Portal HTN/Ascites

Question 1

Describe the classic bleeding pattern of perforated esophageal veins in a pt with portal HTN?

Answer 1

They bleed heavily and constantly (like a hose on medium flow- can die quickly) most commonly at night

It so high pressure that you dont even see pulsations

Question 2

What is the blood supply to the liver?

Answer 2

70% portal vein

30% hepatic artery

Question 3

Describe resistance in the normal liver

Answer 3

Normally, it is a very low resistance system due to the presence of sinusoids as the major blood conduits

Question 4

How does resistance change in a pt. with cirrhosis?

Answer 4

It is drastically increased due to:

• extensive fibrotic induced scarring
• changing of sinusoids into high-resistance capillaries
• increased GI blood flow in these pts.

Question 5

What are the consequences of collateral circulation arising following portal HTN?

Answer 5

• Hormones (e.g. glucagon) that normally goes through the liver are not re-routed into systemic circulation where they have a number of effects including:
• increased splanchnic blood flow
• changing arterial resistance

Question 6

This is where blood goes in portal HTN pts.

Question 7

How does the splenic vein react to portal HTN?

Answer 7

Its part of the splanchnic circulation (high pressure) so it will shunt to the renal vein which will have normal pressure

Question 8

How common are varices in cirrhotic pts?

Answer 8

About 50% will develop them, with 32% bleeding within 2 yrs (massive hemorrhage usually- major cause of death)

Question 9

What are the traid of findings with varices?

Answer 9

• high pressure bleeding
• thrombocytopenia
• coagulopathy (impaired clooting factor synthesis)

Question 10

Why is thrombocytopenia seen in portal HTN?

Answer 10

splenic sequestration

Question 11

What is this?

Answer 11

Portal HTN gastropathy- the stomach will get congested in portal HTN

Question 12

What are the major parts of treatment of portal HTN leading to variceal bleeds?

Answer 12

• endoscopic therapy to sclerose or band the varices
• splanchnic vasoconstriction to decrease blood flow to the stomach and intestine and decrease collateral BF via vasopression or somatostatin
• correction of coagulopathy

Question 13

Why would somatostatin be used to constrict splanchnic blood flow?

Answer 13

it blocks glucagon, a potent vasodilator

Question 14

How can portal HTN be addresses not in an acutely bleeding pt?

Answer 14

• beta blockers
• transjuglar portosystemic shunts
• liver transplant if needed

Question 15

Answer 15

Question 16

Question 17

Answer 17

BP will be low!

Question 18

Answer 18

Question 19

What are the consequences of ascites?

Answer 19

• pressure develops on the stomach and diaphragm, leading to trouble breathing and eating
• hepatic hydrothorax (fluid upward through the diaphgram basically leading to pleural effusion)
• spontaneous bacterial peritonitis (often gram - rods from the GI)

Question 20

How is ascites tx?

Answer 20

large volume paracentesis WITH IV albumin

-sodium restriction

• diuretics
• treat the liver disease/transplant

Question 21

What is a common sequelae of ascites weakening the umilical area?

Answer 21

umbilical hernia

Question 22

Question 23

refractory ascites is a BAD prognosis