This document discusses portal hypertension and its management. It defines portal hypertension as increased portal pressure and describes how hepatic venous pressure gradient (HVPG) is used to measure it noninvasively. The main causes of portal hypertension are discussed as pre-hepatic, intra-hepatic, and post-hepatic. Clinical features include gastroesophageal varices, ascites, and splenomegaly. Management involves screening and treatment of varices, diuretics for ascites, and splenectomy in rare cases. Transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunts are considered if medication fails or is not available.
A presentation on the pathology and current management (with Especial emphasis on surgical management) of Portal Hypertension; a common complication of liver cirrhosis among other liver diseases. Being a copy of seminar presentation I for the HepatoPancreaticoBiliary Unit of the Division of General Surgery, Ahmadu Belllo University Teaching Hospital, Zaria.
A presentation on the pathology and current management (with Especial emphasis on surgical management) of Portal Hypertension; a common complication of liver cirrhosis among other liver diseases. Being a copy of seminar presentation I for the HepatoPancreaticoBiliary Unit of the Division of General Surgery, Ahmadu Belllo University Teaching Hospital, Zaria.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Surgery Resident clinical seminar on the management of a 60yr old male with upper gastrointestinal bleeding presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Surgery Resident clinical seminar on the management of a 60yr old male with upper gastrointestinal bleeding presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
This slide mainly based on complication of liver transplant and their interventional management and also renal(kidney) transplantation ad their complication and their intervention management. Good short review for radiologist
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
4. PATHOLOGY
• Pressure gradient is due to ↑
resistance to blood flow in
➢Pre-sinusoidal
➢Sinusoidal
➢Post-sinusoidal circulation
• (Rarely portal flow ↑ without
resistance eg. Splanchnic AV fistula)
5. Portal Hypertension
PRE-HEPATIC INTRA-HEPATIC POST- HEPATIC
- Thrombosis of PV,SV -Cirrhosis -Constrictive pericarditis
(Umblical Vein Catheterization) - Schistosomiasis -Budd chiari syndrome
- Invasion by malig. Tm. -Congenital Hepatic -IVC web
- Extrinsic press. by L.N. Fibrosis
or other mass
6. PREHEPATIC
• Accounts for 5-10%
• Incidence may be high in India
• Sometimes splenic vein thrombosis is seen with normal PV
- Acute pancreatitis
- Ca body and tail of pancreas
-Presents only with splenomegaly
-Tackled by splenectomy
7. INTRA-HEPATIC
• Accounts for 90%
• Cirrhosis- Alcoholic and Hepatitis C
Hepatic vascular resistance in hepatic sinusoids is due to
fibrosis, scarring and distribution of microvasculature &
Dysregulation of contractile elements including hepatic
myofibroblast.
• Schistosomiasis- seen in middle and Far East and South Africa.
8. POST -HEPATIC
• Accounts for 1-2%
• Outflow block leads to
-Increased sinusoidal pressure
- Centrilobular hepatocyte injury
- Fibrosis, scarring and cirrhosis
9. • Portal vein - lies behind neck of pancreas, formed by joining of
SMV and splenic vein.
• Divide into Rt. and Lt. branches (tributary).
• Feeding tributaries of SMV/SV/PV may have some variations.
10. IMPORTANT VENOUS ANATOMY ( VARIX)
4 Zones identified
➢ Gastric Zone – 2-3 cm below GE Jn.
Veins run longitudinally
➢ Palisade Zone – 2 – 3 cm above Gastric Zone
Parallel palisade run longitudinally & Correspond to
oesophageal mucosal folds
➢ Perforating Zone – 2-3 cm superior to palisade zone
Veins perforate oesophageal wall linking external to
internal veins
➢ Truncal Zone – Extends 8 – 10 cm up the oesophagus, having 4 – 5
longitudinal veins
Irregular perforating veins from submucosa to external
oesophageal plexus
11. CLINICAL FEATURES OF PORTAL HYPERTENSION
• Portal hypertension presents with mainly 3
primary complications
1. Gastro-esophageal Varices with or without
bleed
2. Ascites
3. Splenomegaly and Hypersplenism
12. OESOPHAGEAL VARICES
• 1/3rd cases of portal hypertension will have it
• 1/3rd cases of varices will eventually bleed
❖Predictors of risk of bleeding:
➢ Severe cirrhosis ( Child-Pugh criteria & MELD score )
➢Height of hepatic venous pressure
➢Size of varices
➢Location of varices
➢Tense ascites
Contd…..
