Portal htn

1. PORTAL HYPERTENSION
Dr. Shirjeel
H/O M1

2. ANATOMY AT GLANCE
 Potential collaterals………!
 Are not merely passively dilated
vessels.
 These are also hypertrophied and
hyperplastic
 Reason is the role of angiogenic factors
rather than just the pressure

5. COLLATERALS
 Short gastric and coronary veins with esophageal azygous and intercostal veins
 Result…… esophageal and gastric varices
 Superior hemorrhoidal with middle and inferior hemorrhoidal
 Result……anorectal varices ( not hemorrhoids)
 Portal with epigastric veins through umbilical veins( caput medusae; cruvelheir
Baumgarten syndrome)
 Liver capsule
 Spontaneous splenorenal shunt
 Ectopic varices in duodenum

6. SEQUELE OF PORTAL HYPERTENSION
 Gastroesophageal varices
 Variceal hemorrhage
 Ascites
 Renal dysfunction
 Portal systemic encephalopathy
 Hypersplenism
 Hepatopulmonary syndrome

7. DIMENSIONS OF VEIN
 Length 55-80 mm
 Diameter 11 mm
 Increase is PATHOLOGICAL

8. PORTAL PRESSURE
 Normally 9 mm Hg
 Symptomatic at 12 mm Hg
 In between is Latent or pre clinical portal htn

9. MOST COMMON CAUSE WORLDWIDE
 Cirrhosis
 Most common noncirrhotic cause is
schistosomiasis

10. IDIOPATHIC PORTAL HTN
 INDIA and JAPAN
 30 % of HTNsives in INDIA
 HOW TO DIFFERENTIATE ?
 BIOPSY OF LIVER

11. PATHOPHYSIOOGY OF BLEED
 Damage to varices vs increased pressure ?
 Varices don’t bleed before 12 mm Hg
 BUT REMEMBER………. Not all those
above 12 mm Hg would bleed !!

12. REASONS FOR INCREASED PORTAL PRESSURE
 Pre hepatic
 Post hepatic
 Hepatic
 Our concern is hepatic………i.e……….
cirrhosis

13. CIRRHOSIS
 Damaged architecture is not all causing
portal htn
 Its more than that
 It’s the vasodynamics
Dilator (NO)--------------- Constrictors
 Result HTN

14. IN SPLANCHNIC CIRCULATION….!
 NO increases !!! due to local regulation
 And thus causes increased flow in portal vein
 So increased flow plus constriction of portal vein causes htn
 GUESS: WHY WE USE BETA BLOCKERS TO TREAT PORTAL
HTN ?
 ANS: to constrict splanchnic vessels and reduce the flow into the
portal…….
 Same is the mechanism of vasopressin, terlipressin,
somatostatins.

15. PRECAUTION
 Don’t give Isosorbide mononitrate
 Alpha agonists (prazosin or clonidine)
 Anti endothelins
 WHY???
 Dilators
 If necessary,,,, give with beta blockers

16. WHEN TO INTERVENE
 When varices are more than 5 mm diameter
 For Indefinite time
 OR BAND LIGATE

17. WHAT TO DO IN CASE OF ACTIVE BLEED ??
 Drugs or Endoscopy ?
 Drugs are safer to start with. No
specialization is required.
 TIPS is life saving for child class C……
 But only child pugh <8 can undergo surgery

18. TECHNIQUE
 HEPATIC CATH……
 Difference between
 Wedge pressure (WHVP) and free
pressure(FHVP) of hepatic vein
 Called as hepatic venous pressure gradient (
HVPG)

19. POINT TO PONDER
 ONCE BLEED………………. IS an indication
for liver transplant

20. SAVE YOUR LIVER
 Discard the syringes
 Beware of needles