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R9 > Chapter 164 - Portal hypertension > Flashcards

Chapter 164 - Portal hypertension Flashcards

1
Q

Definition of portal hypertension

A

Abnormal increase in pressure that carry blood from visceral to liver 10 mmHg above systemic venous pressure

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2
Q

Ohm’s law

A

Change in pressure (delta P) = flow (Q) x resistance (R)

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3
Q

Normal portal pressure

A

5-10 mmHg

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4
Q

Pathogenesis of liver cirrhosis

A

decrease vasodilator, increase vasoconstriction, increase fibrosis –> increase portal pressure splanchnic vasodilation –> increase HR and CO –> arterial hypotension –> high pressure baroreceptor and sympathetic nervous system –> vasoconstrictor –> hypodynamic system –> shunt blood to low resistance = esophageal varices

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5
Q

Portal hypertension classes

A

1) extrahepatic 2) intrahepatic 3) post hepatic

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6
Q

Extrahepatic pre-sinusoidal obstruction causes

A

thrombosis of portal vein children: infection adult: cirrhosis, iatrogenic, cancer, hypercoagulable, inflammatory Risk 0.6-22%

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7
Q

Intrahepatic presinusoidal obstruction causes

A

Fibrosis and compression of portal vein deposits of stuff causes inflammation in portal vein 1) hepatic fibrosis 2) chronic arsenic exposure 3) sarcoidosis 4) wilson disease 5) hepatoportal sclerosis 6) primary biliary cirrhosis 7) Schistosomiasis (most common in 3rd world) 8) myeloproliferative disorders

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8
Q

Intrahepatic sinusoidal and postsinusoidal causes and mechanism

A

Most common in western world Cirrhotic bands and regeneration nodules disrupt normal architecture Cause AV shunt and collateral with 33% bypassing hepatocytes Increase CO, decrease systemic resistance, increase hepatic wedge pressure, increase portal pressure Sinusoidal: 1) EtOH 2) viral 3) toxic hepatitis Post-sinusoid 1) EtOH 2) postnecrotic cirrhosis 3) hemochromatosis

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9
Q

Extrahepatic postsinusoidal obstruction causes

A

Hepatic vein thrombosis 1) malignancy 2) trauma 3) pregnancy 4) oral contraceptives 5) Budd-Chiari associated myeloproliferative disease with hypercoagulable state Cardiac disease

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10
Q

AVF in portal hypertension causes

A

Increase in portal circulation causes fibrosis 1) iatrogenic 2) trauma 3) splenic aneurysm 4) sarcoidosis 5) Gauche disease 6) myeloid metaplasia

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11
Q

Clinical presentation of portal hypertension

A

1) Ascites 2) spider angioma 3) palmer erythema 4) Gynecomastia 5) enlarged abdominal wall collaterals (caput medusae) 6) muscle wasting 7) variceal bleed 8) fatigue 9) asterixis 10) encephalopathy

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12
Q

Pathogenesis of variceal formation in portal hypertension

A

1) Dysfunction of preexisting embryonic connection 2) neoangiogenesis Collaterals form at 10-12 mmHg above systemic pressure

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13
Q

Varices pathway in portal hypertension

A

Portal vein –> left gastric vein –> esophageal varices Splenic vein –> short gastric vein –> esophageal and gastric varices Both into venous plexus of lamina propia and submucosa of esophagus and stomach –> azygos venous system

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14
Q

Esophageal varices zones

A

1) Gastric 2) Palisade 3) Transitional (2 cm above GEJ to 2 cm above that) 4) Truncal

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15
Q

Gastric varices types

A

1) extend above GEJ as esophageal 2) isolated to stomach common in fundus

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16
Q

Caput medusae pathogenesis

A

Left portal vein to periumbilical vein in falciform ligament

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17
Q

Rate of varices in cirrhosis at diagnosis

A

50%

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18
Q

Rate of varices in cirrhosis with long term f/u

A

90%

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19
Q

Defn of small or large varices and respective bleed/rupture rate

A

5 mm cutoff small 7%/2 yr large 30%/2yr

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20
Q

Mortality associated with variceal bleed

A

35% 60% if rebleed in 1 yr 20% every subsequent bleed

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21
Q

Pathogenesis of variceal bleeding

A

Explosion hypothesis Hydrostatic pressure increase > 10 mmHg, variceal dilation, decrease wall thickness –> rupture (LaPlace Law)

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22
Q

Critical hepatic venous gradient

A

12 mmHg

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23
Q

Ascites rate in portal hypertension

A

80%

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24
Q

Pathology of ascites in portal hypertension

A

Starling forces with low oncotic pressure and high hydrostatic pressure lymphatic system overwhelmed

