外科学教学课件：门静脉高压

1、Company LOGO Portal Hypertension Company Logo Basic Anatomy 1 Definition 2 Classification 3 Etiology 4 Pathology 5 Pathophysiology 6 Company Logo Clinic Clinical Manifestation 1 Diagnosis 2 Differential Diagnosis 3 Treatment 4 Company Logo Normal Anatomy Of The Portal Venous System v The portal vein

2、 （PV）is formed by the confluence of the splenic(SV), superior mesenteric(SMV), and inferior mesenteric veins(IMV) the entrance of the inferior mesenteric vein (I MV) into the splenic vein （SV）, the mostcommon anatomic arrangement Company Logo Normal Anatomy Of The Portal Venous System v The normal p

3、ortal pressure is 1324cmH2O v Capillaries of the intestine portal vein capillaries of hepatic sinusoids Thus nutrients and hormones are delivered to the liver directly and in high concentration v The lack of valves in the portal venous system provides a system that can accommodate high flow at low p

4、ressure because of the low resistance v Four collaterals between Portacaval System Company Logo Four collaterals between Portacaval System v At normal portal venous pressure very little blood is shunted from the portal venous system into the above pathways . v As the pressure increases, however, the

5、 above communications dilate, and a large amount of blood may be shunted around the liver and into the systemic circulation. Company Logo Normal Anatomy Of The Portal Venous System Four collaterals between Portacaval System v 1).Gastroesophageal collateral vessels: azygos vein (caval system) coronar

6、y or short gastric vein. (portal system) v 2).Anorectal collateral vessels: hemorrhoidal vein and sup.rectal vein (portal system ) Rectal and anal vein.(caval system) v 3).Paraumbilical collateral vessels: Paraumbilical vein (portal system) Superficial, superior, and inferior epigastric vein. (caval

7、 system) v 4).Retroperitoneal collateral vessels: visceral vein of Retzius venous plexus (portal system) inferior vena cava. (caval system) Company Logo Normal Anatomy Of The Portal Venous System v Four collaterals between Portacaval System Company Logo Definition Of Portal hypertension v Definition

8、 :The portal vein system blood flow obstruction and blood stasis , collateral vessels open ,results in increased portal vein system pressure (25cm H2O)and clinical syndrome v Clinic features:Splenomegaly, Hypersplenism, Esophagus gastric varices, Hematemesis and Ascites Company Logo Classification P

9、ortal hypertension can be classified according to the site of obstruction Blockage of the portal vein before the liver e.g. Portal vein thrombosism Distortion of the liver architecture e.g. Various hepatitis and cirrhosis ( 95 ) Venous blockage outside the liver (rare) e.g. Right heart failure (rare

10、) Budd- Chiari syndrome Company Logo Classification Company Logo Classification Company Logo Classification Company Logo Classification Company Logo Classification Company Logo Etiology vThe most common causes of portal hypertension are hepatitis and cirrhosis. Prehepatic Intrahepatic Portal or sple

11、nic vein thrombosis Intra-abdominal infection (acute appendicitis, acute pancreatitis ) Congenital malformation Posthepatic Budd-Chiari syndrome Congestive heart failure Constrictive pericarditis Company Logo Pathology (1)Normally, the hepatic portal venous blood traverses the liver and empties into

12、 the IVC via the hepatic vein (2)In the cirrhosis of liver the collateral pathways open up between the portal and caval venous systems Company Logo Pathophysiology Splenomegaly, Hypersplenism Collateral pathways open up Ascites portal venous flow blocking splenemia fibrous tissue hyperplasia , regen

13、eration of marrow cell splenomegaly, hypersplenis Company Logo Pathophysiology Splenomegaly, Hypersplenism Collateral pathways open up Ascites esophageal and gastric varices hematemesis（呕血） and/or hematochezia （便血） rectal varices hemorrhoids(痔疮） periumbilical varices Caput medusae(海蛇头 ) Company Logo

14、 Pathophysiology Company Logo Pathophysiology Splenomegaly, Hypersplenism Collateral pathways open up Ascites Portal venous pressure increased Increase in filtration pressure of capillary bed Increased formation of hepatic lymph Cirrhosis, hypohepatia (hypoalbuminemia) Clinical Manifestation v Early

