This document provides information on portal hypertension, including its definition, anatomy, pathophysiology, etiology, clinical features, investigations, treatment of variceal bleeding, ascites, encephalopathy, Budd-Chiari syndrome, and various surgical procedures. Portal hypertension is defined as a portal venous pressure greater than 12 mmHg and is characterized by the development of portosystemic collaterals. Common causes include liver cirrhosis, portal vein thrombosis, and Budd-Chiari syndrome. Treatment involves reducing portal pressure, treating complications, and addressing the underlying liver disease.
2. DEFINITION
Normal Portal Pressure : 5-10 mm
Pressure of > 12 mm : Portal Hypertension
Portal Hypertension is characterized by gradient of >5
mm Hg between portal venous and central venous
pressure.
At gradient of 8-10 mm Hg – Varices develops
If gradient >12 mm Hg – Bleeding from varices
4. Portosystemic Collateral Formation
Lower end of esophagus
Azygos vein Lt gastric V
Umblicus
Ant abd. veins Paraumblical
Lower end Rectum
Middle and Inf Superior Haem.
Haemmorrhoidal V
Retroperitoneum
Bare area of liver
6. PATHOPHYSIOLOGY
Portal pressure = resistant X flow
Resistance to portal flow
Rise in portal pressure
Development of portasystem collaterals
Hyperdynamic circulation
7. ETIOLOGY
Extrahepatic (Prehepatic/ EHPVO)
Portal cavernoma
Portal vein thrombosis (most common cause)
Splenic vein thrombosis
Compression from outside
Intrahepatic
Presinusoidal
Schistosomiasis (most common cause)
Primary biliary cirrhosis
Sinusoidal
Alcoholic cirrhosis (most common cause)
Postsinusoidal
Alcoholic cirrhosis (most common cause)
Veno-occlusive disease
Non Cirrhotic Portal Fibrosis
13. ESOPHAGOGASTRO DUODENOSCOPY
Grading as per Endoscopy
Paqet Grading
Grade I: Small varices without luminal prolapse
Grade II: Mod. Size varices showing luminal
prolapse along with minimal obscuring of
gastro esophageal junction.
Grade III: Large varices showing luminal prolapse
substantially obscuring the gastro
esophageal junction.
Grade IV: Very large varices completely obscuring
gastroesophageal junction.
14. USG/Doppler USG:
Portal vein diameter, thrombus, collaterals , splenomegaly &
ascites.
Portal flow direction and velocity – Hepatopetal/Fugal
Portosytemic surgical shunt follow up
To evaluate patency of shunt
To evaluate direction of flow
17. Child’s grade
(Pugh Modification)
Point 1 Point 2 Point 3
Bilirubin mgm/dl <2 2-3 >3
Albumin (gm/dl) >3.5 3-3.5 <3
Ascites None Controlled Uncontrolled
Encephalopathy None Mild Mod-severe
Prothrombin Time* <3 Sec prolonged 3-6 Sec prolonged >6 Sec prolonged
Total : 5-15
Child A < 6 Child B 7-9 Child C 10-15
* In Original Child score it was nutritional status
18. TREATMENT
Portal hypertension treatment involves three
level of management
Reduction of portal pressure
Treatment of complications arising from
portal hypertension
Variceal bleeding
Hypersplenism
Treatment of underlying liver disease and its
complications
19. TREATMENT OF VARICEAL BLEEDING
Primary Prophylaxis : No prior H/O bleed
Propranolol
EST
Secondary Prophylaxis
Propranolol
EST
Surgery
21. PHARMACOLOGICAL THERAPY
Beta blockers
Vasopressin with or without
nitroglycerine
Glypressin
Somatostatin / octreotide
Metoclopramide
Long acting nitrates
22. Beta blockers
bleeding by cardiac output.
Dose 20-60 mg bid 25% in HR.
Reduces 40% of bleeding episodes
23. Vasopressin
vasoconstriction of the splanchnic circulation.
Dose 0.2 unit/kg wt, dissolved in 200 ml of 5%
dextrose, over 20 minutes.
Disadvantages
colicky abdominal pain, & diarrhoea .
Anginal pains, so it is contraindicated in the
elderly.
Produce temporary control of bleeding in about
80% of cases.
To prolong its action it is combined with glycine
(Glypressin).