13. Endoscopic stigmata
➢Red wale sign
➢Hematocystic spot
➢Diffuse erythema
➢Bluish discoloration
➢Cherry red spots
➢White nipple spots Cherry red spots Hematocystic spot Red wale sign
14. ASCITES
• Late sign of portal hypertension
• Diagnosed by physical examination and paracentesis
• Serum Ascites albumin gradient (SAAG) – Replaced exudate/transudate concept
• If gradient (serum albumin:ascitic fluid albumin is > 1.1 g/dL - Portal hypertension
• If gradient (serum albumin:ascitic fluid albumin is < 1.1 g/dL - Malignant/Infectious
➢Small amount – Restrict salts
➢Moderate amount – Add diuretics
➢Refractory – Repeated large volume paracentesis & TIPS ( Increased
Encephalopathy)
• <50 % survive 2 years after onset of ascites .
• So, Consider Liver transplantation at onset of ascites
15. SPLENOMEGALY & HYPERSPLENISM
• Thrombocytopenia – diagnostic of portal hypertension
• Leukopenia
• Splenectomy is treatment under very special circumstances
16. OTHER UNCOMMON PRESENTATIONS
• LIVER FAILURE & ENCEPHALOCEPATHY Due to progressive underlying liver disease
• HEPATOCELLULAR CARCINOMA
➢High prevalence of hepatitis C in cirrhosis
➢Transplantation in carefully selected patients who are otherwise NOT candidates for resection
• HEPATO PORTO PULMONARY SYNDROME – a triad of
➢Liver disease
➢Arterial hypoxemia
➢Intrapulmonary vascular dilatation
Medical treatment has limited success
Transplantation specially in Paediatric patients
17. WORK UP
Multidisciplinary approach
• Diagnostic and prognostic priorities vary for each patient depending on
➢Etiology
➢Presentation
➢Severity of disease
• But essential component of work up are :-
a. Endoscopy
b. Imaging
c. Liver function
18. ENDOSCOPY
➢Done for finding out
• Size of varices
• Extent of varices
• Risk factors of bleeding
• Portal gastropathy ( Changes in mucosa
of stomach like friability and presence of
ectatic blood vessels at the surface) Endoscopic view of Portal Gastropathy
19. IMAGING
• Doppler Ultrasound 1. Size & flow through PV & tributaries
2. Define morphology in Cirrhosis
• CT for Morphological assessment of liver parenchyma & liver tumour
• HVPG Transhepatic/Transvenous catheterization of Hepatic veins ( Gold
standard in diagnosis of PH) & measure Wedge hepatic venous
pressure(WHVP) and Free hepatic venous pressure(FHVP) .
WHVP-FHVP = HVPG ( reducing it to <10 mm Hg will reduce risk of variceal bleeding )
• Angiography – CT /MR angiography to evaluate arterial & venous flow of liver
( replaced the need of variceal angiography)
20. ASSESSMENT OF LIVER FUNCTIONS
Done by several ways
1. Clinical
2. Lab data
3. Child-Pugh criteria
4. MELD Score
There is a scoring system for Oesophageal varices and Portal Gastropathy
21. 1. CLINICAL ASSESSMENT OF LIVER FUNCTIONS
Presence of
• Ascites
• Encephalopathy
• Clinical Jaundice
• Muscle wasting
Indicate impairment of liver functions and actually advanced liver disease
22. 2. LAB DATA FOR ASSESSMENT OF LIVER FUNCTIONS
a. Serum Bilirubin
❑ Serum Albumin
❑ Prothrombin Time
❑ SGOT/SGPT
❑ Serum Alkaline phosphate
b. Haematological parameters
❑ Haemoglobin
❑ Platelet Count - <1 lakh indicate significant Portal Hypertension
❑ White blood cell count
c. PT:INR ratio of 1:5 indicate poor liver function
contd…..
