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Surgery M4 part 2 > Portal Hypertension > Flashcards

Portal Hypertension Flashcards

1
Q

What is the definition of portal hypertension?

A
  • portal vein pressure > 12mmHg

- portal vein to hepatic vein pressure gradient greater than 5

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2
Q

What does the portal vein drain?

A
  • lower esophagus
  • stomach
  • small & large intestines
  • spleen
  • pancreas
  • gallbladder
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3
Q

Which veins form the portal vein?

A

Superior mesenteric vein & splenic vein

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4
Q

Which veins cause the varices in portal hypertension?

A
  • umbilical & paraumbilical veins enlarge -> form umbilical varices
  • coronary vein receives distal esophageal veins -> form esophago-gastric varices
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5
Q

What is the pathophysiology of portal hypertension?

A
  • increase in vascular resistance: in cirrhosis -> mechanical consequence of hepatic architectural disorder
  • > deposition of collagen in spaces of Disse
  • > contraction of myofibroblasts
  • increase in portal blood flow
    Splanchnic arteriolar vasodilatation -> portosystemic collaterals
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6
Q

What are the prehepatic causes of increased vascular resistance?

A
  • portal vein thrombosis
  • splenic vein thrombosis
  • congenital atresia or stenosis of portal vein
  • extrinsic compression
  • umbilical vein sepsis in children
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7
Q

What are the hepatic causes of increased resistance to flow?

A
  • hepatic cirrhosis
  • congenital hepatic fibrosis
  • bilharzial peri-portal fibrosis
  • lymphoma
  • acute & fulminant hepatitis
  • veno-occlusive disease
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8
Q

What are the post hepatic causes of increased resistance to flow?

A
  • IVC obstruction
  • right side heart failure
  • constrictive pericarditis
  • tricuspid regurgitation
  • budd-chiari syndrome
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9
Q

What are the causes of increased blood volume of portal blood flow?

A
  • Porto-hepatic fistula

- increased splenic flow (splenomegaly)

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10
Q

What are the consequences of portal HTN?

A
  • enlargement of liver then shrinks with failure
  • spleen enlarged with RES hyperplasia
  • portosystemic shunt
  • ascitis
  • congestive gastropathy
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11
Q

How to determine the presence of complications?

A
  • upper GI bleeding
  • mental status change: lethargy, increased irritability, altered sleep patterns (portosystemic encephalopathy)
  • increased abdominal girth (ascites formation)
  • hematochezia & melena (bleeding from portal colopathy)
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12
Q

What are the signs of porto-systemic collateral formation?

A
  • dilated veins in the anterior abdominal wall (umbilical epigastric shunts)
  • caput medusa
  • rectal varices
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13
Q

What will be seen on physical examination of person with portal hypertension?

A
  • signs of porto systemic collaterals
  • ascites (dullness in flanks with +ve shifting dullness & fluid thrill)
  • splenomegaly
  • paraumbilical hernia
  • inguinal hernia or hydrocele
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14
Q

What are the signs of liver cell dysfunction?

A
  • ascites
  • jaundice
  • spider angiomas
  • palmar erythema
  • testicular atrophy
  • gynecomastia
  • muscle wasting
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15
Q

What is the cause for morbidity & mortality in portal hypertension?

A
  • variceal hemorrhage: most common
    first episode has mortality of 30-50%
    second episode has mortality of 80%

90% of patients with cirrhosis develop varices

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16
Q

What are the factors that lead to rupture and bleeding in esophageal varices?

A

food, reflux, & PHT causing ulcerations & erosions

17
Q

Which varices are considered risky?

A
  • > 15mm (1.5cm)
  • unhealthy mucosa
  • cherry red spots
18
Q

What is the cause of splenomegaly in portal HTN?

A

EARLY -> toxins -> RE hyperplasia

LATE due to congestive splenomegaly -> 2ndry hypersplenism -> splenic infarction

19
Q

What are the signs of GIT congestion?

A
  • anorexia
  • dyspepsia
  • malabsorption
  • gastric gastropathy
20
Q

Whats the reason for ascities in portal HTN?

A
  • increased aldosterone & ADH leads to salt & water retention
  • increased hepatic transudation (WEEPING LIVER)
  • hypo-albuminemia
  • PHT is a localizing factor of the fluid into the peritoneal cavity
21
Q

How should ascities be treated?

