this an presentation on portal hypertension useful for medical students and surgeons.

1. PORTAL
HYPERTENSION
BY:
DR.KIRAN MAINDALE

2. WHAT IS PORTAL VENOUS
PRESSURE?
 Portal pressure is pressure excerted by blood
on poratl vein.
 Normal portal pressure:5-10 mmhg.
 Portal hypertension
 Is defined as the elevation of the hepatic
venous pressure gradient to > 15mm Hg.

4. Portal venous system

5. Porta caval anastomosis
 1. lower third of
oesophagous
 2.paraumbilical
region
 3. lower end of
rectum
 4.retroperitoneal
region.
 5. bare area of liver

7. Two important factors exist in
the pathophysiology of portal
hypertension
 vascular resistance .
 blood flow.

13. investigation
 CBC
 LFT- SGPT
SGOT
ALKALINE PHOSPHATASE
SR. ALBUMINE.
 Endoscopy: OGD scoppy.
 Upper GI barium studies.

14. Mesasurement of portal
presuure
 Liver angiography
 Transhepatic portography
 Umbilical catheterization
(spleenoportography)
 Portal veinography

16. CLINICAL FEATURES
 • Abdominal wall veins: Prominent collateral
veins radiating from umbilicus are termed
caput medusa.
 A venous hum may be heard usually in the
region of xiphoid process or umbilicus.
 Spleenomegaly (Mild to moderate)
 Ascites
 • Anorectal varices
 • Fetor hepaticus

17. COMPLICATIONS
 Variceal bleeding
 Hepatic encephalopathy
 Ascites
 Congestive gastropathy
 Hypersplenism
 Iron deficiency anaemia
 Renal failure

18. TREATMENT
 Usually patient come with acute variceal bleeding,
so management includes;
 resuscitation-
1. Blood transfusion
2. Saline avoided
3. Ice water stomach wash
4. Rapid bowel clearing by enema
5. Cimetidine
6. Tpr bp monitoring
 Diagnosis- endoscopy

19.  Specific treatment-
1. Vasopressin- 20u in 100ml D5% for 20
min.then contious infusion
2. Propanolol
3. Iv somatostatin
4. Endoscopic variceal sclerosis.
• Paravariceal- for recurrent
• Intravariceal- for acute bleeding
• 2.5%sod. Morrhuate, ethanolamine oleate.

20.  Balloon tamponade
 Sengestaken-blakmore tube
 Gastric 300ml, oseophageal- 45ml
 Transhepatic visceral embolisation
 Percutaneous transhepatic portal vein
puncture cathetarisation and occlusion of left
gastric vein

21. Treatment of complication
 Shock-sedatives ,BT, resuscitation.
 Clotting problems- from liver damage,
thrombocytopenia inj. Vit-k.
 Encephalopathy-gastric lavage neomycin
,bowel wash.
 Liver failure- plenty of carbohydrate orally.
 Ascites- low salt diet, diuretics, tapping.

22. Surgical tratment
1. Transthorasic oesophagotomy:
2. Gasterotomy: stapplers
3. Boerema-crile operation
4. Milnes-walker operation
5. Tanners operation
6. Oesophagial transection with
paraoesophagial devascularisation
7. Endoscopic sclerotherapy.

23.  So in emergency above mentioned procedures
are done to arrest bleeding.
 These procedure dosent decrease portal
pressure.
 Transthorasic oesophagotomy:
Rt lat. Position
Incision on 8-9th rib
Rib resected to reach parital pleura
Lungs retracted forword
oesophagus was transected and resutured
Bleeder occluded in suture.

24. Scoring of Portal HTN

25. SHUNT OPERATIONS
 Decompressive Shunts
Decompression is considered second-line
treatment
 Reserved for patients who rebleed through
pharmacologic therapy and endoscopic
banding or whose varices remain “high risk.”
 1. Radiologically placed shunt—TIPS.
 2. Surgical shunts Total, Partial, and
Selective shunts

26. TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT (TIPS
 Direct puncture of the internal jugular vein (IJV),
 passage of a catheter through the right atrium into
one of the major hepatic veins followed by a trans-
parenchymal puncture of the liver to cannulate the
portal vein.
 • The catheter is passed into the portal vein
 • The intraparenchymal track is then dilated and the
track stented with an expandable metal stent in the
10- to 12-mm-diameter range.
 • The technical success rate is high (>90%) with a
low procedural morbidity and mortality (<10%).
 • Patients are usually in the hospital for 1–2 days
and the shunt patency should be documented the
day after the procedure with a Doppler ultrasound.

28. Shunts
 Total Shunts
1. End-to-side portacaval shunt
2. Side to side portocaval shunt (diameter
>10mm)
 Partial shunts
1. Side to side portocaval shunt(diameter
<8mm)
 Selective shunts
1. Distal splenorenal shunt

32.  The only indication for a total portal systemic
shunt at present is for patients with acute
Budd- Chiari syndrome
Partial Shunts •
 Partial shunts are side-to-side shunts whose
diameter is reduced to 8 mm.
 • 90% control of variceal bleeding
 • polytetrafluoroethylene (PTFE) graft is
approximately 2–3 cm long, and beveled at
each end to give a larger anastomosis.

34. Selective Shunts
 • Selective shunts are most commonly the distal
splenorenal shunt (DSRS)
 • Divide the splenic vein at its junction with the superior
mesenteric vein, and anastomoses the splenic vein to
the left renal vein.
 • This selectively decompresses gastroesophageal
varices.
 • Control of bleeding has been at 94%, with good portal
perfusion maintained in 90% of patients initially.
 • The overall incidence of encephalopathy has been
around 15% following this operation.

36. THANK YOU !!!