Portal Hypertension

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Portal Hypertension

  1. 1. Dr Saeed Al-Shomimi KFHU Khobar
  2. 2. Anatomy <ul><li>6 – 8 cm </li></ul><ul><li>Splenic + s. mesenteric </li></ul><ul><li>(behind neck of the pancreas ) </li></ul><ul><li>i. mesenteric , Lt gastric </li></ul>
  3. 3. Blood Supply of the Liver Hepatic Arterial Autoregularity Vasodilatation
  4. 4. Pathophysiology <ul><li>Pressure = Flow X Resistance </li></ul><ul><li>Portal pressure : 3 – 6 mm Hg </li></ul><ul><li>Normal elevation: </li></ul><ul><ul><li>Eating </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Valsalva </li></ul></ul>
  5. 5. <ul><li>10 mmHg (prolonged) -> Shunting </li></ul><ul><ul><li>Lt Gastric -> esophageal </li></ul></ul><ul><ul><li>Short Gastric -> Gastric Submucosal </li></ul></ul><ul><ul><li>Lt portal -> epigastric </li></ul></ul><ul><ul><li>Retroperetoneal and anorectal collateral </li></ul></ul><ul><li>12 mm Hg -> Bleeding </li></ul>
  6. 6. Causes of Portal Hypertension Pre-sinusoidal Sinusoidal Post Sinusoidal BLOOD FLOW LIVER
  7. 7. <ul><li>Pre-sinusoidal </li></ul><ul><ul><li>Extra-hepatic: </li></ul></ul><ul><ul><ul><li>Portal vein thrombosis </li></ul></ul></ul><ul><ul><ul><li>Splenic vein Thrombosis </li></ul></ul></ul><ul><ul><li>Intra-hepatic: </li></ul></ul><ul><ul><ul><li>Congenital hepatic fibrosis </li></ul></ul></ul><ul><ul><ul><li>Primary biliary cirrhosis </li></ul></ul></ul><ul><ul><ul><li>Sarcidosis </li></ul></ul></ul><ul><ul><ul><li>Schistosomaisis </li></ul></ul></ul>
  8. 8. <ul><li>Sinusoidal </li></ul><ul><ul><li>Steatohepatits </li></ul></ul><ul><ul><li>Wilson disease </li></ul></ul>
  9. 9. <ul><li>Post Sinusoidal </li></ul><ul><ul><li>Extra-hepatic: </li></ul></ul><ul><ul><ul><li>Budd Chiari syndrome </li></ul></ul></ul><ul><ul><ul><li>R heart Failure </li></ul></ul></ul><ul><ul><li>Intra-hepatic: </li></ul></ul><ul><ul><ul><li>Heamochromatosis </li></ul></ul></ul><ul><ul><ul><li>Alcoholic cirrhosis </li></ul></ul></ul><ul><ul><ul><li>Post-hepatitic cirrhosis </li></ul></ul></ul>
  10. 10. Variceal Bleeding <ul><li>Mortality associated with 1 st episode: </li></ul><ul><ul><li>Cirrhotic patient : 40% - 70% </li></ul></ul><ul><ul><li>Non cirrhotic : 5% - 10% </li></ul></ul><ul><li>If bleeding resolved spontaneously </li></ul><ul><ul><li>30% re-bleed , 6 weeks </li></ul></ul><ul><ul><li>70% re-bleed , 1 year </li></ul></ul><ul><li>(30% of the initial bleeding episodes are fatal) </li></ul>
  11. 11. Acute Variceal Bleeding
  12. 12. Initial evaluation & stabilization <ul><li>Assessment of intravascular volume status </li></ul><ul><li>Fluid resuscitation </li></ul><ul><li>Endotracheal intubation prior to endoscopy for: </li></ul><ul><ul><li>Uncontrolled bleeding </li></ul></ul><ul><ul><li>Altered mental status, severe agitation </li></ul></ul><ul><ul><li>Respiratory distress or depression </li></ul></ul>
  13. 13. Pharmacologic Radiologic shunt TIPSS Surgical Shunt Balloon Tamponade Pharmacologic and endoscopic therapy are the usual 1 st and 2 nd interventions Endoscopic Treatment for Acute Variceal Bleeding
  14. 14. Pharmacologic Therapy <ul><li>Octreotide </li></ul><ul><ul><li>Synthetic analogue of somatostatin </li></ul></ul><ul><ul><li>Decreases portal pressure and azygos blood flow </li></ul></ul><ul><ul><li>Stops variceal bleed in 80% of the cases </li></ul></ul><ul><ul><li>Efficacy is similar to endoscopic sclerotherapy and better than vasopressin </li></ul></ul>
