Portal Hypertension

Portal hypertension Portal hypertension is defined by a portal pressure higher than 5 mm Hg.

Type prehepatic portal hypertension intrahepatic portal hypertension posthepatic portal hypertension

Prehepatic portal hypertension portal vein thrombosis: the most common Infection in the abdominal cavity omphalophlebitis A-V fistula between HA and PV

Intrahepatic portal hypertension Type: the presinusoidal level the sinusoidal level the postsinusoidal level Cause: schistosomiasis hepatitis B and hepatitis C hepatocellular carcinoma

Postsinusoidal portal hypertension Cause: Budd-Chiari syndrome (hepatic vein thrombosis) constrictive pericarditis heart failure. massive splenomegaly (idiopathic portal hypertension) a splanchnic arteriovenous fistula

Anatomy of portal hypertension The portal vein is formed from the confluence of the superior mesenteric inferior mesenteric and splenic veins

The extrahepatic portal venous circulation

Four collateral pathways Esophageal and gastric venous plexus umbilical vein from the left portal vein to the epigastric venous system retroperitoneal collateral vessels the hemorrhoidal venous plexus

Portosystemic collateral pathways

Pathophysiology of portal hypertension The portal vein contributes two thirds of the total hepatic blood flow Indirectly regulated by vasoconstriction and vasodilation of the splanchnic arterial bed.

Pathophysiology of portal hypertension portal venous resistance portal venous pressure increase hyperdynamic systemic circulation splanchnic hyperemia portal hypertension collateral pathways established

Clinical manifestation Upper gastrointestinal hemorrhage Ascite Enlarged spleen 、 hypersplenia Hepatic coma

Ascite

Laboratory tests Blood test Hepatic function: aminotransferase alkaline phosphatase serum bilirubin level α-fetoprotein level CT CTA Magnetic resonance imaging ultrasound Doppler ultrasonography

A three-dimensional reconstruction of a CT angiogram

Liver Biopsy A useful technique for establishing the cause of cirrhosis and for assessing activity of the liver disease. Laparoscopic biopsy

Pressure test portal pressure can be indirectly estimated by measurement of hepatic venous wedge pressure (HVWP)

Child-Pugh criteria for hepatic functional reserve Clinical and Laboratory Measurement Patient Score for Increasing Abnormality 1 2 3 Encephalopathy (grade) None 1 or 2 3 or 4 Ascites None Mild Moderate Bilirubin (mg/dL) 1–2 2.1–3 ≥3.1 Albumin (g/dL) ≥3.5 2.8–3.4 ≤2.7 Prothrombin time (increase, sec) 1–4 4.1–6 ≥6.1 Grade A, 5 and 6; grade B, 7–9; grade C, 10–15.

Diagnosis History Symptom and Physical examination Laboratory examination Hematology exam CT、CTA USG Endoscopic examination

Treatment Nonoperative treatments operative treatments

Nonoperative treatments Pharmacotherapy Endoscopic treatment Balloon Tamponade Transjugular intrahepatic portosystemic shunt （TIPS）

Pharmacotherapy Vasopressin: a bolus dose of 20 units over 20 minutes and a continuous infusion of 0.2 to 0.4 unit/minute Somatostatin is a250-μg intravenous bolus and a continuous infusion of 250 μg/hour for 2 to 4 days Octreotide :an intravenous bolus of 50 μg and an infusion of 25 to 50 μg/hour for a similar length of time β-adrenergic blockade

Endoscopic treatment Sclerosis Ligation

Sclerosis

Ligation

Balloon Tamponade Complications esophageal perforation ischemic necrosis of the esophagus

Transjugular intrahepatic portosystemic shunt （ TIPS ） Access is gained to a major intrahepatic portal venous branch through puncture through a hepatic vein. A parenchymal tract between hepatic and portal veins is then created with a balloon catheter,and a 10-mm expandable metal stent is inserted, thereby creating the shunt

Operative treatments operative mortality rates for Child-Pugh classes A, B, and C patients are in the range of 0 to 5%, 10% to 15%, and greater than 25%, respectively.

Operative method a shunt procedure a nonshunt operation hepatic transplantation

Nonselective shunts The end-to-side portacaval shunt The side-to-side portacaval shunt The large-diameter interposition shunts The conventional splenorenal shunt

Nonselective shunts

Selective shunts the distal splenorenal shunt the left gastric vena caval shunt a vein graft between the left gastric (coronary) vein and the inferior vena cava

The distal splenorenal shunt

Partial shunts a small-diameter interposition portacaval shunt

Partial shunts

Nonshunt Operations esophagogastric devascularization procedures

Hepatic Transplantation

Removal

New liver implantation

Schematic of completed liver

Piggyback Technique

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