1. Portal Hypertension portal venous pressure > 5 mmHg
collaterals > 10 mmHg
bleeding > 12 mmHg

2. Portal Hypertension
intrahepatic - sinusoidal / post-sinusoidal (cirrhosis)
pre-sinusoidal (schistosomiasis)
posthepatic - Budd-Chiari syndrome
Veno-occlusive disease
prehepatic - portal vein thrombosis
cavernous transformation of the portal vein
isolated splenic vein thrombosis
left sided portal hypertension (inflammation – tumor)

3. Cirrhosis alcohol viral hepatitis B & C
cholestatic primary biliary cirrhosis
secondary biliary cirrhosis
primary sclerosing cholangitis
autoimmune lupoid
metabolic hemochromatosis
Wilson’s
alpha 1 – antitrypsin deficiency
cryptogenic

4. Cirrhosis hepatocellular necrosis - fibrosis & nodular regeneration
two major phenomena:
loss of cell mass - hepatocellular failure
increased hepatic vascular resistance -
portal hypertension

5. Portal Hypertension splenomegaly porto-systemic collaterals
- coronary & short gastric veins to azygos vein –
esophageal varices
- recanalized umbilical vein –
caput medusae
- retroperitoneal
- hemorrhoidal venous plexus

7. Bleeding esophageal varices 80 % gastric varices 20 %
portal hypertensive gastropathy

8. Bleeding patients with varices – bleeding in 33 - 50 %
acute variceal bleeding – mortality %
rebleeding - 70 %

9. Bleeding chronic liver disease spider angiomas palmar erythema
testicular atrophy
gynecomastia
jaundice
ascites
splenomegaly
caput medusae
asterixis (liver flap)

10. Immediate Management hemodynamic stabilization - PT - platelets
- electrolytes
- creatinine
endoscopy
- diagnostic
- therapeutic

11. Pharmacotherapy vasopressin glypressin – terlipressin
splanchnic vasoconstrictors
vasopressin
(hypertension, bradycardia, decreased cardiac output, coronary vasoconstriction) Tx combined with nitroglycerin
glypressin – terlipressin
somatostatin - octreotide

12. Endoscopic Treatment variceal sclerosis – sclerotherapy
variceal ligation – banding
control of bleeding – 85 %

15. Balloon Tamponade
Sengstaken – Blakemore tube

17. Encephalopathy neomycin – suppresses urease containing bacteria
lactulose –
acidifies colonic contents
cathartic effect

18. Further Treatment rebleeding – 70 % options:
pharmacotherapy – propranolol
repeat endoscopic therapy
TIPS
porto-systemic shunt operations
devascularization procedures
liver transplantation

19. Hepatic Functional Reserve
Child’s classification
A B C
albumin (g/dl) > – < 3
bilirubin (mg/dl) < – > 3
ascites none mild moderate
encephalopathy none minimal marked
nutritional state excellent good poor

20. Hepatic Functional Reserve
Child – Pugh classification
points
albumin (g/dl) > – < 2.8
bilirubin (mg/dl) < – > 3
PT (sec prolonged) – – > 6
ascites none mild moderate
encephalopathy none minimal marked

21. Hepatic Functional Reserve
Pugh score – 6 = Child’s A
good hepatic reserve
good operative candidate < 5 % mortality
Pugh score – 9 = Child’s B
moderate hepatic reserve
modest operative candidate 10 – 15 % mortality
Pugh score – 15 = Child’s C
low hepatic reserve
poor operative candidate > 25 % mortality

22. Portosystemic Shunts effective decompression of portal system
- effective in preventing recurrent bleeding
diversion of portal blood
- accelerated hepatic failure
- encephalopathy

23. Portal Blood cerebral toxins - ammonia
bypass of the liver prevents inactivation
hepatotrophic elements – insulin
diversion causes atrophy

24. Surgical Shunts nonselective (total)
end-to-side portocaval shunt (Eck’s fistula)
other nonselective shunts
side-to-side
meso-caval
spleno-renal
selective shunts
distal spleno-renal (Warren shunt)

31. TIPS Transjugular Intrahepatic Portosystemic Shunt
major advantage – nonoperative
disadvantage -
nonselective shunt – encephalopathy 30 %
shunt stenosis or occlusion at 1 year 50 %

32. Devascularization Procedures
transection & reanastomosis
- of esophagus = Sugiura procedure
- of stomach = Tanner procedure