1. Portal Hypertension

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

3. Type prehepatic portal hypertension intrahepatic portal hypertension
posthepatic portal hypertension

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

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

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

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

8. The extrahepatic portal venous circulation

9. 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

10. Portosystemic collateral pathways

11. 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.

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

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

14. Ascite

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

16. A three-dimensional reconstruction of a CT angiogram

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

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

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

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

21. Treatment
Nonoperative treatments
operative treatments

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

23. 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

24. Endoscopic treatment
Sclerosis
Ligation

25. Sclerosis

26. Ligation

27. Balloon Tamponade Complications esophageal perforation
ischemic necrosis of the esophagus

29. 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

31. 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.

32. Operative method a shunt procedure a nonshunt operation
hepatic transplantation

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

34. Nonselective shunts

35. 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

36. The distal splenorenal shunt

37. Partial shunts
a small-diameter interposition portacaval shunt

38. Partial shunts

39. Nonshunt Operations
esophagogastric devascularization procedures

41. Hepatic Transplantation

42. Removal

43. New liver implantation

44. Schematic of completed liver

45. Piggyback Technique

46. Thank you