A
  • best rest
  • sodium restriction
  • fluid restriction
  • diuretics
  • large volume paracentesis with 6-10g albumin/1L fluid
  • TIPS
  • LeVeen shunt & Denver shunt (peritoneovenous shunt)
  • side to side portocaval shunt
22
Q

What are the investigations done for portal HTN?

A
  • assessment of liver function
  • detection of varices (endoscope, barium swallow, Duplex)
  • detection of hypersplenism (radioactive isotope, CBC, BM exam)
  • liver biopsy, ultrasound
  • pre-op measurement of portal HTN
23
Q

What is the most effective method for screening for portal HTN & helps in diagnosing the cause?

A

DUPLEX ULTRASONOGRAPHY

  • can demonstrate volume & direction of portal flow
  • diagnoses the cause (PV thrombosis or splenic vein thrombosis)
24
Q

How is portal pressure measured?

A
  • hepatic venous pressure gradient (HVPG)

- wedge hepatic venous pressure WDVP - free hepatic venous pressure (FHVP)

25
Q

What is Child’s classification?

A

predicts mortality of cirrhosis patients
bilirubin <2 2-3 >3
albumin >3.5 2.8 - 3.5 <2.8
PT 1-3 4-6 >6
ascites - slight moderate
encephalopathy - minimal advanced
1 2 3

A = 5-6 B = 7-9 C=10-15

26
Q

When should endoscopy be performed?

A
  • all patients with cirrhosis should be screened for presence of varices at initial diagnosis of cirrhosis
  • in grade A (5-6) compensated patients without varices: repeat endoscopy every 2-3 years
  • in compensated patients with small varices: endoscopy every 1-2 years
  • in patients with risky varices: measures should be taken before bleeding (injection/banding using endoscopy)
27
Q

How should bleeding varices be managed?

A

1- admission
2- resuscitation (wide bore cannula central line catheter)
3- correct coagulopathy (fresh blood - FFP - vit K)
4- prevent encephalopathy: oxygenation - warm patient - neomycin - NG tube to remove blood)
5- stop bleeding (endoscopic ligation/sclerotherapy in hemodynamically stable OR balloon tamponade)
6- Pharmacological therapy (octreotide, somatostatin, nitroglycerin)

28
Q

What is the cause of encephalopathy?

A

bacteria + blood -> fermentation ===== ammonia

29
Q

What are the types of tubes used in tube tamponade?

A

Minnesota tube

Sungestaken-Blackmoore tube

30
Q

How is the Sungestake Tube used to stop the bleeding?

A 
TRIPLE WAY
- gastric balloon = 150cc saline 
- esophageal balloon = 35mmHg air 
- Ryle = suction & wash 
leave it 24h then deflate in place for 8hr
USED IN SHOCKED PATIENTS
31
Q

What pharmacological therapy is used in emergency treatment?

A
  • Somatostatin to decrease portal flow + nitroglycerin
  • octreotide
  • vasopressin + nitroglycerin: splanchnic vasoconstrictor, decreases portal pressure
32
Q

What surgeries are used in emergency management of portal hypertension?

A
  • shunt surgery

- esophageal transection

33
Q

What are the indications for shunt surgeries?

A
  • intractable bleeding
  • failed endoscopic management
  • recurrent bleeding
  • in preparation for liver transplant
34
Q

What are the types of shunt surgeries used in portal HTN?

A
  • end-to-side portocaval shunt: increases encephalopathy because no filtration of blood will occur in the liver
  • side-to-side portocaval or mesocaval: less encephalopathy
  • splenorenal: proximal (nonselective + splenectomy) OR distal (selective)
35
Q

What are the types of selective shunts?

A

Corono-caval (non-selective)
Warrem-Sallam (distal spleino-renal) (selective)
- decompress varices while maintaining PV
- decompresses GE varices through short gastric & splenic vein to left renal vein
- looses selectivity over time

36
Q

What should be the first choice for shunt surgery in portal hypertension?

A

TIPS (transjugular intrahepatic porto-systemic shunt)
- Palmaz balloon expandable stent is introduced through jugular vein to reach hepatic vein -> enters branch of portal vein -> creates porto-systemic shunt

37
Q

When is liver transplantation indicated in portal hypertension?

A

CHILD C PAtiENTS

- relives portal hypertension, prevents bleeding, manages ascites & encephalopathy

Surgery M4 part 2 (36 decks)

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