  15. 15. <ul><ul><li>5-day course reduces bleeding after endoscopic therapy </li></ul></ul><ul><ul><li>Can cause mild hyperglycemia and abdominal cramping </li></ul></ul><ul><ul><li>250 µg Iv Bolus – followed by infusion 25 – 50 µg/h (2-4 days) </li></ul></ul>
  16. 16. <ul><li>Vasopressin </li></ul><ul><ul><li>Reduces portal pressure but causes myocardial and mesenteric ischemia (more side effects) </li></ul></ul><ul><ul><li>20 u IV bolus (over 20 min) – infusion 0.2 – 0.4 u/min </li></ul></ul><ul><ul><li>Control approximately 50% of acute episodes </li></ul></ul>
  17. 17. <ul><li>Terlipressin </li></ul><ul><ul><li>Efficacy similar to endoscopic sclerotherapy and as effective as balloon tamponade when used with nitroglycerin </li></ul></ul><ul><ul><li>Not approved for use in U.S. </li></ul></ul>
  18. 18. Endoscopic Therapy <ul><li>Sclerosant injection </li></ul><ul><li>Band ligation </li></ul><ul><li>Became a standard form of therapy in acute variceal bleeding </li></ul><ul><li>Initial control of hge in 70 – 95% </li></ul><ul><li>Re-bleeding 20 – 50% </li></ul>
  19. 19. sclerotherapy <ul><li>5% sodium morrhuate </li></ul><ul><li>5% ethanolamine oleate </li></ul><ul><li>Intravariceally : to obliterate the varix </li></ul><ul><li>Paravariceally : induce submucus fibrosis </li></ul>
  20. 20. <ul><li>3 prospective randomized controlled trials studies comparing sclerotherapy and balloon temponade: </li></ul><ul><ul><li>Sclerotherapy achieved better initial hge control </li></ul></ul><ul><ul><li>Fewer episodes of rebleeding </li></ul></ul><ul><ul><li>Improved long-term survival </li></ul></ul><ul><li>(furthermore, routine use of balloon temponade after sclerotherapy confer no additional benefit) </li></ul>
  21. 21. <ul><li>Complications: </li></ul><ul><ul><li>Pulmonary complications </li></ul></ul><ul><ul><li>Transient chest pain </li></ul></ul><ul><ul><li>Esophageal stricture </li></ul></ul><ul><ul><li>Portal vein thrombosis </li></ul></ul><ul><ul><li>Esophageal perforation </li></ul></ul><ul><ul><li>Bacteremia </li></ul></ul>
  22. 22. <ul><li>Alternative to sclerotherapy </li></ul><ul><li>Fewer rebleeding episodes </li></ul><ul><li>Fewer endoscopic interventions </li></ul><ul><li>Lower procedure related mortality and over all mortality </li></ul>Band Ligation
  23. 23. Pharmacologic versus Endoscopic Therapy <ul><li>2 meta-analysis compared medical pharmacotherapy with emergency sclerotherapy as 1 st line treatment for acute bleeding: </li></ul><ul><ul><li>No significant difference regarding initial hge control or mortality </li></ul></ul><ul><ul><li>Administration of somatostatin before and after sclerotherapy : </li></ul></ul><ul><ul><ul><li>Improve treatment efficacy </li></ul></ul></ul><ul><ul><ul><li>Reduce blood transfusion </li></ul></ul></ul>
  24. 24. Balloon Temponade <ul><li>Application of direct upward pressure against varices at G-E junction </li></ul><ul><li>Should be intubated: </li></ul><ul><ul><li>Prevent aspiration </li></ul></ul><ul><ul><li>Prevent airway occlusion </li></ul></ul>
  25. 25. Balloon positioning
  26. 26. <ul><ul><li>1. Tube inserted to 50 cm </li></ul></ul><ul><ul><li>2. Auscultate in stomach </li></ul></ul><ul><ul><li>3. Inflate gastric balloon with 50 cc </li></ul></ul><ul><ul><li>4. Stat portable film </li></ul></ul><ul><li>Re-confirm proximal position </li></ul><ul><li>Inflate GB 300-400 cc air </li></ul><ul><li>Pull to insure anchorage </li></ul><ul><li>Recheck film </li></ul><ul><li>1-2 lbs of pully traction </li></ul>Tube Positioning and Gastric Balloon Inflation
