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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.
By the end of the module, you will be able to:
Define Arterio Venous Fistula and Arterio Venous Graft
Identify Complications and Management
Familiarise and use the Pre Needling Cannulation Tool
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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.
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
6.
7. Two important factors exist in
the pathophysiology of portal
hypertension
vascular resistance .
blood flow.
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
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.
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.
27.
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
29.
30.
31.
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.
33.
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.
