Portal Hypertension, C53 P357-363 Flashcards Preview

Section II General Surgery P203Surgical Recall Sixth > Portal Hypertension, C53 P357-363 > Flashcards

Flashcards in Portal Hypertension, C53 P357-363 Deck (51):
1

Identify the anatomy of the
portal venous system:
P357 (picture)

1. Portal vein
2. Coronary vein
3. Splenic vein
4. IMV (inferior mesenteric vein)
5. SMV (superior mesenteric vein)
6. Superior hemorrhoidal vein

2

Describe drainage of
blood from the superior
hemorrhoidal vein.
P358

To the IMV, the splenic vein, and then
the portal vein

3

Where does blood drain into
from the IMV?
P358

Into the splenic vein

4

Where does the portal vein
begin?
P358

At the confluence of the splenic vein and
the SMV

5

What are the (6) potential
routes of portal–systemic
collateral blood flow (as seen
with portal hypertension)?
P358

1. Umbilical vein
2. Coronary vein to esophageal venous
plexuses
3. Retroperitoneal veins (veins of Retzius)
4. Diaphragm veins (veins of Sappey)
5. Superior hemorrhoidal vein to middle
and inferior hemorrhoidal veins and
then to the iliac vein
6. Splenic veins to the short gastric
veins

6

What is the pathophysiology
of portal hypertension?
P358

Elevated portal pressure resulting from
resistance to portal flow

7

What level of portal
pressure is normal?
P358

<10 mm Hg

8

What is the etiology?
P358

Prehepatic—Thrombosis of portal vein/
atresia of portal vein
Hepatic—Cirrhosis (distortion of
normal parenchyma by regenerating
hepatic nodules), hepatocellular
carcinoma, fibrosis
Posthepatic—Budd-Chiari syndrome:
thrombosis of hepatic veins

9

What is the most common
cause of portal hypertension
in the United States?
P358

Cirrhosis (>90% of cases)

10

How many patients with
alcoholism develop
cirrhosis?
P358

Surprisingly, < 1 in 5

11

What percentage of patients
with cirrhosis develop
esophageal varices?
P359

≈40%

12

How many patients with
cirrhosis develop portal
hypertension?
P359

Approximately two thirds

13

What is the most common
physical finding in patients
with portal hypertension?
P359

Splenomegaly (spleen enlargement)

14

What are the associated
CLINICAL findings in
portal hypertension (4)?
P359 (picture)

1. Esophageal varices
2. Splenomegaly
3. Caput medusae (engorgement of
periumbilical veins)
4. Hemorrhoids

15

What other physical findings
are associated with cirrhosis
and portal hypertension?
P359

Spider angioma, palmar erythema,
ascites, truncal obesity and peripheral
wasting, encephalopathy, asterixis (liver
flap), gynecomastia, jaundice

16

What is the name of the
periumbilical bruit heard
with caput medusae?
P359

Cruveilhier-Baumgarten bruit

17

What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Esophageal varices?
P360

Coronary vein backing up into the
azygous system

18

What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Caput medusae?
P360

Umbilical vein (via falciform ligament)
draining into the epigastric veins

19

What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Retroperitoneal varices?
P360

Small mesenteric veins (veins of Retzius)
draining retroperitoneally into lumbar veins

20

What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Hemorrhoids?
P360

Superior hemorrhoidal vein (which
normally drains into the inferior mesenteric
vein) backing up into the middle
and inferior hemorrhoidal veins

21

What is the etiology?
P360

Cirrhosis (90%), schistosomiasis,
hepatitis, Budd-Chiari syndrome,
hemochromatosis, Wilson’s disease,
portal vein thrombosis, tumors, splenic
vein thrombosis

22

What is the most common
cause of portal hypertension
outside North America?
P360

Schistosomiasis

23

What is Budd-Chiari
syndrome?
P360

Thrombosis of the hepatic veins

24

What is the most feared
complication of portal
hypertension?
P360

Bleeding from esophageal varices

25

What are esophageal
varices?
P360

Engorgement of the esophageal venous
plexuses secondary to increased collateral
blood flow from the portal system as a
result of portal hypertension

26

What is the “rule of 2/3” of
portal hypertension?
P360

2/3 of patients with cirrhosis will develop
portal hypertension
2/3 of patients with portal hypertension
will develop esophageal varices
2/3 of patients with esophageal varices
will bleed from the varices

27

In patients with cirrhosis and
known varices who are
suffering from upper GI
bleeding, how often does that
bleeding result from varices?
P361

Only ≈50% of the time

28

What are the signs/symptoms?
P361

Hematemesis, melena, hematochezia

29

What is the mortality rate
from an acute esophageal
variceal bleed?
P361

≈50%

30

What is the initial treatment
of variceal bleeding?
P361

As with all upper GI bleeding: large
bore IVs x 2, IV fluid, Foley catheter,
type and cross blood, send labs, correct
coagulopathy (vitamin K, fresh frozen
plasma), +/ – intubation to protect from
aspiration

31

What is the diagnostic test
of choice?
P361

EGD (upper GI endoscopy)
Remember, bleeding is the result of
varices only half the time; must rule
out ulcers, gastritis, etc.

32

If esophageal varices cause
bleeding, what are the EGD
treatment options?
P361

1. Emergent endoscopic
sclerotherapy: a sclerosing substance
is injected into the esophageal varices
under direct endoscopic vision
2. Endoscopic band ligation: elastic
band ligation of varices

33

What are the pharmacologic
options?
P361

Somatostatin (Octreotide) or IV
vasopressin (and nitroglycerin, to
avoid MI) to achieve vasoconstriction of the
mesenteric vessels; if bleeding continues,
consider balloon (Sengstaken-Blakemore
tube) tamponade of the varices, -blocker

34

What is a Sengstaken-
Blakemore tube?
P361

Tube with a gastric and esophageal
balloon for tamponading an esophageal
bleed (see page 268)

35

What is the next therapy after
the bleeding is controlled?
P361

Repeat endoscopic sclerotherapy/banding

36

What are the options
if sclerotherapy and
conservative methods fail to
stop the variceal bleeding or
bleeding recurs?
P362

Repeat sclerotherapy/banding and treat
conservatively
TIPS
Surgical shunt (selective or partial)
Liver transplantation

37

What is a “selective” shunt?
P362

Shunt that selectively decompresses the
varices without decompressing the portal
vein

38

What does the acronym
TIPS stand for?
P362

Transjugular Intrahepatic Portosystemic
Shunt

39

What is a TIPS procedure?
P362

Angiographic radiologist places a small
tube stent intrahepatically between the
hepatic vein and a branch of the portal
vein via a percutaneous jugular vein route

40

What is a “partial shunt”?
P362

Shunt that directly decompresses the
portal vein, but only partially

41

What is a Warren shunt?
P362 (picture)

Distal splenorenal shunt with ligation of the
coronary vein—elective shunt procedure
associated with low incidence of
encephalopathy in patients postoperatively
because only the splenic flow is diverted
to decompress the varices

42

What is a contraindication to
the Warren “selective”
shunt?
P363

Ascites

43

Define the following shunts:
End-to-side portocaval shunt
P363

“Total shunt”—portal vein (end) to IVC
(side)

44

Define the following shunts:
Side-to-side portocaval
shunt
P363

Side of portal vein anastomosed to side of
IVC—partially preserves portal flow
(“partial shunt”)

45

Define the following shunts:
Synthetic portocaval
H-graft
P363

“Partial shunt”—synthetic tube graft
from the portal vein to the IVC
(good option for patients with alcoholism;
associated with lower incidence
of encephalopathy and easier
transplantation later)

46

Define the following shunts:
Synthetic mesocaval
H-graft
P363

Synthetic graft from the SMV to the IVC

47

What is the most common
perioperative cause of death
following shunt procedure?
P363

Hepatic failure, secondary to decreased
blood flow (accounts for two thirds of
deaths)

48

What is the major
postoperative morbidity
after a shunt procedure?
P363

Increased incidence of hepatic
encephalopathy because of decreased
portal blood flow to the liver and
decreased clearance of toxins/metabolites
from the blood

49

What medication is infused
to counteract the coronary
artery vasoconstriction of IV
vasopressin?
P363

Nitroglycerin IV drip

50

What lab value roughly
correlates with degree of
encephalopathy?
P363

Serum ammonia level (Note: Thought
to correlate with but not cause
encephalopathy)

51

What medications are used to
treat hepatic encephalopathy?
P363

Lactulose PO, with or without
neomycin PO