26. Sclerosants :
5% Ethanolamine oleate
0.5% sodium polidocanol
5% sodium morrhuate
1% to 3% sodium tetradecyl sulphate
High concentration of alcohol
3% phenol
27. ENDOSCOPIC VARICEAL LIGATION (EVL)
Occludes venous channels
Sessions < sclerotherapy
Same results as sclerotherapy
complications vs sclerotherapy
Endoscopic treatment of choice
28. BALLOON TEMPONADE
Temporary measure
Hazardous in infants and small children
Success rate is 80-90%
Complications : Aspiration pneumonia,
pressure necrosis , obstruction of
pharynx, ulceration of esophagus,
rupture of balloon, re-bleeding after
deflation (60%).
29. TYPES OF BALLOON TEMPONADE TUBE:
Sengstaken Black’s more tube
Linton-Nicholos tube for gastric variceal haemorrhage
Minnesota tube – 4 lumen tube
30. TIPS(Transjugular Intrahepatic Porta systemic shunt)
• Shunt between portal vein
and hepatic vein
• Can be used as short term
bridge to liver
transplantation
• Goal – To reduce
portosystemic gradient
< 12 mm Hg
31.
32. SURGICAL TREATMENT
SHUNT SURGERY
Prophylactic
Emergency shunt surgery
Reduced with advent of other non surgical procedure
End to side porto-caval shunt preferred
Elective shunt surgery
33. Types of Shunt Surgery
Non Selective
Portacaval (end to side/ side to side)
Mesocaval (With or without graft)
Proximal Leino Renal Shunt
Spleen preserving Side to side Splenorenal
shunt (Mitra)
Selective Shunt
Distal Leino Renal Shunt (Warren)
Coronary Caval (Inokuchi)
Porta Caval (SARFEH SHUNT) 8 mm graft
36. Types of Operation
Non Shunt Surgery:
Stapler transection, (Johnston)
Boerema,
Milnes Walker
Suigura and Futagawa,
Tanner,
Hassab,
Liver Transplantation
37. Non Selective shunt operations
1- Porta-caval operation
End to side Side to side
38. Porta-caval operation
very efficient in lowering the portal pressure
no bleeding occurs from the varices.
disadvantages:
deprives the liver of portal blood flow
accelerates the onset of liver failure.
Recurrent hepatic encephalopathy in 30-50%
of patients.
39. Proximal spleno-renal shunt
indicated if the portal
vein is thrombosed or if
splenectomy is
indicated due to
hypersplenism .
The incidence of
encephalopathy is less
than after porta caval
shunt.
it is less effective In
preventing further
bleeding.
If the splenic vein is
less than 1 cm the
anastomosis is liable to
thrombosis.
40. Mesocaval (Drapanas) shunt
insertion of a a
synthetic graft as
dacron, or autogenic
vein between the
superior mesenteric
vein and inferior
vena cava.
The incidence of
thrombosis is high
41. Selective shunt (Warren shunt)
The Rt and Lt gastric vessels
are ligated.
The proximal end of splenic
vein is ligated while the distal
end is anastomosed to the
left renal vein.
The short gastric veins are
preserved and will selectively
decompress the lower end of
the oesophagus.
The incidence of
encephalopathy is low, and
the liver functions remain
normal.
44. Sugiura and Futagawa procedure
(1973) Transthoracic
paraesophageal devascularization
and esophageal transaction
combined with an abdominal
component consisting of
splenectomy, devascularization of
upper stomach, vagotomy and
pyeloroplasty
Modified Sugiura procedure (Ginsberg 1982) –
Abdominal approach. Splenectomy, paraesophageal and
gastric devascularization, vagotomy, stapler esophageal
transaction via gastrostomy and pyeloroplasty.
45. HYPERSPLENISM
SELECTIVE SPLENIC EMBOLIZATION :
Splenic immune function is conserved, size of spleen is
reduced and portal flow is maintained.
Aim of procedure is to infarct 70-80% of splenic tissue.
Pneumococcal vaccination is given with this therapy and
sometimes long term antibiotics prophylaxis is needed.
SPLENECTOMY:
Usually not advocated
Indicated in isolated portal vein thrombosis with recurrent or
life threatening haemorrhage and a massive spleen.
Shunt Procedures
46. Ascites
Disordered albumin synthesis and decreased plasma
colloid osmotic pressure caused by hepatocellular
function damage
Increased capillary filter pressure due to increased portal
hypertension
Lymph liquid leakage into abdominal cavity from surface
of the liver because of lymph back-flow obstruction
Salt and water retention by aldosterone and antidiuretic
hormones deactivation disturbance