Portal Hypertension CME for surgeons

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Information about Portal Hypertension CME for surgeons
Science-Technology

Published on February 5, 2014

Author: johnact

Source: authorstream.com

PORTAL HYPERTENSION: PORTAL HYPERTENSION Dr Pravin John MS , Dr. John AC Thanakumar MBBS(Vellore), MS(Vellore), MNAMS(Vellore), FRCS (Ed), FRCS (G), FICS, Dip MIS(Fr), FALS, PRESIDENT IAGES 2012-14, CONSULTANT ADVANCED LAPAROSCOPIC AND BARIATRIC SURGEON, ANURAG HOSPITAL, COIMBATORE. drjact@gmail.com Tel: 0422-6587871 Values : Values Normal 5-10 mm Hg Collaterals develop at 10-12 mm Hg Normal hepatic venous pressure gradient: 6-8 mm Hg Anatomy of Heptaic Portal System: Anatomy of Heptaic Portal System Causes : Causes Pre- hepatic Portal vein thrombosis Splenic vein thrombosis (left sided PHT) Hepatic Pre-sinusoidal – schistosomiasis, non-alcoholic cirrhosis Sinusoidal – alcoholic cirrhosis Post-hepatic Budd-Chiari, constrictive pericarditis, right heart failure. Clinical Signs: Clinical Signs An older Miss Muffet decided to rough it And lived upon whiskey and gin. Red hands and spider Developed outside her. Such are the wages of sin. Clinical features: Clinical features Signs of liver cell failure Caput medusae Cruvellhier-Baumgarten murmur Ascites Approach to portal hypertension: Approach to portal hypertension Cause of liver cell failure Estimate functional liver reserve Look for complications Decide curative (transplant) or palliative treatment (shunt) Lab: Lab LFT Pro Time Hb Renal function Electrolytes Viral markers Cause of failure: Cause of failure Liver function tests ( ( Anti-mitochondrial antibody – primary biliary cirrhosis Anti-neutrophil antibody – primary sclerosing cholangitis a1-anti trypsin, ceruloplasmin levels, iron levels, autoimmune panel) Hepatitis screening Functional reserve: Functional reserve Child-Pugh score MELD score(Model for End Stage Liver Disease) MELD score to quantify end-stage liver disease for transplant planning. Dialysis at least twice a week Creatinine Bilirubin INR ext Text Total Bilirubin Albumin PT Ascitis Hepatic Encephlopathy Complications : Complications Variceal bleeding Ascites Hepatic encephalopathy Variceal bleeding: Variceal bleeding LIFE THREATENING COMPLICATION!! 30% cirrhotics develop varices 30% varices bleed in PHT ENDOSCOPY Endoscopic view of Varices: Endoscopic view of Varices ACUTE VARICEAL HEMORRHAGE: ACUTE VARICEAL HEMORRHAGE RESUSCITATION ENDOSCOPIC THERAPY PHARMACOLOGICAL THERAPY SURGERY PREVENT REBLEEDING ENDOSCOPIC THERAPY: ENDOSCOPIC THERAPY ENDOSCOPIC SCLEROSANT ENDOSCOPIC VARICEAL LIGATION ENDOSCOPIC GLUE THERAPY Endoscopic Sclerotherapy: Endoscopic Sclerotherapy Endoscopic Variceal Ligation: Endoscopic Variceal Ligation PHARMACOLOGICAL THERAPY: PHARMACOLOGICAL THERAPY Octreotide infusion (prolonged use – gall stones) Vasopressin (concomitant GTN) Terlipressin Surgery: Surgery Portosystemic shunts Devascularization procedures Orthotopic liver transplantation(OLT) Shunt Surgery for which pts: Shunt Surgery for which pts Child class A patients with recurrent bleeding despite adequate combination therapy. Types of Shunts: Types of Shunts Decompressive shunts include Total portal systemic shunts, Partial portal systemic shunts, and Other selective shunts Total Portal Systemic Shunts: Total Portal Systemic Shunts Total portal systemic shunts include any shunt >10 mm in diameter, between the portal vein (its main tributaries) & inferior vena cava (IVC) (or its tributaries). PS Shunts- End to side or - Side to Side Total Portal Systemic Shunt-Problems: Total Portal Systemic Shunt-Problems Encephalopathy – 40 to 60% Excellent control of ascitis Excellent control of hematemesis Indications Limited to Massive hematemesis with ascitis Budd Chiari with no Liver failure Conventional End to side PC shunt: Conventional End to side PC shunt Partial Porto Systemic Shunts: Partial Porto Systemic Shunts Side to side shunts – 8 mm Portal Pressure reduced to 12 mm Hg Portal Flow maintained in 80% Use vein or graft interposition Results:90% bleed controlled. Less liver cell failure and encephalopathy Interposition Meso Caval Shunt: Interposition Meso Caval Shunt Selective Shunts: Selective Shunts Controls blood from GE junction, but maintains portal flow Warren (Distal Splenorenal ) Shunt But Encephalopathy 10-15% Liver cell failure is less Produces ascitis Conventional Spleno Renal shunt: Conventional Spleno Renal shunt Warren’s Distal Spleno Renal Shunt: Warren ’ s Distal Spleno Renal Shunt Central Spleno renal Shunt: Central Spleno renal Shunt Devascularisation Procedures: Devascularisation Procedures Devacularisation of 5 cm of Esophagus And Upper stomach Transection of esophagus or stomach+-Spleen No liver failure +- Lead to PV and SV thrombosis Esophageal transection: Esophageal transection Gastro Esophageal Devascularisation (Sugiura): Gastro Esophageal Devascularisation (Sugiura) Devascularise Entire > Curve upto plyorus 2/3of upper Lesser Curvature & 7 cm of esophagus Used in repeated sclerotherapy cases Sugiura Devacularisataion: Sugiura Devacularisataion Orthotopic Liver Transplant: Orthotopic Liver Transplant Chronic Liver Disease with bleeding and LCF Controls Liver Cell Failure, Bleeding and Ascitis Liver Transplant: Liver Transplant Split Liver Transplant: Split Liver Transplant Transjugular Intrahepatic Portosystemic Shunt: 38 Transjugular Intrahepatic Portosystemic Shunt As a bridge before transplant As a non surgical temporary procedure in esophageal bleed failed endoscopically When OTLTx ?: When OTLTx ? Child A – Shunt Child B – Shunt or TIPS Child C – TIPS or OTLTx Secondary Prophylaxis: Secondary Prophylaxis To prevent a rebleed Non Selective B blocker:Propranolol or nadolol Endoscopic Sclerotherapy Endoscopic Variceal Ligation Combination of Endoscopy and Pharmacology PowerPoint Presentation: ANURAG HOSPITAL, Coimbatore 0422-6587871

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