23. LAB DATA FOR ASSESSMENT OF LIVER FUNCTIONS
d. Specific Liver disease markers ( Hepatic panel )
❑ Antinuclear antibody
❑ Antimitochondrial antibody
e. Metabolic markers
❑ Iron
❑ Copper
❑ Alfa 1 antitrypsin
f. Risk of hepatoma by screening through
❑ estimation of Alfa fetoprotein
24. 3. CHILD –PUGH SCORE FOR SEVERITY OF LIVER DISEASE
Parameter Score 1 Score 2 Score 3
Encephalopathy None 1 or 2 3 or more
Ascites None Mild Moderate
Bilirubin(mg/dL) 1 - 2 2.1 - 3 Equal to or >3.1
Albumin(g/dL) Equal to or >3.5 2.8 – 3.5 Equal to or <2.7
PT increase (in seconds) 1 - 4 4.1 - 6 Equal to or > 6.1
25. SCORING SYSTEM FOR SEVERITY OF LIVER DISEASE
# CHILD – PUGH SCORE
> Grade A severity = 5 – 6 points
> Grade B severity = 7 – 9 points
> Grade C severity = 10 – 15 points
# MELD SCORE (Model for End stage Liver disease )
Score = 0.957x log e Creatinine(mg/dL) + 0.378 x log e Bilirubin ( mg/dL)+1.20 log e INR
@ MELD Score 19 = Refer for liver transplantation evaluation
@ MELD Score 12 = Initiate prophylaxis for Spontaneous bacterial peritonitis
@ MELD Score 10 = Continue follow up and Repeat MELD at 1 month
@ MELD Score 8 = Continue follow up and Repeat MELD at 3 months
MELD routinely used in patients awaiting Transplantation.
26. MANAGEMENT
Clinical reality- Address advanced stage complications of PH
1. Prophylaxis for oesophageal varices
2. Management of acutely bleeding varices/Prevention of re-bleed
3. Management of Ascites
4. Management of Splenomegaly /Hypersplenism
27. OESOPHAGEAL VARICES
Past century – seen a shift in treatment paradigm From Expectant treatment to
➢ Screening
➢ Pharmacologic treatment
➢ Endoscopic prophylaxis
All patients with signs/symptoms of Cirrhosis are screened for
➢ Oesophageal varices at the time of diagnosis
➢ Every 2 – 3 years thereafter
➢ Every year if progresses to Child B or beyond
28. OESOPHAGEAL VARICES
• Small Varices – No intervention
• Moderate to large varices ( 5 – 10 mm ) Prophylactic pharmacological intervention
• Presence of risk factors of bleeding
• Child C Score Non selective β blockers
Non responders –Carvedilol ( α1 receptor
blocker besides being nonselective β blocker)
-PLUS EVL
30. MANAGEMENT OF ACUTE BLEED
Mortality of acute bleeding 15 – 20%
➢ Splanchnic vasoconstrictors e.g. Somatostatin / Octreotide ( Vasopressin almost
obsolete ), followed by
➢ Endoscopy therapy ( mostly variceal band ligation: Sclerotherapy not the choice of
Gastroenterologist now)
➢ If Endoscopic treatment not available- SENGSTAKEN – BLACKMORE TUBE
➢ If varices extend into proximal stomach , endoscopic therapy fails
➢ Consider TIPS ( Expandable metallic stent to create P-S shunt)
➢ If TIPS is also not available, Surgical oesophageal transection – Rarely used as the
outcome very poor
31. RECENT BLEED
• Repeated variceal ligation until all varices are obliterated
• Beta blockers as adjunct and stop after all varices obliterated
• Take all supportive measures for achieving
Hemoglobin – 8 g/dL
Hematocrritt – 24 %
• EVL- came in 1988 and virtually replaced sclerotherapy
- Complete obliteration of varices achieved in fewer
sessions than sclerotherapy
- Each session of EVL interspaced by 7 – 10 days
32. IF ENDOSCOPIC TREATMENT NOT AVAILABLE
SENGSTAKEN – BLACKMORE TUBE
❖ Principle: BALLOON TEMPONADE
➢Gastric Balloon – 200 ml
➢Oesophageal Balloon – 40 mm Hg
➢After control of bleeding with Balloon – it is mandatory to decompress
varices within 24 hours
33.