  27. 27. <ul><li>Esophageal Balloon inflated to 35 - 40 mmHg </li></ul><ul><li>Last resort </li></ul><ul><li>Deflate periodically </li></ul><ul><li>Use minimum effective pressure </li></ul><ul><li>Complication </li></ul><ul><li>- ulcer </li></ul><ul><li>- perforation </li></ul><ul><li>- stricture </li></ul>Gastric and Esophageal Balloon Inflation
  28. 28. <ul><li>Direct temponade therapy is 90% effective in controlling the bleeding </li></ul><ul><li>50% rebleeding after removal </li></ul><ul><li>Serious potential complications (mortality 20%) </li></ul><ul><li>Bridge therapy </li></ul>
  29. 29. TIPS (Transjagular Intrahepatic Portosystemic Shunting) <ul><li>Creating an intrahepatic portosystemic fistula to decompress the portal hypertension </li></ul><ul><li>First performed in 1982 </li></ul><ul><li>(non- selective side to side portosystemic shunt) </li></ul>
  30. 30. <ul><li>1 -Cannulating the Rt hepatic vein via internal jagular vein </li></ul><ul><li>2 – passing needle through liver parenchyma to portal vein branch </li></ul><ul><li>3- guide wire </li></ul><ul><li>4 balloon dilatation </li></ul>
  31. 31. <ul><li>5 – stenting the tract </li></ul>
  32. 33. <ul><li>Meta-analysis comparing TIPS with endoscopy in acute hge: </li></ul><ul><ul><li>Significant improvement in controlling the hge </li></ul></ul><ul><ul><li>Coast : ↑rate of hepatic encephalopathy </li></ul></ul>
  33. 34. <ul><li>Contraindications: </li></ul><ul><ul><li>R side heart failure </li></ul></ul><ul><ul><li>Polycystic liver </li></ul></ul><ul><ul><li>Portal vein thrombosis </li></ul></ul>
  34. 35. <ul><li>Complications: </li></ul><ul><ul><li>Intraperitoneal bleeding due to perforation of the hepatic capsule, hepatic, or portal veins </li></ul></ul><ul><ul><li>TIPS embolization </li></ul></ul><ul><ul><li>Acute right heart failure due to increased venous return to right heart </li></ul></ul>
  35. 36. <ul><li>Late: </li></ul><ul><ul><li>recurrent bleeding due to TIPS stenosis or thrombosis </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>hepatic encephalopathy. </li></ul></ul>
  36. 37. Surgical Therapy <ul><li>Operative intervention is reserved for cases refractory to other modalities </li></ul>
  37. 38. <ul><li>Esophageal transection EEA stapler </li></ul><ul><ul><li>Operative mortality 75% </li></ul></ul><ul><ul><li>Complications 25%: </li></ul></ul><ul><ul><ul><li>Perforation </li></ul></ul></ul><ul><ul><ul><li>Stricture </li></ul></ul></ul><ul><ul><ul><li>Esophagitis </li></ul></ul></ul><ul><ul><ul><li>-> not useful in acute state </li></ul></ul></ul>
  38. 39. <ul><li>Portosystemic Shunt (side-to-side) </li></ul><ul><ul><li>Non-selective shunt </li></ul></ul><ul><ul><li>Manipulation and dissection in porta hepatica -> </li></ul></ul><ul><ul><li>Scaring and fibrosis -> complicate future liver transplant </li></ul></ul>
  39. 40. <ul><li>DSRS </li></ul><ul><ul><li>Selective shunt </li></ul></ul><ul><ul><li>Some cases un accompanied by refractory ascitis </li></ul></ul>
  40. 41. Prevention of Recurrent Variceal Bleeding
  41. 42. <ul><li>Pharmacotherapy: </li></ul><ul><ul><li>Rebleeding without treatment 70% in 1 year </li></ul></ul><ul><ul><li>Non-selective B blockers (propranalol) </li></ul></ul><ul><ul><li>↓ portal pressure </li></ul></ul><ul><ul><li>Effect is variable and unpredictable </li></ul></ul><ul><ul><li>Less benefit with decompesated liver </li></ul></ul>
  42. 43. <ul><li>Endoscopic therapy: </li></ul><ul><ul><li>Advocated as a means for complete eradication of esophageal varices </li></ul></ul><ul><ul><li>Once eliminated routine endoscopy 6-12 months </li></ul></ul><ul><ul><li>Fewer rebleeding episodes than medical treatment </li></ul></ul><ul><ul><li>50 % rebleding in 1 year </li></ul></ul><ul><ul><li>30% need conversion </li></ul></ul><ul><ul><li>Reserved for complaint patients </li></ul></ul>
