Portal Hypertension, C53 P357-363 Flashcards by Tiggee R

Identify the anatomy of the
portal venous system:
P357 (picture)

Portal vein
Coronary vein
Splenic vein
IMV (inferior mesenteric vein)
SMV (superior mesenteric vein)
Superior hemorrhoidal vein

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Describe drainage of
blood from the superior
hemorrhoidal vein.
P358

To the IMV, the splenic vein, and then

the portal vein

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Where does blood drain into
from the IMV?
P358

Into the splenic vein

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Where does the portal vein
begin?
P358

At the confluence of the splenic vein and

the SMV

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What are the (6) potential
routes of portal–systemic
collateral blood flow (as seen
with portal hypertension)?
P358

Umbilical vein
Coronary vein to esophageal venous
plexuses
Retroperitoneal veins (veins of Retzius)
Diaphragm veins (veins of Sappey)
Superior hemorrhoidal vein to middle
and inferior hemorrhoidal veins and
then to the iliac vein
Splenic veins to the short gastric
veins

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What is the pathophysiology
of portal hypertension?
P358

Elevated portal pressure resulting from

resistance to portal flow

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What level of portal
pressure is normal?
P358

<10 mm Hg

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What is the etiology?

P358

Prehepatic—Thrombosis of portal vein/
    atresia of portal vein
Hepatic—Cirrhosis (distortion of
    normal parenchyma by regenerating
    hepatic nodules), hepatocellular
    carcinoma, fibrosis
Posthepatic—Budd-Chiari syndrome:
    thrombosis of hepatic veins

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What is the most common
cause of portal hypertension
in the United States?
P358

Cirrhosis (>90% of cases)

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How many patients with
alcoholism develop
cirrhosis?
P358

Surprisingly, < 1 in 5

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What percentage of patients
with cirrhosis develop
esophageal varices?
P359

≈40%

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How many patients with
cirrhosis develop portal
hypertension?
P359

Approximately two thirds

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What is the most common
physical finding in patients
with portal hypertension?
P359

Splenomegaly (spleen enlargement)

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What are the associated
CLINICAL findings in
portal hypertension (4)?
P359 (picture)

Esophageal varices
Splenomegaly
Caput medusae (engorgement of
periumbilical veins)
Hemorrhoids

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What other physical findings
are associated with cirrhosis
and portal hypertension?
P359

Spider angioma, palmar erythema,
ascites, truncal obesity and peripheral
wasting, encephalopathy, asterixis (liver
flap), gynecomastia, jaundice

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What is the name of the
periumbilical bruit heard
with caput medusae?
P359

Cruveilhier-Baumgarten bruit

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What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Esophageal varices?
P360

Coronary vein backing up into the

azygous system

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What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Caput medusae?
P360

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

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What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Retroperitoneal varices?
P360

Small mesenteric veins (veins of Retzius)

draining retroperitoneally into lumbar veins

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What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Hemorrhoids?
P360

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

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What is the etiology?

P360

Cirrhosis (90%), schistosomiasis,
hepatitis, Budd-Chiari syndrome,
hemochromatosis, Wilson’s disease,
portal vein thrombosis, tumors, splenic
vein thrombosis

What is the most common
cause of portal hypertension
outside North America?
P360

Schistosomiasis

What is Budd-Chiari
syndrome?
P360

Thrombosis of the hepatic veins

What is the most feared
complication of portal
hypertension?
P360

Bleeding from esophageal varices

What are esophageal varices? P360

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

What is the “rule of 2/3” of portal hypertension? P360

``` 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 ```

``` In patients with cirrhosis and known varices who are suffering from upper GI bleeding, how often does that bleeding result from varices? P361 ```

Only ≈50% of the time

What are the signs/symptoms? | P361

Hematemesis, melena, hematochezia

What is the mortality rate from an acute esophageal variceal bleed? P361

≈50%

What is the initial treatment of variceal bleeding? P361

``` As with all upper GI bleeding: large bore IVs x 2, IV fluid, Foley catheter, type and cross blood, send labs, correct coagulopathy (vitamin K, fresh frozen plasma), +/ – intubation to protect from aspiration ```

What is the diagnostic test of choice? P361

EGD (upper GI endoscopy) Remember, bleeding is the result of varices only half the time; must rule out ulcers, gastritis, etc.

If esophageal varices cause bleeding, what are the EGD treatment options? P361

1. Emergent endoscopic sclerotherapy: a sclerosing substance is injected into the esophageal varices under direct endoscopic vision 2. Endoscopic band ligation: elastic band ligation of varices

What are the pharmacologic options? P361

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, -blocker

What is a Sengstaken- Blakemore tube? P361

Tube with a gastric and esophageal balloon for tamponading an esophageal bleed (see page 268)

What is the next therapy after the bleeding is controlled? P361

Repeat endoscopic sclerotherapy/banding

``` What are the options if sclerotherapy and conservative methods fail to stop the variceal bleeding or bleeding recurs? P362 ```

``` Repeat sclerotherapy/banding and treat conservatively TIPS Surgical shunt (selective or partial) Liver transplantation ```

What is a “selective” shunt? | P362

Shunt that selectively decompresses the varices without decompressing the portal vein

What does the acronym TIPS stand for? P362

Transjugular Intrahepatic Portosystemic | Shunt

What is a TIPS procedure? | P362

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

What is a “partial shunt”? | P362

Shunt that directly decompresses the | portal vein, but only partially

What is a Warren shunt? | P362 (picture)

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

What is a contraindication to the Warren “selective” shunt? P363

Ascites

Define the following shunts: End-to-side portocaval shunt P363

“Total shunt”—portal vein (end) to IVC | side

Define the following shunts: Side-to-side portocaval shunt P363

Side of portal vein anastomosed to side of IVC—partially preserves portal flow (“partial shunt”)

Define the following shunts: Synthetic portocaval H-graft P363

``` “Partial shunt”—synthetic tube graft from the portal vein to the IVC (good option for patients with alcoholism; associated with lower incidence of encephalopathy and easier transplantation later) ```

Define the following shunts: Synthetic mesocaval H-graft P363

Synthetic graft from the SMV to the IVC

What is the most common perioperative cause of death following shunt procedure? P363

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

What is the major postoperative morbidity after a shunt procedure? P363

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

``` What medication is infused to counteract the coronary artery vasoconstriction of IV vasopressin? P363 ```

Nitroglycerin IV drip

What lab value roughly correlates with degree of encephalopathy? P363

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

What medications are used to treat hepatic encephalopathy? P363

Lactulose PO, with or without | neomycin PO