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Portal Hypertension
Portal hypertension occurs when blood pressure in the portal vein system leading to the liver is elevated above normal levels. It has many potential causes but is most commonly caused by cirrhosis of the liver. Diagnosis involves blood tests, imaging like ultrasound and endoscopy. Management depends on the underlying cause but often involves endoscopic procedures to treat variceal bleeding and may progress to surgical shunts, TIPSS, or liver transplantation in advanced cirrhosis.
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Portal Hypertension
- 1. Portal Hypertension Dr HarshJ Shah MS, FMAS, DNB, MCh (GI) GI & HPB Surgeon Kaizen Hospital, Ahmedabad
- 2. Portal Hypertension • Anatomy& Physiology • Diagnosis • Etiology • Management of Bleed
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- 4. Characteristics • Starts &ends in capillaries • Major source of blood supply to liver • No Valves in portal circulation – Blood can flow in either directions • Portosystemic collaterals
- 5. Portal Hypertension • NormalPortal venous pressure – 5-8 mm Hg • Portal Hypertension >10mmHg • Variceal bleeding > 12mm Hg • HVPG (Hepatic venous portal gradient)
- 6. Physics Ohm’s law P (Pressure)= R (Resistance) x Q ( Flow) • Resistance – Cirrhosis – NCPF – EHPVO • Flow – Cirrhosis – AV fistula
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- 8. Sites of portalhypertension Extrahepatic Presinusoidal Sinusoidal Postsinusoidal EHPVO NCPF Cirrhosis Budd-chiari syndrome
- 9. Manifestations of PortalHT • Asymptomatic – Detected Incidentally • Ascites • Splenomegaly • Hypersplenism • Jaundice • Encephalopathy
- 10. Investigations Haematology • CBC, Plateletscount Chemistry • Liver Functions • Synthetic function – Protein, Albumin • Renal functions- Urea, Creatinine • Coagulation profile – PT, APTT
- 11. USG Abdomen inPHT • Liver architecture & Size • Portal vein, Splenic vein diameter • Spleen enlargement • Ascites • PV thrombosis & cavernoma • Hepatic veins & IVC Doppler for blood flow direction
- 12. Flexible UGI Endoscopy •Oesophageal Varices • Gastric varices • Grade of Varices ( I-IV) • Gastropathy • Risk factor bleed - Red spots
- 13. Endoscopic view ofEsophageal Varices Normal Low Grade High Grade
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- 15. Liver Biopsy inPHT - For Diagnosis of Cirrhosis if unclear on clinical grounds - For prognosis - As a guide to antiviral treatment - Contra-indication – Massive Ascites, prolonged PT
- 16. Causes of portalhypertension • Cirrhosis of liver • Extrahepatic portal venous obstruction • Non-cirrhotic portal fibrosis
- 17. Cirrhosis of liver •End stage liver disease
- 18. Causes of livercirrhosis • Alcohol • Viral hepatitis (Hep B & C) • Biliary obstruction • Hemochromatosis • Wilson’s disease • Autoimmune • Drugs and toxins • Metabolic diseases • Idiopathic
- 19. Clinical Stages 1. Novarices 2. Varices but no bleeding 3. Ascites 4. Variceal bleed 5. Renal failure, infected ascites or encephalopathy
- 20. Child Pugh Scoring 12 3 Ascites None Mild Severe Encephalopathy None Low grade High grade S. Bilirubin < 1 mg % 1-2 mg % >2mg% S. Albumin >3.5 gm% 2.8 –3.5 <2.8 Pro. Time <3 Sec 4-6 Sec >6 sec Childs A -5,6, B - 7-9, C>9 Score
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- 23. Portal Hypertension Cirrhotic • Coagulopathy •Altered LFT, Albumin • Ascites • Bleed • Encephalopathy • Renal failure • Liver tumour(HCC) • Limited survival without Transplant Non cirrhotic (EHPVO, NCPF) • Normal coagulation • Normal LFT, Albumin • Bleed • Shunt surgery
- 24. Management of VaricealBleed Endoscopic (Sclerotherapy, Band, Glue) + Medical (Somatostatin, Octreotide, Terlipressin)
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- 26. Endoscopic Sclerotherapy (EST) •Agents – Polidocanol, Absolute Alcohol • Methods – Intra / Paravariceal • Mechanism – fibrosis of connective tissue
- 27. Endoscopic Glue Injection •Cyanoacrylate glue (Histoacryl) • Mainly used for gastric variceal bleed • Mech. of action – obliteration of varix • Hazardous to eyes & endoscopes
- 28. Surgical shunts incirrhosis results in high morbidity..
- 29. Esophageal & GastricDevascularization
- 30. Transjuglar intrahepatic Portosystemic stentshunt (TIPSS) • Percutaneous transjugular technique • Tract between hepatic vein & Portal vein created & expandable stent - 8 Fr placed. • Indication-Temporary control of bleed in poor risk cirrhotic patient waiting for liver transplant • Problems –Expertise, cost, complications, thrombosis
- 31. TIPSS (Transjugular Intrahepatic Portosystemicstent shunt)
- 32. MELD (Model forEnd stage liver disease) (9.57 x loge creatinine mg/dl + 3.78 x loge bilirubin mg/dl + 11.20 x loge INR + 6.43) • Range : 6-40 • Candidate for liver transplant: >14
- 33. Liver transplant • Definitivetreatment for end stage liver disease • MELD score >14 • Two types of donors – Diseased donors (Brain dead) – Living related donors • Blood group matching is required • 5 year survival – 75-80 %
- 34. Splenectomy & Spleno-RenalShunt • One time treatment • For EHPVO & NCPF • Emergency or elective • Effective in bleed control • Relieves hypersplenism • Low post-operative morbidity
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- 36. Take Home Message •Variceal bleed is the most common symptom of PHTN • Cirrhosis - most common cause of PHTN • Endoscopic management is successful in >90% cases • Surgical devascularization or TIPSS in cirrhotics • Stage 3,4,5 cirrhosis – Liver transplant • EHPVO & NCPF – Easily treated with shunt surgery