  43. 44. <ul><li>TIPS: </li></ul><ul><ul><li>Bridge therapy -> liver transplant </li></ul></ul><ul><li>Advantiges over surgery: </li></ul><ul><ul><li>No risk of general anesthesia </li></ul></ul><ul><ul><li>No post-operative complications </li></ul></ul><ul><li>Limitations </li></ul><ul><ul><li>Stenosis (50% in 1 st year) </li></ul></ul><ul><ul><li>Encephalopathy (1/3) </li></ul></ul>
  44. 45. <ul><li>Surgical Therapy: </li></ul><ul><ul><li>Most effective method in controlling portal hypertension and recurrent bleeding </li></ul></ul><ul><ul><li>1 Portosystemic shunt procedures </li></ul></ul><ul><ul><li>2 Esophagogastric devascularization </li></ul></ul><ul><ul><li>3 Orthotopic liver transplantation </li></ul></ul>
  45. 46. Portosystemic Shunt <ul><li>Decompressing the hypertensive portal Venus system into the low pressure systemic venous circulation </li></ul><ul><li>Toxins -> systemic circulation -> encephalopathy </li></ul>
  46. 47. <ul><li>To minimize these effects shunting operations have evolved: </li></ul><ul><ul><li>Non-selective </li></ul></ul><ul><ul><li>Selective </li></ul></ul><ul><ul><li>partial </li></ul></ul>
  47. 48. 1 – Non selective Shunts <ul><li>End to side portocaval (Eck fistula): </li></ul><ul><ul><li>Higher rate of encephalopathy among operative shunting groups </li></ul></ul><ul><ul><li>Better control of rebleeding than medical treatment </li></ul></ul><ul><ul><li>Eck fistula – medical therapy -> same incidence of encephalopathy </li></ul></ul>
  48. 49. <ul><li>Side to Side portocaval shunt: </li></ul><ul><ul><li>Maintain the anatomic continuity of the portal vein </li></ul></ul><ul><ul><li>Encephalopathy rate : no difference </li></ul></ul><ul><ul><li>Decompress the sinusoidal pressure -> better ascitis control </li></ul></ul><ul><ul><li>Recommended for Budd Chiari Syndrome </li></ul></ul><ul><ul><li>More difficult than end to side </li></ul></ul>
  49. 50. <ul><li>Interposition Mesocaval Shunt: </li></ul><ul><ul><li>Prosthetic – autogennous vien </li></ul></ul><ul><ul><li>Avoid hilar dissection (future transplant) </li></ul></ul><ul><ul><li>Shunt ligation in refractory post-op encephalopathy </li></ul></ul><ul><ul><li>Drawback -> thrombosis (35%) </li></ul></ul>
  50. 51. <ul><li>Proximal Spleno-Renal Shunt: </li></ul><ul><ul><li>Splenectomy + anastomosing proximal Splenic vein to Lt Renal vein </li></ul></ul><ul><ul><li>Divert all portal flow into renal vein -> non selective </li></ul></ul><ul><ul><li>Shunt occlusion 18% </li></ul></ul>
  51. 52. 2 – Selective Shunts <ul><li>In response to post-op complications of non-selective procedures </li></ul><ul><li>1967 DSRS </li></ul><ul><li>Distal Splenic vein to Lt renal Vein </li></ul><ul><li>Selectively decompress the esophagogastric veins </li></ul>
  52. 53. <ul><li>Contraindications: </li></ul><ul><ul><li>Refractory ascitis </li></ul></ul><ul><ul><li>Splenic vein thrombosis </li></ul></ul><ul><ul><li>Previously underwent splenectomy </li></ul></ul><ul><ul><li>Splenic vein diameter < 7 mm </li></ul></ul>
  53. 54. <ul><li>Coronary – Caval Shunt: </li></ul><ul><ul><li>Described in Japan in 1984 </li></ul></ul><ul><ul><li>Interposition graft between L Gastric and inferior vena cava </li></ul></ul><ul><ul><li>Little experience with this procedure </li></ul></ul>
  54. 55. 3 – Partial Shunts <ul><li>Small diameter interposition grafts </li></ul><ul><li>Maintaining a degree of hepatopedal portal flow to the liver </li></ul>
