Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgical Recall > Chapter 52: Portal Hypertension > Flashcards

Chapter 52: Portal Hypertension Flashcards

1
Q

Where does the portal vein begin?

A

At the confluence of the splenic vein and the SMV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the six potential routes of portal–systemic collateral blood flow (as seen with portal hypertension)?

A
  1. Umbilical vein
  2. Coronary vein to esophageal venous plexuses
  3. Retroperitoneal veins (veins of Retzius)
  4. Diaphragm veins (veins of Sappey)
  5. Superior hemorrhoidal vein to middle and inferior hemorrhoidal veins and then to the iliac vein
  6. Splenic veins to the short gastric veins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the pathophysiology of portal hypertension?

A

Elevated portal pressure resulting from resistance to portal flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the etiology?

Prehepatic

A

Thrombosis of portal vein/atresia of portal vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the etiology?

Hepatic

A
  1. Cirrhosis (distortion of normal parenchyma by regenerating hepatic nodules)
  2. hepatocellular carcinoma
  3. fibrosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the etiology?

Post hepatic

A

Budd–Chiari syndrome: thrombosis of hepatic veins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the most common cause of portal hypertension in the United States?

A

Cirrhosis (>90% of cases)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How many patients with alcoholism develop cirrhosis?

A

Surprisingly, <1 in 5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What percentage of patients with cirrhosis develop esophageal varices?

A

≈40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How many patients with cirrhosis develop portal hypertension?

A

≈2/3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the most common physical finding in patients with portal hypertension?

A

Splenomegaly (spleen enlargement)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the four associated CLINICAL findings in portal hypertension?

A
  1. Esophageal varices
  2. Splenomegaly
  3. Caput medusae (engorgement of periumbilical veins)
  4. Hemorrhoids
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What other physical findings are associated with cirrhosis and portal hypertension?

A
  • Spider angioma
  • palmar erythema
  • ascites
  • truncal obesity and peripheral wasting
  • encephalopathy
  • asterixis (liver flap)
  • gynecomastia
  • jaundice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the name of the periumbilical bruit heard with caput medusae?

A

Cruveilhier–Baumgarten bruit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What constitutes the portal–systemic collateral circulation in portal hypertension in the following conditions:

Esophageal varices?

A

Coronary vein backing up into the azygous system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What constitutes the portal–systemic collateral circulation in portal hypertension in the following conditions:

Caput medusae?

A

Umbilical vein (via falciform ligament) draining into the epigastric veins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What constitutes the portal–systemic collateral circulation in portal hypertension in the following conditions:

Retroperitoneal varices?

A

Small mesenteric veins (veins of Retzius) draining retroperitoneally into lumbar veins

18
Q

What constitutes the portal–systemic collateral circulation in portal hypertension in the following conditions:

Hemorrhoids?

A

Superior hemorrhoidal vein (which normally drains into the inferior mesenteric vein) backing up into the middle and inferior hemorrhoidal veins

19
Q

What is the etiology?

A
  1. Cirrhosis (90%)
  2. schistosomiasis
  3. hepatitis
  4. Budd–Chiari syndrome
  5. hemochromatosis
  6. Wilson’s disease
  7. portal vein thrombosis
  8. tumors
  9. splenic vein thrombosis
20
Q

What is Budd–Chiari syndrome?

A

Thrombosis of the hepatic veins

21
Q

What is the most feared complication of portal hypertension?

A

Bleeding from esophageal varices

22
Q

What are esophageal varices?

A

Engorgement of the esophageal venous plexuses secondary to increased collateral blood flow from the portal system as a result of portal hypertension

23
Q

What is the “rule of 2/3” of portal hypertension?

A

2/3 of patients with cirrhosis will develop portal hypertension

2/3 of patients with portal hypertension will develop esophageal varices

2/3 of patients with esophageal varices will bleed from the varices

24
Q

In patients with cirrhosis and known varices who are suffering from upper GI bleeding, how often does that bleeding result from varices?

A

Only ≈50% of the time

25
Q

What are the signs/symptoms?

A

Hematemesis, melena, hematochezia

26
Q

What is the initial treatment of variceal bleeding?

A

As with all upper GI bleeding:

  • large-bore IVs × 2
  • IV fluid
  • Foley catheter
  • type and cross blood
  • send labs
  • correct coagulopathy (vitamin K, fresh frozen plasma)
  • ± intubation to protect from aspiration
27
Q

What is the diagnostic test of choice?

A

EGD (upper GI endoscopy)

Remember, bleeding is the result of varices only half the time; must rule outulcers, gastritis, etc.

28
Q

If esophageal varices cause bleeding, what are the EGD treatment options?

A
  1. Emergent endoscopic sclerotherapy:
    • ​ a sclerosing substance is injected intothe esophageal varices under direct endoscopic vision
  2. Endoscopic band ligation:
    • elastic band ligation of varices
29
Q

What are the pharmacologic options?

A
  • Somatostatin (octreotide) or IV vasopressin (and nitroglycerin, to avoid MI) to achieve vasoconstriction of the mesenteric vessels
  • if bleeding continues,consider balloon (Sengstaken–Blakemore tube) tamponade of the varices
  • β-blocker
30
Q

What is a Sengstaken–Blakemore tube?

A

Tube with a gastric and esophageal balloon for tamponading an esophageal bleed

31
Q

What is the next therapy after the bleeding is controlled?

A

Repeat endoscopic sclerotherapy/banding

32
Q

What are the options if sclerotherapy and conservative methods fai lto stop the variceal bleeding or bleeding recurs?

A

Repeat sclerotherapy/banding and treat conservatively

TIPS

Surgical shunt (selective or partial)

Liver transplantation

33
Q

What does the acronym TIPS stand for?

A

Transjugular Intrahepatic Portosystemic Shunt

34
Q

What is a TIPS procedure?

A

Angiographic radiologist places a small tube stent intrahepatically between the hepatic vein and a branch of the portal vein via a percutaneous jugular vein route

35
Q

What is a Warren shunt?

A

Distal splenorenal shunt with ligation of the coronary vein—elective shunt procedure associated with low incidence of encephalopathy in patients postoperatively because only the splenic flow is diverted to decompress the varices

36
Q

What is the most common perioperative cause of death following shunt procedure?

A

Hepatic failure, secondary to decreased blood flow (accounts for two thirds of deaths)

37
Q

What is the major postoperative morbidity after a shunt procedure?

A

Increased incidence of hepatic encephalopathy because of decreased portal blood flow to the liver and decreased clearance of toxins/metabolites from the blood

38
Q

What medication is infused to counteract the coronary artery vasoconstriction of IV vasopressin?

A

Nitroglycerin IV drip

39
Q

What lab value roughly correlates with degree of encephalopathy?

A

Serum ammonia level

(Note: Thought to correlate with but not cause encephalopathy)

40
Q

What medications are used to treat hepatic encephalopathy?

A

Lactulose PO, with or without neomycin PO

41
Q

Name the most likely diagnosis:39-year-old man with caput medusae, hemorrhoids, and splenomegaly

A

Portal hypertension

Surgical Recall (168 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions