Portal Hypertension+liver Flashcards
What is portal hypertension?
It is blood pressure of >12mmHg in the portal vein
What are the 2 broad categories of liver disease?
- diffuse-cirrhosis and hepatitis
2. focal-focal tumours and lesions that surgery can intervene
What are the causes of portal hypertension?
1. Pre-hepatic portal vein thrombosis splenic vein thrombosis 2. Hepatic -cirrhosis -schistosomiasis -hepatic mets 3. Post hepatic -right heart failure -constrictive pericarditis Budd chiari syndrome
What is the clinical presentation of someone with portal hypertension:
- A-ascites
- Bleeding-oesophageal varices, hemetemisis, melena
- caput medusae
- Dysfunctional liver- hepatic encephalopathy, jaundice, anaemia, thrombocytopenia, leucopenia, splenomegaly, gyanecomastia
What are the complications of portal hypertension?
- oesophageal varices
- refractory ascites
- hyperspenism
- encephalopathy
- hepatorenal syndrome
What is primary prophylaxis?
This occurs in high risk patients where endoscopy is done and rubber band ligation is done with beta blockers to prevent bleeding
What is secondary prophylaxis?
This is when patients are already bleeding and we do endoscopy and rubber band ligation with beta blocker treatment then do another rubber band ligation
What are the 2 types of surgeries we can do for portal HPT?
- Devascularisation
2. porto-systemic shunt
How does devascularisation work?
There is devascularisation of he lower oesophagus and stomach and spleen but it is usually the last resort because the varices may recur
What are the 3 types of porto-systemic shunts?
- porto-caval
- mesocaval shunt
- distal spleno-renal shunt
What is the major drawback of porto-systemic shunts?
-It leads to hepatic encephalopathy due to the decreased amount of blood that gets filtered by the liver
In which patients is a porto-systemic shunt good for?
In patients with good liver function because of the reduced incidence of encephalopathy
Explain the distal spleno-renal shunt?
This is when the splenic vein and the left renal vein have an end to end anastomosis and theres ligation of the left gastric vein this reduces the pressure going to the lower oesophagus but this procedure is more technically demanding
What is budd chiari syndrome?
This is when there is a clot/thrombi in the hepatic veins or possibly the IVC which leads to liver failure
What is left sided portal hypertension?
Splenic vein thrombosis which leads to gastric varices and these can be treated endoscopically with glue injection
What is the management for ascites?
- diuretics like lasix 20mg or aldactone 50mg
- ascitic parenthesis
- low sodium diet-consult dietician
- shunt/TIPPS
- liver transplant
What is the management for hypersplenism if all else fails?
splenectomy
What are simple cysts?
These are congenital in origin and occur in 10% of people and can occur in polycystic kidney disease
-these are asymptomatic and require no treatment unless being drained into the peritoneal cavity
What do we do if it is a large polycystic liver?
Liver transplant
What are cystic neoplasms?
These mucinous neoplasms that can be either benign or malignant
We excise them because of the malignant potential
-the walls will appear thicker, with or without nodularity
What are the cystic, benign lesions?
- simple cysts
- hydatid cysts
- traumatic cysts
- abscess
- cystic neoplasm
What are the cystic, malignant lesions?
invasive biliary cystic neoplasm
What are the solid, benign lesions?
haemangioma
hepatic adenoma
focal nodular hyperplasia
What is the intermediate host of the hyatid cyst?
sheep and humans if humans eat the grass that is infested with the worm
What is the definitive host of the hydatid cyst?
dog or other carnivore and worm resides in the gut
How does the parasite get into humans?
Human accidentally ingest grass with dogs faeces, it enters the intestines and crosses over to the portal circulation and reaches the liver where the cyst will occur
What organs can the hydatid cyst affect?
- liver
- lungs
- brain
What are the complications of the hydatid cyst?
- bacterial infection
- rupture into biliary tract causing juandice
- rupture into abdominal cavity
How do we diagnose hydatid cysts?
- serology
2. CT/ultrasound
What are the 2 types of liver abscesses?
- amoebic
2. pyogenic
How do amoebic liver abscesses present?
- they are usually just one lesion in the right lobe of the liver and present with right upper quadrant pain and low grade fever
The treatement is metronidazole or if the lesion is >7cm and not responding to Rx then treat with percutaneous sonar guided needle aspiration
What causes the amoebic liver abscess?
entamoeba hystolitica
What are the causes of pyogeic abscess?
This is when other liver lesions(haematoma, hydatid cyst) become infected and causes inflammatory signs and symptoms and the patient becomes toxically ill
What is the treatment of pyogenic cysts?
<3cm IV atibiotics
3-5cm we aspirate
>5cm then we use percutanous pigtail drains
Always culture the fluid to figure out which organism it is
What are the 3 types of solid benign lesions?
- hemangioma
- hepatic adenoma
- focal nodular hyperplasia
What are the 4 types of liver cancers?
- hepatocellular carcinoma
- angiosarcoma
- hepatoblastoma
- intra-hepatic cholangiocarcinoma
What investigations can we do to diagnose hepatocellular carcinoma?
- alpha fetoprotein in 70% of patients
2. CT abdomen
What are the causes of hepatocellular carcinoma?
- alcohol
- hepatitis b and c
- liver cirrhosis
- intake of grain foods that have aflatoxin
