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PORTAL HYPERTENSION

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					PORTAL HYPERTENSION
   Dr. ADEFEMI O. AFOLABI
 HEPATOBILIARY & ENDOCRINE
           DIVISION
  DEPARTMENT OF SURGERY
    COLLEGE OF MEDICINE
    UNIVERSITY OF IBADAN
              &
UNVERSITY COLLEGE HOSPITAL,
       IBADAN, NIGERIA.
       INTRODUCTION
• HYPERTENSION WITHIN THE PORTAL VEIN &
  ITS TRIBUTARIES
• ACCOMPANY HEPATIC DISEASE
• DISTURBANCE- EXTRAHEPATIC VASCULAR
  SYSTEM
• CONGESTION OF COLLATERALS
• MANIFESTATIONS:
   OESOPHAGOGASTRIC VARICES,
   ASCITES,
   HYPERSPLENISM,
   ENCEPHALOPATHY
AETIOLOGICAL FACTORS
• INCREASED HEPATOPETAL FLOW
  WITHOUT OBSTRUCTION
• EXTRAHEPATIC OUTFLOW
  OBSTRUCTION
• EXTRAHEPATIC PORTAL VENOUS
  OBSTRUCTION
• INTRAHEPATIC OBSTRUCTION-
  >90% OF CAUSES
   PATHOPHYSIOLOGY
• NOMAL PRESSURE- <250mm H2O
  (MEAN- 215)
• MEASUREMENT-
   OMENTAL/PORTAL V. CANNULA
   SPLENIC PULP MANOMETRY
 *SPLENOPORTOGRAPHY
 *UMBILICAL VENOGRAPHY
 PATHOLOGIC ANATOMY
• FUNCTIONAL COLLATERALS-
 2 GROUPS-
  *HEPATOPETAL FLOW-
    HEPATOCOLIC, HEPATORENAL,
    EPIPLOIC, DIAPHRAGM Vv
  *HEPATOFUGAL FLOW-
    CORONARY, SUPERIOR
    HAEMORRHOIDAL, UMBILICAL,
    RETROPERITONEAL Vv
   OESOPHAGOGASTRIC
        VARICES
• DILATED, ENGORGED VEINS IN
  THE SUBMUCOSAL PLEXUS-
  OESH., CARDIA, FUNDUS, LESS
  CURV., DUOD., ILEUM
• RUPTURE & BLEEDING
  ALARMING
• INTRAHEPATIC DX IN >90%
• EXTRAHEPATIC IN CHILDREN
NATURAL COURSE OF ‘OGV’
• WHO BLEEDS? 30% OF
  CIRRHOTICS WITH VARICES
• TIME BTW DIAG. & BLEED-
  1-187/52- WITHIN 2 YEARS
• EXTRAHEP. LOW MORTALITY
• CIRRHOTIC VARICES-HIGH MORT.
• 60% CIRRHOTIC REBLEED <IYR
• PROPHYLACTIC RX UNHELPFUL
  EXCEPT CHILD A & B
    ACUTE BLEEDING
• USU IST MANIFESTATION IN
  CHILDREN
• 70% BEFORE 7, 90% BEFORE 10
• ADULT-25-33% OF MASSIVE ‘UGH’
• IN CIRRHOTICS,
    VARICES- 50%
    GASTRITIS- 30%
    DUODENAL ULCERS- 9%
        ACUTE BLEEDING-
           DIAGNOSIS
•   STIGMATA OF CIRRHOSIS
•   SPLENOMEGALY- SUGGESTIVE
•   LIVER FUNCTION TEST- UNRELIABLE
•   BARIUM SWALLOW- HIGH FALSE NEG.
•   COELIAC SMA ANGIOGRAPHY
•   OESOPHAGEAL BALLOON TAMPONADE
•   OESOPHAGOSCOPY- MOST RELIABLE
    MAY MISS VARICES- OBSERVER
    VARIATION
    ACUTE BLEEDING-
  TREATMENT(CONTROL)
• NON-OPERATIVE
  DIRECT CONTROL-TAMPONADE
  INDIRECT-REDUCE PRESSURE-
    DRUGS, TIPSS
• OPERATIVE
   DIRECT CONTROL-
     DEVASC.,LIGATION, GE RESECTION
   INDIRECT- PORTO-SYSTEMIC
     SHUNT
      PREVENTION OF
   RECURRENT BLEEDING
• SCLEROTHERAPY +/- SOMATOSTATIN
• SURGERY ESPECIALLY IN CHILDREN
• PRESINUSOIDAL- GOOD OUTCOME OF
  SURGERY
• POSTSINUSOIDAL- POOR POSTOP
  OUTCOME
• 2-YR SURVIVAL SAME- SHUNT v
  SCLEROTHERAPY
• END STAGE LIVER DX- TIPSS/SCLERX,
  THEN TRANSPLANT
        ASCITES-
    PATHOPHYSIOLOGY
• COMPLEX & INCOMPLETELY
  UNDERSTOOD
• PORTAL HT-MINOR FACTOR
• LYMPHATIC, ARTERIAL, VENOUS
• HYPOALBUMINAEMIA
• SODIUM & WATER RETENTION-
  INCREASED URINARY A.D.H. IN
  CIRRHOTICS WHO HAVE ASCITES
  ASCITES- TREATMENT
• REST
• DIET-HIGH CHO, PROTEIN, VITAMIN,
       K+ SUPPL., LOW Na+
• DIURETICS- ALDACTONE,
             CHLORTHIAZIDE & K+
• PARACENTESIS
• PORTOCAVAL SHUNT (S-S)
• PERITONEOVENOUS SHUNT-DENVER,
  LEVEEN
     HYPERSPLENISM
• SPLENOMEGALY# PORTAL
  HYPERTENSION
• WBC<4000/cmm,
  PLATELET<100,000/cmm
• SPLENECTOMY RARELY
  INDICATED
• PORTOCAVAL & DISTAL
  SPLENORENAL SHUNT CORRECT
  HYPERSPLENISM IN 2/3 OF CASES
ENCEPHALOPATHY & COMA
• PORTO-SYSTEMIC ENCEPHALOPATHY
   - A NEUROPSYCHIATRIC SYNDROME
• ASSOCOCIATED WITH CIRRHOSIS &
  HEPATIC DYSFUNCTION
• RARE IN EXTRAHEPATIC PORTAL
  VENOUS OBSTRUCTION
• COMA RELATED TO
  HYPERAMMONAEMIA
     ->125Ug/dl ASSOC. WITH COMA
     TREATMENT OF PSE
•   REDUCE DIETARY PROTEIN
•   ADD GLUCOSE
•   COTROL G.I.T. BLEEDING
•   K+ SUPPLEMENT
•   CARTHATICS & ENEMAS
•   NONABSORBABLE ANTIBIOTICS
•   LACTULOSE- REDUCES COLONIC
     pH & NH3 TRANSFER
  SURGERY FOR PORTAL
     HYPERTENSION
• CONTROL OF MANIFESTATION
  *BLEEDING- LIGATION,
    TRANSECTION,
    OESOPHAGECTOMY+
    JEJUNAL INTERPOSITION
  *ASCITES-
     PERITONEOVENOUS SHUNT
  REDUCTION OF PORTAL
    PRESSURE & FLOW
• SPLENECTOMY
• PORTOCAVAL SHUNT- END-SIDE,
  SIDE-SIDE, H-GRAFT
• SPLENORENAL SHUNT-END-END,
  END-SIDE, DISTAL SPLENORENAL
• SMV-IVC- MESOCAVAL SHUNT
    SIDE-SIDE, H-GRAFT

				
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