Understanding Portal hypertension

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Understanding Portal hypertension

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Understanding Portal hypertension

  1. 1. Portal Hypertension: Learn from the start Pratap Sagar Tiwari, Lecturer, NGMC
  2. 2. What does Portal HTN mean ? • In simpler terms. It means Hypertension or increased blood pressure in the Hepatic portal system. • Note: this isnt an standard definition What is hepatic portal System ????
  3. 3. Hepatic portal system • The hepatic portal system is the system of veins that consists of the hepatic portal vein and its tributaries. • It is also called the portal venous system. Pic taken from : http://imageradiology. blogspot.com/2010/10/hepatic-portal-vein.html It is one of the two portal system in the body and the other being is the Hypophyseal portal system is a blood system of vessels in the brain that connects the hypothalamus with the anterior pituitary.
  4. 4. Portal circulation Hepatic vein IVC 25 % Hepatic Artery Proper 75 % Hepatic portal vein SMV GI tract Splenic vein Spleen IMV Gastric vein Cystic vein
  5. 5. Portal circulation • The liver receives about 75% of its blood through the hepatic portal vein, with the remainder coming from the hepatic artery proper. • The hepatic portal vein is a blood vessel that conducts blood from the gastrointestinal tract and spleen to the liver. • The blood leaves the liver to the heart in the hepatic veins. • The hepatic portal vein is usually formed by the confluence of the superior mesenteric and splenic veins and also receives blood from the inferior mesenteric, gastric, and cystic veins.
  6. 6. Portal triad Pic taken from : https://cms.webstudy.com/WebstudyFileSystem/testovaci/GetFile/293875/Ch%2022/Ch22b/index.html
  7. 7. Portal triad A portal triad (a component of the hepatic lobule) It consists of the following five structures: 1. proper hepatic artery 2. hepatic portal vein 3. common bile duct 4. lymphatic vessels 5. branch of the vagus nerve
  8. 8. PostHepatic Portal vein & tributaries PreHepatic Bile canaliculi & sinusoids Hepatic vein IntraHepatic IVC Occulsion↑ resistance↑ pressure hypertension Systemic cirulation HEART
  9. 9. Portal HTN :causes Ref: HEMODYNAMIC PRINCIPLES OF PORTAL HYPERTENSION. Sleisenger-2010. http://www.uptomed.ir
  10. 10. Portal HTN : manifestations
  11. 11. Understanding HVPG Ref: http://www.ias.ac.in/meetings/annmeet/71am_talks/sksarin/img46.html
  12. 12. Portal hypertension • PHTN is hypertension (high BP) in the portal vein system, which is composed by the portal vein, and its branches. • Portal venous pressure is the blood pressure in the hepatic portal vein, and is normally between 5-10 mmHg. • • • NOTE: Wedged hepatic venous pressure (WHVP)= hepatic sinusoidal pressure hepatic venous pressure gradient HVPG= WHVP- FHVP Normal HVPG = < 5 mmhg • Portal hypertension is defined as elevation of hepatic venous pressure gradient to >5mmHg.
  13. 13. Summary • Normal portal venous pressure is generally considered to be between 5 -10 mm Hg. • Once the portal venous pressure rises to 12 mm Hg or greater, complications can arise, such as varices ,ascites etc. • Portal hypertension is defined as elevation of hepatic venous pressure gradient to >5mmHg.
  14. 14. Prognostic value of HPVG in CLD Measurement(mmhg) Significance 1-5 normal 6-10 Preclinical sinusoidal portal htn ≥10 Clinically significant phtn ≥12 Increase risk of rupture of varices ≥16 Increase risk of mortality ≥20 Treatment failure and mortality in acute variceal bleeding An HPVG of ≥10 mmHg defines clinically significant portal hypertension Ref: Iris W. Liou, MD. Screening for Varices and Prevention of Bleeding http://hepatitisc.uw.edu/ Portal hypertension is defined as elevation of hepatic venous pressure gradient to >5mmHg.
  15. 15. Differentiating Sinusoidal from preSinusoidal portal HTN Intrahepatic PVP WHVP FHVP HVPG Presinusoidal ↑ N N N SInusoidal ↑ ↑↑ ↑ ↑ WHVP = sinusoidal pressure HVPG = WHVP – FHVP Portal venous pressure is increased ,so portal hypertension But WHVP increases in Sinusoidal ,so Ascites is common in Sinusoidal causes of portal htn (increased Sinusoidal pressure= transudation of fluid )
  16. 16. Schematic dig showing blood flow Normal Source: emedicine Portal HTN
  17. 17. Overall Manifestations: PHTN • • • • Ascites Varices Hepatic encephalopathy Splenomegaly
  18. 18. Next Part : • Investigation & Management of portal hypertension
  19. 19. • Thankyou

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