34. IF VARICES EXTEND INTO PROXIMAL STOMACH , ENDOSCOPIC THERAPY FAILS
THEN, RESORT TO BALLOON OCCLUDED OBLITERATION OF VEINS
• Gastric varices often associated with
➢Compensatory gastro-renal and Gastro-caval shunts which are
less amenable to portal decompression
• Such cases managed by Balloon occluded obliteration of veins.
• 2 techniques
➢BRTO ( Balloon occluded retrograde obliteration )
➢BATO ( Balloon occluded antegrade obliteration )
depending upon vascular anatomy of problematic varices
• Balloon catheter can be introduced via femoral vein or IJV approach
36. TRANS JUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT(TIPS)
• EVALUATE PATIENTS FOR
✓ Cardio-pulmonary function
✓ Portal vein patency
✓ Liver functions
contd…
37. TIPS ( IMPORTANT STEPS)
• Trans jugular, to
• Right or Middle hepatic vein, to
• Substance of liver traversed and needle punctures portal vein
• Catheter placed over guide wire into vein
• Pressure taken and portogram done
• Trans parenchymal tract dilated and stent placed
• Stent dilated to bring pressure gradient to < 10 mm Hg
• Success rate 95%
• 1 Year patency rate 90%
39. TIPS ( INDICATIONS)
• Indications
➢Failed endoscopic treatment
➢Failed medical treatment
➢Poor surgical risk
➢Bridge to transplantation
40. TIPS ( CONTRA-INDICATIONS)
ABSOLUTE RELATIVE
Primary prevention of variceal bleeding Hepatoma, particularly if central
Severe congestive heart failure Obstruction of all hepatic veins
Tricuspid regurgitation Hepatic encephalopathy
Multiple hepatic cysts Significant portal vein thrombosis
Uncontrolled systemic infection or sepsis Severe uncorrectable coagulopathy (INR > 5)
Unrelieved biliary obstruction Thrombocytopenia (< 20,000 platelets/mm3)
Severe pulmonary hypertension Moderate pulmonary hypertension
Contraindications to placement of a TIPS
41. SURGICAL SHUNTS
• Porta-systemic shunts viable option for;
➢Patient optimum for methods but the facilities not available
➢Long term bridge to transplantation in carefully selected patients
➢3 types of shunts
• Total
• Partial
• Selective
42. SURGICAL SHUNTS
➢Total shunts
➢ Complete/Near total diversion of portal flow to IVC via
1. Porto caval shunt
2. Mesenterico-caval shunt
3. Proximal Spleno-renal shunt
➢Partial shunts
• Small diameter shunt e.g. H shunt or graft shunt
• Maintain some flow to liver
• Thrombosis is a problem
H Shunt or graft shunt
43. SURGICAL SHUNTS
• Selective shunts
➢Distal Spleno-renal shunt (DSR)
➢Currently used commonly
➢Selectively decompresses oesophageal
varices
➢While maintaining portal flow and pressure
➢Success rate – 85% ( Child A) & 75% ( Child
B )
44. DISTAL SPLENO –RENAL SHUNT(DSR)
➢Explore left renal vein and Splenic vein
➢Splenic vein isolated & divided near Spleno-SMV
junction
➢Brought down and anastomosed end to side
with left renal vein
➢Complete operation by interrupting left gastric
vein both at portal vein and above pancreas
45. OESOPHAGEAL DEVASCULARIZATION
SIGUIRA’S PROCEDURE
❑ 2 stage procedure of Esophago-gastric devascularization + sutured
anastomosis with Splenectomy, vagotomy & pyloroplasty
MODIFIED SIGUIRA’S PROCEDURE
❑ 1 stage procedure of oesophageal devascularization with stapled
anastomosis without vagotomy and pyloroplasty