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25
Q

Risk of ascites

A

Spontaneous bacterial peritonitis 30% need hospitalization due to SBP

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26
Q

Type of bacteria in spontaneous bacterial peritonitis

A

Gram negative aerobes most (GI source) 1/3 Gram +

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27
Q

Encephalopathy definition

A

Any neuropsychiatric dysfunction caused by liver disease ranging from subclinical to coma/death

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28
Q

Pathology of encephalopathy

A

Hepatocyte malfunction –> portosystemic shunt –> ammonia and glutamine –> brain astrocyte mitochondrial dysfunction –> altered cerebral function, edema, herniation

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29
Q

Wes Haven Criteria is for

A

Hepatic encephalopathy Grade 1 + 2 = cognition, sleep patter alteration, mood, disorientation, asterixis, apathy, drowsy Grade 3 + 4 = coma, somnolence

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30
Q

Rate of encephalopathy in decompensated liver failure

A

30-40%

31
Q

Hepatorenal syndrome defn

A

Renal dysfunction in presence of cirrhosis and ascites Diagnosis of exclusion

32
Q

Symptom of hepatorenal syndrome

A

1) oliguria 2) hyponatremia 3) low urine sodium

33
Q

Hepatorenal syndrome types

A

rapid (within 2 weeks of hepatic) vs chronic rapid poor prognosis 90% inhospital mortality

34
Q

Hepatopulmonary/portopulmonary syndrome defn

A

Combination of portal hypretension, pulmonary hypertension, pulmonary vasodilate/shunt, impaired oxygenation

35
Q

Symptoms of hepatopulmonary syndrome

A

1) clubbing 2) dyspnea 3) deoxygenation

36
Q

Laboratory workup for portal hypertension

A

1) arterial gas 2) lactate 3) CBC 4) PTT/INR 5) fibrinogen 6) factor V 7) AST/ALT/ALP 8) bili 9) LDH 10) amylase/lipase 11) magnesium, PO4 12) CK 13) metabolic panels

37
Q

Other specific tests for portal hypertension

A

1) HIV 2) Hepatitis 3) ceruloplasmin 4) serum copper 5) ANA 6) tox screen 7) testosterone (low in 90% of men with cirrhosis; associated with mortality)

38
Q

When to GI scope in portal hypertension and what can be found

A

All with varices should get scope repeat 3-6 months after bleed Dx: gastropathy, gastritis, ulcers, mucosal laceration

39
Q

Benefit of liver biopsy in portal hypertension and what can be found

A

Etiology and acuity information Cirrhosis: 1) rounding of edges 2) nodularity 3) loss of terminal hepatic venules 4) increase vascular channels in scars and fibrosis 5) hepatocyte regeneration

40
Q

Liver biopsy: finding of plastma cell in portal/septal interface

A

Hepatitis B

41
Q

Liver biopsy: Mallory-Denk bodies

A

Eosinophilic cytoplasmic inclusion bodies that hover hepatocyte nucleus 1) EtOH 2) Wilson 3) drug induced 4) primary biliary cirrhosis

42
Q

Liver biopsy: pipestem fibrosis

A

chronic schistosomiasis (calcified egg and granuloma) if live will see live egg with eosinophils

43
Q

Success in endoscopic sclerotherapy

A

Cyanoacrylate 93% success; 7% rebleed

44
Q

Side effect of endoscopic sclerotherapy

A

Pulmonary and cerebral embolization

45
Q

Sclerotherapy vs banding in varices

A

similar results

46
Q

Acute hemorrhage spontaneous resolution rate and why

A

40-50% 1) hypovolemia 2) splanchnic vasoconstriction

47
Q

Treatment for acute variceal bleed

A

1) vasopresin (60-80% success; decrease mortality, SE decrease CO) 2) somatostatin 3) octreotide 4) balloon tamponade 5) EVBL 6) sclerotherapy 7) BRTO/BATO 8) TIPS

48
Q

Benefit of octreotide over somatostatin in variceal bleed

A

half life, octreotide 100 min vs somatostatin 2 min

49
Q

Sengstaken-Blakemore balloon

A

AKA Linton-Nachlas 2 balloons: 1 for esophageal and 1 for gastric port to sunction gastric content Minnesota balloon has 2nd suction for esophagus

50
Q

Risk of balloons in esophageal varices

A

1) aspiration pneumonia 2) airway obtsruction 3) tube migration 4) esophageal ulceration 5) rupture

51
Q

Balloon-occluded retrograde transvenous obliteration (BRTO) goal and steps

A

Goal: occlude portosystemic collaterals between stomach and renal vein 1) treat esophageal varices first 2) evaluate portal vein patency 3) sclerosing agent injected with balloon in place 4) balloon up for 4-24 hours 5) can increase portal HTN and worsen it Success rate 91-100%

52
Q

Balloon-occluded antegrade transvenous obliteration (BATO) goals and steps

A

Goal: occlude collaterals from portal system from gastric veins in antegrade fashion 3 ways to access: 1) perc transhepatic 2) existing TIPS 3) trans-ileocolic vein (for mesenteric varices only) increase BRTO alone success to 98-100%