  55. 56. Esophagogastric Devascularization <ul><li>The most effective non-shunt operation for preventing variceal bleeding: </li></ul><ul><ul><li>Devascularization + transection + splenectomy </li></ul></ul><ul><ul><li>Sugiura procedure </li></ul></ul>
  56. 57. Orthotopic Liver Transplantation <ul><li>The most definitive form of therapy for complications of portal hypertension </li></ul><ul><li>Selective patients: </li></ul><ul><ul><li>Coast </li></ul></ul><ul><ul><li>Unavailability </li></ul></ul><ul><ul><li>Immunosuppresion </li></ul></ul>
  57. 58. <ul><li>Child A – mild B -> non-transplant surgery </li></ul><ul><li>Child C – advanced B -> transplant </li></ul>
  58. 59. Prophylaxis
  59. 60. <ul><li>Likehood of variceal bleeding : </li></ul><ul><ul><li>Alcoholic cirrhosis </li></ul></ul><ul><ul><li>Active alcohol consumption </li></ul></ul><ul><ul><li>Sever hepatic dysfunction </li></ul></ul><ul><ul><li>Endoscopy: </li></ul></ul><ul><ul><ul><li>Variceal wall thinning </li></ul></ul></ul><ul><ul><ul><li>Variceal tortuosity </li></ul></ul></ul><ul><ul><ul><li>Superimposition of varices on other </li></ul></ul></ul><ul><ul><ul><li>Gastric varicose </li></ul></ul></ul>
  60. 61. <ul><li>Non selective B blockers </li></ul><ul><li>Prophylactic shunts showed no benefit , ↑morbidity </li></ul>
  61. 62. <ul><li>Portal hypertension in north Indian children </li></ul><ul><li>Arora NK, Lodha R, Gulati S, Gupta AK, Mathur P, Joshi MS, Arora N, Mitra DK </li></ul><ul><li>Department of Paediatrics </li></ul><ul><li>All India Institute of Medical Sciences </li></ul><ul><li>New Delhi. </li></ul>
  62. 63. <ul><li>cross-sectional observational study </li></ul><ul><li>Tertiary care centre in northern India </li></ul><ul><li>January, 1990 to December, 1994 </li></ul><ul><li>Children below the age of 14 years with suspected portal hypertension </li></ul><ul><li>To determine the etiology and clinical profile of portal hypertension </li></ul>
  63. 64. <ul><li>115 patients with portal hypertension </li></ul><ul><ul><li>76.5% had extrahepatic portal hypertension (EHPH) </li></ul></ul><ul><ul><li>23.5% had intrahepatic causes of portal hypertension </li></ul></ul>
  64. 65. <ul><li>Results: </li></ul><ul><ul><li>Children with EHPH had a significantly earlier onset of symptoms as compared to those with intrahepatic portal hypertension (p = 0.002) </li></ul></ul><ul><ul><li>And bled significantly more frequently (p = 0.00). </li></ul></ul>
  65. 66. <ul><li>History suggestive of potential etiological factors could be elicited in only 7% of EHPH patients . </li></ul><ul><li>The commonest site of block in splenoportal axis was at the formation of the portal vein . </li></ul>
  66. 67. <ul><li>An inverse relation of bleeding rates with duration of illness was seen in EHPH </li></ul>
  67. 68. <ul><li>Conclusion: </li></ul><ul><ul><li>Understanding the natural history of EHPH and portal hypertension due to other etiologies may have significant implications in choosing the appropriate intervention and predicting the outcome . </li></ul></ul>
  68. 69. <ul><li>References </li></ul><ul><ul><li>ACS Surgery : Principles and Practice 2004 Web,MD </li></ul></ul><ul><ul><li>Schwartz Principles of Surgery 7 th Edition </li></ul></ul><ul><ul><li>Indian J Pediatr. 1998 Jul-Aug;65(4):585-91. </li></ul></ul><ul><ul><li>Johns Hopkins Gastroenterology & Hepatology Resource Center http://hopkins-gi.nts.jhu.edu </li></ul></ul>
  69. 70. <ul><li>Thank You </li></ul>

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