15、 changes : cannot be detected by physical examination. v Signs of advances: increased abdominal venous markings, ascites and splenomegaly Hematemesis, Melena Ascites Splenomegaly, Hypersplenism Company Logo Clinical Manifestation Hematemesis, Melena Ascites Splenomegaly, Hypersplenism Company Logo C

16、linical Manifestation Hematemesis, Melena Ascites Splenomegaly, Hypersplenism Esophageal and gastric varices rupture Acutely upper gastrointestinal bleeding Every third patient with variceal hemorrhage dies The risk of rebleeding after a hemorrhage is 70% Company Logo Clinical Manifestation Others：

17、Jaundice, Caput Medusae, Liver Palms（肝掌）, Spider Angioma（蜘蛛痣） etc Company Logo Diagnosis Medical History And Clinic Features vMedical History China: Hepatitis B or Schistosomiasis Western nations: Hepatitis C or Alcoholism vClinic Features: splenomegaly and hypersplenism hematemesis and melena ascit

18、es spider angioma jaundice Company Logo Diagnosis Laboratory Examinations Blood routine examination : WBC leukopenia , infecion Hypersplenism RBC anemia PLT thrombocytopenia haemorrhage Company Logo Diagnosis Laboratory Examinations Liver Function: Hepatocyte damage bilirubinjaundice ALT, AST Liver

19、synthesis function serum albuminedema , ascites Liver diseases (inflammation , cirrhosis) serum globulin A/G ratio reversing Company Logo ChildTurcottePugh (CTP) classification of the severity of cirrhosis Company Logo One-year probability (%) of developing variceal hemorrhage according to risk fact

20、ors Company Logo Diagnosis Laboratory Examinations v Tumor marker： Marked elevation of the serum -fetoprotein will contribute to making the diagnosis for liver cancer v Markers of hepatitis B or C v Coagulation function v Immunologic test v Liver fibrosis test Company Logo v 肝硬化合并肝细胞癌肝硬化合并肝细胞癌 肝硬化无合

21、并肝细胞癌肝硬化无合并肝细胞癌 Diagnosis Endoscopic Examinations Esophago-Gastro-Duodenoscopy v Emergency Esophago-Gastro-Duodenoscopy is the most useful procedure for diagnosing bleeding varices v It should be performed as soon as the patients general condition is stabilized by blood transfusion and other support

22、ive measures v Varices appear as three or four large, tortuous submucosal bluish vessels running longitudinally in the distal esophagus Company Logo Diagnosis Image Examinations Upper Gastrointestinal Series Company Logo Diagnosis Image Examinations Abdominal Ultrasound Company Logo blood flow in th

23、e portal vein(blue ) hepatic artery flow (red) Diagnosis Image Examinations Abdominal Ultrasound Company Logo v B-ultrasound and Doppler ultrasound: can help to understand the degree of cirrhosis of the liver, splenomegaly, ascites, portal vein thrombosis or not Diagnosis Image Examinations Computed

24、 Tomography Company Logo v Liver cirrhosis Ascites Diagnosis Image Examinations Computed Tomography Company Logo v Esophageal and gastric varices Spleen venous distension Diagnosis Image Examinations Computed Tomography Company Logo v Regional portal hypertension caused by pancreatic cyst Diagnosis

25、Image Examinations Computed Tomography Company Logo v Regional portal hypertension caused by pancreatitis, pancreatic pseudocyst Diagnosis Image Examinations Computed Tomography Company Logo v 2014-04 2014-02 v Regional portal hypertension caused by pancreatitis, pancreatic pseudocyst v Perigastric

26、varices Splenomegaly Diagnosis Image Examinations Computed Tomography Company Logo v2014-04 2014-02 v Regional portal hypertension caused by pancreatitis, pancreatic pseudocyst v Perigastric varices Splenomegaly Diagnosis Image Examinations Magnetic Resonance Imaging Company Logo v Splenomegaly Sple

27、en venous distension Diagnosis Image Examinations Angiography Company Logo Differential Diagnosis Company Logo Differential diagnosis of causes of hemorrhage Hemorrhage from peptic ulcer Erosive gastritis Gastric carcinoma Other causes Differential diagnosis of causes of ascites Tuberculosis of peri

