Chapter 164 - Portal hypertension

Question 1

Definition of portal hypertension

Answer 1

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

Question 2

Ohm’s law

Answer 2

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

Question 3

Normal portal pressure

Answer 3

5-10 mmHg

Question 4

Pathogenesis of liver cirrhosis

Answer 4

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

Question 5

Portal hypertension classes

Answer 5

1) extrahepatic 2) intrahepatic 3) post hepatic

Question 6

Extrahepatic pre-sinusoidal obstruction causes

Answer 6

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

Question 7

Intrahepatic presinusoidal obstruction causes

Answer 7

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

Question 8

Intrahepatic sinusoidal and postsinusoidal causes and mechanism

Answer 8

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

Question 9

Extrahepatic postsinusoidal obstruction causes

Answer 9

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

Question 10

AVF in portal hypertension causes

Answer 10

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

Question 11

Clinical presentation of portal hypertension

Answer 11

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

Question 12

Pathogenesis of variceal formation in portal hypertension

Answer 12

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

Question 13

Varices pathway in portal hypertension

Answer 13

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

Question 14

Esophageal varices zones

Answer 14

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

Question 15

Gastric varices types

Answer 15

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

Question 16

Caput medusae pathogenesis

Answer 16

Left portal vein to periumbilical vein in falciform ligament

Question 17

Rate of varices in cirrhosis at diagnosis

Answer 17

50%

Question 18

Rate of varices in cirrhosis with long term f/u

Answer 18

90%

Question 19

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

Answer 19

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

Question 20

Mortality associated with variceal bleed

Answer 20

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

Question 21

Pathogenesis of variceal bleeding

Answer 21

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

Question 22

Critical hepatic venous gradient

Answer 22

12 mmHg

Question 23

Ascites rate in portal hypertension

Answer 23

80%

Question 24

Pathology of ascites in portal hypertension

Answer 24

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

Question 25

Risk of ascites

Answer 25

Spontaneous bacterial peritonitis 30% need hospitalization due to SBP

Question 26

Type of bacteria in spontaneous bacterial peritonitis

Answer 26

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

Question 27

Encephalopathy definition

Answer 27

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

Question 28

Pathology of encephalopathy

Answer 28

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

Question 29

Wes Haven Criteria is for

Answer 29

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

Question 30

Rate of encephalopathy in decompensated liver failure

Answer 30

30-40%

Question 31

Hepatorenal syndrome defn

Answer 31

Renal dysfunction in presence of cirrhosis and ascites Diagnosis of exclusion

Question 32

Symptom of hepatorenal syndrome

Answer 32

1) oliguria 2) hyponatremia 3) low urine sodium

Question 33

Hepatorenal syndrome types

Answer 33

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

Question 34

Hepatopulmonary/portopulmonary syndrome defn

Answer 34

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

Question 35

Symptoms of hepatopulmonary syndrome

Answer 35

1) clubbing 2) dyspnea 3) deoxygenation

Question 36

Laboratory workup for portal hypertension

Answer 36

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

Question 37

Other specific tests for portal hypertension

Answer 37

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)

Question 38

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

Answer 38

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

Question 39

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

Answer 39

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

Question 40

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

Answer 40

Hepatitis B

Question 41

Liver biopsy: Mallory-Denk bodies

Answer 41

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

Question 42

Liver biopsy: pipestem fibrosis

Answer 42

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

Question 43

Success in endoscopic sclerotherapy

Answer 43

Cyanoacrylate 93% success; 7% rebleed

Question 44

Side effect of endoscopic sclerotherapy

Answer 44

Pulmonary and cerebral embolization

Question 45

Sclerotherapy vs banding in varices

Answer 45

similar results

Question 46

Acute hemorrhage spontaneous resolution rate and why

Answer 46

40-50% 1) hypovolemia 2) splanchnic vasoconstriction

Question 47

Treatment for acute variceal bleed

Answer 47

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

Question 48

Benefit of octreotide over somatostatin in variceal bleed

Answer 48

half life, octreotide 100 min vs somatostatin 2 min

Question 49

Sengstaken-Blakemore balloon

Answer 49

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

Question 50

Risk of balloons in esophageal varices

Answer 50

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

Question 51

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

Answer 51

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%

Question 52

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

Answer 52

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%

Question 53

Duplex scanning in portal hypertension use

Answer 53

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

Question 54

CTA in portal hypertension use

Answer 54

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

Question 55

Percutaneous angiogram in portal hypertension uses

Answer 55

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

Question 56

Prevent bleeding in primary prevention of portal hypertension

Answer 56

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

Question 57

Beta blockade in portal hypertension

Answer 57

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

Question 58

Endoscopic variceal band ligation in portal hypertension risks

Answer 58

Perforation pain bleed

Question 59

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

Answer 59

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

Question 60

TIPS vs BRTO results

Answer 60

no direct comparisons available; TIPS lower recurrence

Question 61

Rebleeding in portal hypertension most common when

Answer 61

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

Question 62

Secondary prevention in portal hypertension bleed

Answer 62

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

Question 63

Ascites treatment

Answer 63

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

Question 64

Encephalopathy treatment

Answer 64

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)

Question 65

Hepatic and portal recanalizations steps

Answer 65

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

Question 66

Portosystemic bypass bleed recurrence

Answer 66

\< 3% no role as prophylaxis because risk of encephalopathy

Question 67

Selective vs non-selective shunts in portal hypertension

Answer 67

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

Question 68

Portocaval shunt steps

Answer 68

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%

Question 69

Mesocaval shunt used for

Answer 69

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

Question 70

Steps in mesocaval shunt

Answer 70

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

Question 71

Ddistal spleno-renal shunt steps

Answer 71

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%

Question 72

Benefit of surgery in portal hypertension

Answer 72

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

Question 73

Causes of portal hypertension

Answer 73