 5 – 10mmHg. As portal hypertension produce no symptoms it is usually diagnosed following presentation with decompensated chronic liver disease encephalopathy, ascites or variceal bleeding.
  • 4.  Pre – Hepatic: 1- Congenital portal atresia 2- Portal vein thrombosis (Neonatal sepsis) 3- Phlebitis of portal vein (abdominal infection) 4- Trauma or thrombosed porto – caval shunt. Hepatic: 1- Cirrhosis (alcoholic most frequently) 2- Chronic Active hepatitis 3- Parasitic diseases (Schiatosomiasis) Post – Hepatic: 1- Budd – Chiari syndrome (Hepatic venous thrombosis) 2- Constrictive pericarditis 3- Tricuspid valve incompetence
  • 5.  Decrease or reverse portal blood flow to the liver promote the development of the portosystemic anastomosis between the portal system and systemic circulation. 1- Left gastric vein into the esophageal veins at gastro- esophageal junction – esophageal and gastric varices. 2- Superior rectal vein into inferior rectal vein at lower rectum rectal varices. 3- Obliterated umbilical vein into epigastric vein – capute medusae. Esophageal and gastric varices may bleed torrentially Liver cell dysfunction/liver failure occurs in hepatic and post – hepatic causes Splenomegaly (hypersplenism may be result) The child – pug classification use to asses the severity.
  • 6. Conditions Point – 1 Point – 2 Point - 3Bilirubin (µmol/L) <34 34 – 51 >51Albumin (g/L) >35 28 – 35 <28PT (sec) <3 3 – 10 >10Ascites None Moderate Moderate – severeEncephalopathy None Moderate Moderate – severe
  • 7.  Many investigations may be used at different time in portal hypertension such as 1- FBC, Urea & electrolytes and clotting 2- Screening tests for the causes of the cirrhosis 3- CT & ultrasound scan to assess liver morphology, diagnose Portal hypertension and assess cause. 4- Transabdominal Doppler ultrasound to assess blood flow in the portal vein and hepatic artery. Gastroscopy in acute variceal bleeding
  • 8.  General resuscitation Anti – coagulation for Budd – Chiari syndrome Treatment of hepatic cause Treatment Of Chronic Complication such as Esophageal gastric varices: 1- Beta – blocker (propranolol or nadolol), reduce portal venous pressure. 2- Repeated injection sclerotherapy or variceal ligation 3- Elective porto – systemic shunt (spleno – renal anastomosis) 4- Liver transplant may be considered for treatment if associated with severe liver diseases. Rectal Varices: Injection sclerotherapy Symptomatic splenomegaly: laparoscopic or open splenectomy. Ascites: Oral spironolactone, in cases of ascites, paracentesis may be required with IV albumin replacement.
  • 9.  Hemorrhage from the varices is acute complication of the portal hypertension. Mortality rate of first variceal bleed established portal hypertension is 30%. Causes & Features: Typical variceal bleeding is rapid in onset, copious dark blood with little mixing with food. Feature of established portal hypertension e.g. capute medusae Feature of developing hepatic encephalopathy (ingested blood provide an extremely rich meal)
  • 10.  Established large caliber IV access, give crystalloid fluid up to 1000 mL, if tachycardic or hypotensive. Only use O - ve blood if the patient is in extremis, otherwise wait for cross – match blood. Catheterize and place on fluid balance chart if hypotensive. Send blood for FBC, HB conc. WCC, U&E, Na, K, LFT, albumin and clotting. Always consider HDU, variceal bleeding can deteriorate extremely rapidly. Monitor pulse rate, BP and urinary output. Insertion Of sangstaken Blackmore gastro-esophageal tube may be a life saving resuscitation manure, usually only inserted without prior gastroscopy if the patient known to have varices and has life – threatening bleeding.
  • 11.  Blood transfusion Correct coagulopathy Esophageal balloon tamponade (sangstaken Blackmore tube) Drug therapy (vasopressin or octreotide) Endoscopic sclerotherapy or banding Assess portal vein patency (Doppler ultrasound or CT) Transjuglar intrahepatic portosystemic stent shunt Surgery: Portosystemic shunts Esophageal transection Splenectomy and gastric devescularization.