This document provides information on portal hypertension, including its definition, causes, presentations, investigations, and management. Some key points:
- Portal hypertension is defined as a sustained elevation of portal pressure above 12 mm Hg. It can be caused by conditions affecting blood flow pre-sinusoidally (e.g. portal vein thrombosis), sinusoidally (e.g. cirrhosis), or post-sinusoidally (e.g. Budd-Chiari syndrome).
- Common presentations include esophageal varices, splenomegaly, ascites, and features of hepatic encephalopathy. Investigations include liver function tests, ultrasound, and endoscopy to identify varices.
-
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
Pyelonephritis
It is the inflammation of the kidney & upper urinary tract that usually results from the bacterial infection of the bladder.
Pyelonephritis can be classified in several different catagories:
-acute pyelonephritis
-chronic pyelonephritis
-xanthogranulomatous pyelonephritis
Brief explanation of each *refer harrison textbook for details causes of TIN
Acute interstitial nephritis
Chronic interstitial nephritis
Reflux nephropathy
Papillary necrosis
Sickle-cell nephropathy
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
Pyelonephritis
It is the inflammation of the kidney & upper urinary tract that usually results from the bacterial infection of the bladder.
Pyelonephritis can be classified in several different catagories:
-acute pyelonephritis
-chronic pyelonephritis
-xanthogranulomatous pyelonephritis
Brief explanation of each *refer harrison textbook for details causes of TIN
Acute interstitial nephritis
Chronic interstitial nephritis
Reflux nephropathy
Papillary necrosis
Sickle-cell nephropathy
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
2. PORTAL HYPERTENSION
• Defi nition: Sustained elevation of portal pressure more than
• 12 mm Hg (normal 8-12 mmHg)
• Left sided portal hypertension (sinistral) can be caused by
isolated splenic vein thrombosis, which is often caused by
adjacent pancreatitis.
• A rise in portal pressure stimulates portasystemic circulation.
• Portal vein carries 75% of blood flow to liver with all nutrients
to maintain its integrity and gives 50% oxygen supply
to liver. 25% hepatic arterial blood flow gives remaining
50% of oxygen supply to liver.
3. • Portal hypertension causes compensatory
portosystemic venous collateral formation,
altered intrahepatic circulation and increased
splanchnic blood flow. High pressure portal
blood is diverted via coronary (left gastric vein),
short gastric and esophageal veins into azygos
venous system.
• There is increased portal resistance and altered
portal blood flow. Increased resistance may be
presinusoidal, sinusoidal and postsinusoidal.
5. • 30% of varices patients will bleed; 30% of
them will die of bleed; 30% of patients with
cirrhosis will develop portal hypertension;
30% of them have variceal bleed in 2 years.
• 70% of patients who had bleeding once, will
rebleed later.
• Variceal bleed accounts for 7% of upper GI
bleed.
6. Sites of Portosystemic
Collateralisation
1. Lower end of oesophagus :-between left gastric
and short gastric veins with azygos vein resulting
in oesophageal varices—commonest
2. Umbilicus:- between paraumbilical vein and
anterior abdominal vein resulting in caput
medusae.
3. Lower end of rectum:-between superior haemor
rhoidal vein and inferior, middle haemorrhoidal
vein resulting in piles.
4. Retroperitoneum (vein of Retzius).
5. Bare area of the liver.
9. Presentations
• Triad of portal hypertension
i. Oesophageal varices.
ii. Splenomegaly.
iii. Ascites.
• Jaundice.
• Features of encephalopathy.
• Coagulopathy.
• Hepatorenal syndrome.
10. Investigations
• Liver function tests.
• Ultrasound.
• Alfa-feto protein.
• CT/MRI to look for cause
• MELD scoring is Model for End-stage Liver Disease
• Doppler imaging to see vascular pattern :-direction of blood flow,
size of the vein.
• Hepatic venous pressure gradient (HVPG): It is done using a balloon
catheter. Difference between free hepatic vein pressure and
wedged hepatic vein pressure is HVPG. Normal HVPG is 8 mm Hg. It
is more than 10 mm Hg in cirrhosis.
• GI scopy—to identify varices.
• Liver biopsy(confirm the cause for the portal hypertension)
• Endosonography.
11. Management of Portal Hypertension
• General measures:
– Anaemia to be corrected.
– Nutrition supplementation.
– Inj. vitamin K—10 mg IM for 5 days.
• Specific measures:
– Treatment of oesophageal varices.
– Prevention of hepatic encephalopathy.
– Treatment of ascites.
• Measures to reduce portal pressure:
– Surgeries—Portosystemic shunt.
Nonselective.
Selective.
– TIPSS.
– Drugs to reduce the portal pressure like pro pranolol, nadolol,
isosorbide-5-mono nitrate.
• Liver transplantation.
12. OESOPHAGEAL VARICES
• May be asymptomatic.
• May present with haematemesis or melaena or as
recurrent bleeding. Varices begin to bleed when
portal pressure exceeds 12 mmHg.
• When present with severe haematemesis, patient
shows features of shock.
• Mortality in bleeding varices is 25-30%.
• Factors related to variceal bleed are—portal venous
pressure; gastro-oesophageal reflux causing
ulceration; variceal size; variceal wall tension.
