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Portal Hypertension Guide
- 1. PORTAL HYPERTENSION Dr Winston Makanga, M.B.Ch.B., M.Med. (Surg) Consultant General and Laparoscopic Surgeon
- 2. Outline • Introduction and definition • Pathogenesis • Presentation • Investigation • Management
- 3. Introduction & definition • Normal portal pressure – 5-6mmHg • Portal HTN >12mmHg • Resistance to flow through the portal vascular system • ?Increase in blood flow through the portal system
- 6. Pathology • 1.5L/min flows through the portal vein • Obstruction to this flow increases the portal pressure • Reversal of flow in the coronary vein • Reopening of previously obliterated shunts • Increase in caliber of previously low flow collateral veins • Decreased reabsorption of peritoneal fluid • Splenomegaly due to increased pressure/flow
- 8. Pathogenesis • Risk of bleeding through ruptured esophageal varices • Morbidity of ascites • Bypassing the liver results in toxins getting into the systemic circulation • ?Hemorrhoidal disease
- 9. Etiology
- 11. Clinical assessment • History: hematemesis, melaena stool, abdominal swelling, symptoms of anemia • General signs of liver disease • Jaundice, finger clubbing, hair redistribution, spider naevi, testicular atrophy, edema, palmar erythema, Duputryen’s contracture, encephalopathy • Abdominal – Ascites, hepatomegaly, splenomegaly, caput Multifactorial
- 12. Investigation • Hemogram (hypersplenism and CLD) • LFTs • UEC • Abdominal imaging (ultrasound and CT scan) • Wedge portal pressure measurement • Endoscopy (red wale, sherry red, hematocystic spots, G3 varices)
- 13. Management • Variceal bleeding • Hypersplenism • Ascites
- 14. Variceal bleeding • Primary prophylaxis vs prevention of recurrence • Medical treatment • Beta blockers – propranolol • Endoscopic • Variceal banding • Variceal injection sclerotherapy • Surgical/shunting • Central/peripheral porto-venous shunting • Interventional radiology • Transjugular intrahepatic porto-venous shunting (TIPS)
- 15. Banding
- 16. Transjugular intrahepatic porto-systemic shunt (TIPS)
- 18. Emergency treatment of variceal bleeding • Resuscitate with fluids and blood products • Vasopressin • Octreotide • Beta blockers • Balloon tamponade - Sengstaken-Blakemore tube • Emergency banding/sclerotherapy
- 20. Hypersplenism and splenomegaly • Splenectomy (with other shunting procedure) • Manage primary liver disease • Paracentesis • Shunting procedures Ascites
- 21. Liver transplant is the only true definitive management
- 22. Review • Definitions • Normal porto-venous circulation and pathogenesis of pHTN • Etiology • Clinical evaluation • Investigation • Management (symptomatic, emergency, definitive)
- 23. Thank you