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PORTAL HYPERTENSION

PORTAL HYPERTENSION

PORTAL HYPERTENSION

PORTAL HYPERTENSION

The normal hepatic venous pressure gradient is 5–6 mm Hg.

https://www.videosprofitnetwork.com/watch.xml?key=a08654b1e8a2c73f8751ccfb26c1c05e

Clinically significant portal hypertension is present when the gradient exceeds 10 mm Hg and risk of variceal bleeding increases beyond a gradient of 12 mm Hg.

Pre hepatic causes

  • portal vein thrombosis.
  • Abdominal trauma

Intra hepatic causes.

  • Schistosomiasis*
  • Cirrhosis*
  • Venous occlusion diseases
  • Polycystic liver disease
  • hyperplasia
  • Metastatic malignancy
  • Congenital hepatic fibrosis
  • Drugs I .e Vinyl chloride
  • Sarcoidosis

Post-hepatic post-sinusoidal

  • Budd–Chiari syndrome

Pathophysiology

  • Increased portal vascular resistance leads to a gradual reduction in the flow of portal blood to the liver and simultaneously to the development of collateral vessels,allowing portal blood to bypass the liver and enter the systemic circulation directly.
  • Portosystemic shunting occurs, particularly in the gastrointestinal tract and especially the distal oesophagus, stomach and rectum,in the anterior abdominal wall, and in the renal, lumbar, ovarian and testicular vasculature.

Clinical features

  • Splenomegaly.
  • hepatomegaly. Except in cirrhosis
  • Jaundice.
  • Collateral vessels may be visible on the anterior abdominal wall occasionally several radiate from the umbilicus to form a caput medusae.
  • Ascites.
Ascites.
Ascites.

Complication of portal hypertension

  • Variceal bleeding:
  • Congestive gastropathy
  • Hypersplenism
  • Ascites
  • Iron deficiency anaemia
  • Renal failure
  • Hepatic encephalopathy

 

Ix (investigation )

  • FBC – Thrombocytopenia is common due to hypersplenism, and platelete counts are usually low.
  • endoscopy to determine whether gastro-oesophageal varices are present. Once the diagnosis of cirrhosis is made, endoscopy should be performed to screen for oesophageal varices (and repeated every 2 years).
  • Ultrasonography often shows features of portal hypertension, such as splenomegaly and collateral vessels.
  • RFT
  • LFT

 

MEDICAL RX(treatment )

 

1.) Beta blockade propranol 40mg bd

Decrease bleeding by decreasing variceal flow / portal venous pressure

  • Alductone 100mg OD
  • Iron supplements FeSO4 200mg x 3/12

 

4)Preziquantel 20mg/kg if there is schistosomalperiportal fibrosis

 

NB in case of variceal bleeding add

  • Keep the patient NPO.

             Intravenous access

using 2 large bore cannula Start IV fluids (colloid ie NS or RL)- Extracellular volume replacement

 

  • Octreotide 50 microgram i/v bolus then start octreotide 50 mocrogram /hr for 48hr

 

  • Prophylactic antibiotics(cephalosporin IV)-Reduces incidence of SBP

 

  • Lactulose-To prevent hepatic encephalopathy

 

  • Vasopressor (terlipressin) -Reduces portal pressure, acute bleeding and risk of early rebleeding

 

  • Consider BT

 

  • Vitamin k 10mg if patient have coagulopathy or on warfarin Rx

 

  • Emergency endoscopy- Confirms variceal rather than ulcer bleed

 

This should be carried out after adequate resuscitation, balloon tamponade

 

Rx; thermal or‘heater probe’ or endoscopic

 

clips, combined with injection of dilute

ADRENALINE.

 

  • Banding ligation and sclerotherapy. This is the most widely used initial treatment and is undertaken if possible at the time of diagnostic endoscopy.

https://www.videosprofitnetwork.com/watch.xml?key=a08654b1e8a2c73f8751ccfb26c1c05e
Banding ligation and sclerotherapy
Banding ligation and sclerotherapy

 

Surgical menagement

  • transjugular intrahepatic portosystemic stent shunting (TIPSS) and, rarely, oesophageal transection
transjugular intrahepatic portosystemic stent shunting (TIPSS)
transjugular intrahepatic portosystemic stent shunting (TIPSS)