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This presentation is made by Dr Ashok Jaisingani
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Portal Hypertension Dr. Ashok Jaisingani
The hepatic portal circulation carries blood from GI tract (i.e. from the distil esophagus to anorectal junction) to the liver.
Porto – systemic anastomosis occurs in junctional areas of venous drainage.
Portal venous blood drain into liver venous sinusoids and hence in to the hepatic veins.
Introduction
Portal hypertension develop when there is elevation of portal pressure is greater than 12 mmHg, while normal portal pressure is 5 – 10mmHg.
As portal hypertension produce no symptoms it is usually diagnosed following presentation with decompensated chronic liver disease encephalopathy, ascites or variceal bleeding.
Portal Hypertension
Pre – Hepatic: 1- Congenital portal atresia 2- Portal vein thrombosis (Neonatal sepsis) 3- Phlebitis of portal vein (abdominal infection) 4- Trauma or thrombosed porto – caval shunt.
Hepatic: 1- Cirrhosis (alcoholic most frequently) 2- Chronic Active hepatitis 3- Parasitic diseases (Schiatosomiasis)
Post – Hepatic: 1- Budd – Chiari syndrome (Hepatic venous thrombosis) 2- Constrictive pericarditis 3- Tricuspid valve incompetence
Causes Of Portal Hypertension
Decrease or reverse portal blood flow to the liver promote the development of the portosystemic anastomosis between the portal system and systemic circulation.
1- Left gastric vein into the esophageal veins at gastro-esophageal junction – esophageal and gastric varices.
2- Superior rectal vein into inferior rectal vein at lower rectum rectal varices.
3- Obliterated umbilical vein into epigastric vein – capute medusae.
Esophageal and gastric varices may bleed torrentially Liver cell dysfunction/liver failure occurs in hepatic and post
– hepatic causes Splenomegaly (hypersplenism may be result) The child – pug classification use to asses the severity.
Features & Complication
Conditions Point – 1 Point – 2 Point - 3
Bilirubin (µmol/L)
<34 34 – 51 >51
Albumin (g/L) >35 28 – 35 <28
PT (sec) <3 3 – 10 >10
Ascites None Moderate Moderate – severe
Encephalopathy None Moderate Moderate – severe
Child – Pug Classification Of Portal Hypertension
Many investigations may be used at different time in portal hypertension such as
1- FBC, Urea & electrolytes and clotting 2- Screening tests for the causes of the
cirrhosis 3- CT & ultrasound scan to assess liver
morphology, diagnose Portal hypertension and assess cause.
4- Transabdominal Doppler ultrasound to assess blood flow in the portal vein and hepatic artery.
Gastroscopy in acute variceal bleeding
Diagnosis & Investigation
General resuscitation Anti – coagulation for Budd – Chiari syndrome Treatment of hepatic cause Treatment Of Chronic Complication such as Esophageal
gastric varices: 1- Beta – blocker (propranolol or nadolol), reduce portal venous
pressure. 2- Repeated injection sclerotherapy or variceal ligation 3- Elective porto – systemic shunt (spleno – renal anastomosis) 4- Liver transplant may be considered for treatment if associated
with severe liver diseases. Rectal Varices: Injection sclerotherapy Symptomatic splenomegaly: laparoscopic or open splenectomy. Ascites: Oral spironolactone, in cases of ascites, paracentesis
may be required with IV albumin replacement.
Treatment
Hemorrhage from the varices is acute complication of the portal hypertension.
Mortality rate of first variceal bleed established portal hypertension is 30%.
Causes & Features: Typical variceal bleeding is rapid in onset,
copious dark blood with little mixing with food. Feature of established portal hypertension e.g.
capute medusae Feature of developing hepatic encephalopathy
(ingested blood provide an extremely rich meal)
Acute Variceal Hemorrhage
Established large caliber IV access, give crystalloid fluid up to 1000 mL, if tachycardic or hypotensive.
Only use O - ve blood if the patient is in extremis, otherwise wait for cross – match blood.
Catheterize and place on fluid balance chart if hypotensive. Send blood for FBC, HB conc. WCC, U&E, Na, K, LFT, albumin
and clotting. Always consider HDU, variceal bleeding can deteriorate
extremely rapidly. Monitor pulse rate, BP and urinary output. Insertion Of sangstaken Blackmore gastro-esophageal tube
may be a life saving resuscitation manure, usually only inserted without prior gastroscopy if the patient known to have varices and has life – threatening bleeding.
Emergency management (Resuscitation)
Blood transfusion Correct coagulopathy Esophageal balloon tamponade (sangstaken
Blackmore tube) Drug therapy (vasopressin or octreotide) Endoscopic sclerotherapy or banding Assess portal vein patency (Doppler ultrasound or CT) Transjuglar intrahepatic portosystemic stent shunt Surgery: Portosystemic shunts Esophageal transection Splenectomy and gastric devescularization.
Management
Recommended