13. Types of Varices
1. Oesophageal which is in the lower 1/3rd of the
oesophagus,usually 3 or more in number, graded as I, II,
III, IV (based on gastroscopic findings) (80%).
2. Gastric which is fundal or in upper part of the stomach
– A. Extension of oesophageal varices
• I. Into lesser curve
• II. Into fundus
– B. Isolated gastric varices
• I. In fundus common
• II. In other parts—stomach, duodenum—rare
• Gastric varices are treated by endoscopic N butyl
cyanacrylate glueing, sclerotherapy. Banding is usually
not done.
14. Grading of varices
I. Minimal varices without luminal prolapse
II. Moderate varices, with luminal prolapse and
with minimal obscuring of O-G junction
III. Large varices, with luminal prolapse and with
moderate obscuring of O-G junction
IV. Very large varices, with luminal prolapse and
with complete obscuring of O-G junction
15. Treatment of Oesophageal Varices
• PRIOR TO BLEED
– Drugs—propranolol (reduces the portal pressure by
20% with pulse rate below 55/minute or 25% of
resting pulse); nadolol (long acting, less lipophilic, not
metabolised by liver); isosorbide mononitrate. Drugs
reduce bleeding by 40%.
– Endotherapy.
• AFTER ONE OR MORE EPISODE OF BLEEDING.
– Endotherapy.
– Shunt surgeries.
– Drugs.
16. EMERGENCY MANAGEMENT IN SEVERE
HAEMORRHAGE
Initial important measures
– Volume and electrolyte corrections; volume replacement using crystalloids with central line (CVP line
placement with CVP maintained at 5 cm of water, sudden overload should be avoided which may precipitate
pulmonary oedema/ascites/hyponatraemia)
– Blood and blood products transfusion
– Antibiotics, nutrition (TPN)/Vitamin K injection
– – Catheterisation and hourly urine output monitoring
– – Prevention of encephalopathy
– – Rest/sedation only if needed with care
• Pharmacotherapy
– Inj. Vasopressin (constricts the splanchnic vessels thus lowers the portal pressure)
– Somatostatin (reduces the splanchnic and hepatic blood fl ow.)
– Propranolol (decreases the portal pressure)
– Ranitidine(Acid inhibiting drugs)
– tranexamic acid(antifi brinolysins )
• Endoscopic banding/sclerotherapy (Banding/band ligation has become gold standard and ideal for
oesophageal varices.) glue therapy(Butyl cyanoacrylate :-tissue adhesive)
• Balloon tamponade(If bleeding does not stop by banding/sclerotherapy/gluing, balloon
tamponade should be tried)
• TIPSS
• Devascularisation surgical procedures
17. DEFINITIVE MANAGEMENT OF
VARICES
• Sclerotherapy
• Shunt surgery (Shunt surgeries should not be
done if the varices have not bleed before.)
• Splenectomy(Left sided portal hypertension
also called as segmental portal hypertension is
due to splenic vein thrombosis)
• TIPSS (Transjugular Intrahepatic
portosystemic Stenting / Shunt)
18.
19. PORTAL HYPERTENSIVE
GASTROPATHY
• Portal hypertension causes vascular dilatation and ectasia
in the stomach which appears pink, speckled, with red
mosaic pattern in the gastric mucosa. It occasionally causes
upper GI bleed
• Endoscopy is diagnostic.
• Portal gastropathy is more common in cirrhotic patients.
• Commonly presents with chronic bleed causing anaemia;
bu acute bleed with haematemesis and melaena also can
occur.
• Treatment is mainly to reduce the portal pressure using
• propranolol.
20. ASCITES
• It is pathological collection of fl uid in the
peritoneal cavity.
• Ascites is the most common complication of
cirrhosis.
• It is a poor prognostic factor.
• Portal hypertension, renin angiotensin
aldosterone pathway causing renal sodium
retention, increased hydrostatic pressure in
hepatic sinusoids and splanchnic vessels cause
ascites.
21. Types of ascites
• Mild — Up to 150 ml amount required to demonstrate radiologically
• Moderate — 1500-2000 ml causes clinical dullness in flanks.
• Severe — > 2000 ml.
Classification of ascites
– Transudate (Protein < 2.5 gm/ dl).
• CCF—Commonest (SAAG > 1.1).
• Hypoproteinaemia.
• Anaemia.
• Nephrotic syndrome.
• Portal hypertension.
– Exudate (Protein > 2.5 gm/dl) (SAAG < 1.1).
• Peritoneal diseases.
– Tuberculosis.
– Neoplasm.
• Collagen disorder.
22. ASCITES IN PORTAL HYPERTENSION
CAUSES
• Hypoproteinaemia.
• Increased hydrostatic pressure.
• Decreased colloidal osmotic pressure.
• Lymphatic blockage.
• Altered aldosterone mechanism.
Treatment
• Medical—spironolactone, salt restriction
• Abdominal paracentesis(below the umbilicus, lateral to the rectus
muscle. Bladder should be empty before tapping. Slow gradual
tapping is important, otherwise patient goes in for fluid and
electrolyte imbalance.)
• TIPS as a bridge to liver transplant
• Liver transplantation