53
Q

Duplex scanning in portal hypertension use

A

1) portal vein patency 2) direction of flow via portal vein 3) surveillance post treatment

54
Q

CTA in portal hypertension use

A

1) determine patency of portal vein 2) chronicity 3) pathologic features

55
Q

Percutaneous angiogram in portal hypertension uses

A

Transhepatic portal venography 1) portal tributaries 2) portal hepatic wedge pressure Severe cirrhosis: 1) dense collaterals 2) dilation of hepatic artery 3) reversal of flow in portal vein

56
Q

Prevent bleeding in primary prevention of portal hypertension

A

1) beta blockade 2) endosopic variceal band ligation 3) endoscopic sclerotherapy

57
Q

Beta blockade in portal hypertension

A

Non-selective Propranol or carvedilol Reduce CO –> decrease systemic pressure –> decrease portal pressure

58
Q

Endoscopic variceal band ligation in portal hypertension risks

A

Perforation pain bleed

59
Q

Transjugular intrahepatic portosystemic shunt (TIPS) uses and success rate and steps

A

For refractory variceal bleed and ascites Success 97%, complication < 3% 1) IJ access 2) select right hepatic vein (middle and left less optimal) 3) balloon catheter to wedge venogram 4) direct guide cath to portal vein 5) trocar stylet pass parenchyma towards portal vein 6) 10 Fr guide cath to portal system 8) deploy covered stent 9) check pressure gradient to less than 12 mmHg

60
Q

TIPS vs BRTO results

A

no direct comparisons available; TIPS lower recurrence

61
Q

Rebleeding in portal hypertension most common when

A

first 5 days; otherwise 80% in 1 year without prophylaxis

62
Q

Secondary prevention in portal hypertension bleed

A

1) beta blocker 2) EBVL TIPS decrease bleed but increase risk of encephalopathy

63
Q

Ascites treatment

A

1) Spironolactone 100 mg - 400 mg for weight loss 2) furosemide 40 - 160 mg; prevent hyperkalemia

64
Q

Encephalopathy treatment

A

1) correct inciting condition (bleed, infection, electrolyte imbalance, restric ammonia) 2) lactulose (prevent ammonia absorption and increase fecal nitrogen excretion 3) neomycin (SE: nephrotoxic and ototoxic)

65
Q

Hepatic and portal recanalizations steps

A

1) IJ or fem approach to get hepatic vein 2) if fail then transhepatic percutaneous then snare wire Vs TIPS: less complication, less encephalopathy For liver transplant candidacy may embolize varices to maintain portal patency

66
Q

Portosystemic bypass bleed recurrence

A

< 3% no role as prophylaxis because risk of encephalopathy

67
Q

Selective vs non-selective shunts in portal hypertension

A

Selective: preseve blood flow to portal vein while decompressing esophageal varices i.e. distal splenorenal shunt Non-selective shunt = drain all portal blood to caval system 1) portocaval shunt 2) mesocaval shunt selective has less liver failure and encephalopathy

68
Q

Portocaval shunt steps

A

1) midline or RUQ subcostal incision 2) mobilize duodenum 3) isolate IVC 4) isolate PV from hepatic artery and bile duct 5) divide portal vein if doing end-to-side; ligate hepatic side of it and sew the other to IVC 5b) portal to IVC proximity and sew together or use PTFE if doing side-to-side Portal pressure should decrease by > 50%

69
Q

Mesocaval shunt used for

A

1) hemorrhage 2) massive ascites 3) obliterated portal vein 4) obesity 5) Budd-Chiari syndrome

70
Q

Steps in mesocaval shunt

A

1) midline laparotomy 2) colon rotate superiorly 3) SB rotate inferiorly 4) expose root of SB mesentary 5) open root of transverse mesocolon to expose SMV 6) identify IVC 7) PTFE 18-20 mm bypass SMV to IVC Should decrease portal pressure by > 50% and palpate thrill in graft

71
Q

Ddistal spleno-renal shunt steps

A

1) bilateral subcostal incision 2) open lesser sac 3) identify splenic vein 4) right gastroepiploic vein divided but preserve short gastric veins 5) rotate pancreas anteriorly to expose splenic vein 6) ligate connection to pancreas 7) divide ligament of treitz and rotate 4th duodenum inferiorly 8) identify renal vein 9) divide splenic vein 10) divide connection to SMV 11) end to side renal vein 12) divide collateral betwen portal-azygos and portal-mesenteric 13) divide left gastric vein and umbilical vein and falciform ligament should crease splenic pressure by 60-70%

72
Q

Benefit of surgery in portal hypertension

A

1) better patency 2) better prevention of recurrent bleed 3) more likely to survive after transplant

73
Q

Causes of portal hypertension

A

R9 (200 decks)

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