28、toneum Cardiac insufficiency Immune system disease Kidney disease Abdominal or ovarian cancer Treatment Company Logo v Bleeding from esophagogastric varices is the single most life-threatening complication of portal hypertension v The risk for death from bleeding is mainly related to the underlying

29、hepatic functional reserve v Nonoperative treatments are generally preferred for acutely bleeding patients; they are often high operative risks because of decompensated hepatic function (e.g., Child-Pugh class C) Non-surgical treatment Company Logo vPatients with jaundice, massive ascites and severe

30、ly impaired liver function if bleeding occurs. vWhen the position of the upper gastrointestinal bleeding is not clear, active rescue, as well as the necessary checks should be taken to confirm the diagnosis vAs a preparation for surgery. vNon-surgical treatment should be adopted in the patients with

31、 gastroesophageal variceal bleeding, especially the patients with Child C grade of the hepatic functional reserve. The indications Non-surgical treatment Company Logo vto evaluate the status of the blood volume and restore the patients blood volume The lack of hypotension or tachycardia in the supin

32、e patient is not adequate, as 25% of the blood volume may be lost without any change in these values Overexpansion of the plasma volume will increase portal pressure and may precipitate variceal hemorrhage General measures Treatment Company Logo Treatment options of Bleeding Esophageal Varices Non-s

33、urgical treatment Company Logo Vasopressin and Nitroglycerin Somatostatin and Analogs（Octreotide） Medical therapy should be initiated at the onset of variceal bleeding Antibiotic prophylactic should be initiated. Because infections are common in patients with variceal bleeding Pharmacotherapy Non-su

34、rgical treatment Company Logo Vasopressin can diminish splanchnic blood flow in severe cases of hemorrhage. Nitroglycerin should be simultaneously used to achieve blood pressure control, because of the adverse systemic effects of vasopressin Somatostatin and Analogs are as efficacious as endoscopic

35、treatment for control of acute variceal bleeding. Combination of octreotide and endoscopic therapy is the preferred treatment for most patients Pharmacotherapy Non-surgical treatment Company Logo Balloon Tamponade Sengstaken-Blakemore tube Non-surgical treatment v Balloon tamponade is as effective a

36、s pharmacotherapy and endoscopic therapy in controlling acute variceal bleeding v The major advantages of Sengstaken-Blakemore tube are immediate cessation of bleeding in more than 85% of patients Company Logo Balloon Tamponade Sengstaken-Blakemore tube Non-surgical treatment Usage： vInflating gastr

37、ic balloon150 200ml vInflating esophageal balloon 100150 ml vCatheter depth 5060cm Company Logo Balloon Tamponade Sengstaken-Blakemore tube Non-surgical treatment Precautions ： vComplication: pneumonitis vLateral recumbent position vLeft 24-72hours vEvery 12 hours, empty the balloon for 10-15min. Co

38、mpany Logo Balloon Tamponade Sengstaken-Blakemore tube Non-surgical treatment Company Logo Endoscopic ligation of esophageal varices Non-surgical treatment Company Logo Endoscopic sclerotherapy（硬化剂） of esophageal varices Non-surgical treatment v Endoscopic treatment (e.g.sclerosis or ligation) has b

39、ecome the mainstay of nonoperative treatment of acute hemorrhage because bleeding can be controlled in more than 85% of patients v Sclerotherapy is as good as balloon tamponade and better than treatment with vasopressin or terlipressin and similar with the efficacy of somatostatin or octreotide Comp

40、any Logo Endoscopic Therapy Non-surgical treatment v Esophageal band ligation is as effective as sclerotherapy in the control of acute bleeding and has replaced sclerotherapy because of the less frequent side effects and the more rapid disappearance of varices Company Logo Endoscopic Therapy Surgica

41、l treatment The operation should be done immediately when the bleeding occurs in the patients(Child A, B grade) with no jaundice or obvious ascites, together with the condition of no response to the 2448 hours non-surgical treatment Company Logo The indications Surgical treatment Surgical shunts. Su

42、rgical devascularization procedures. Liver transplantation. Company Logo Surgical Procedures Role of therapy options and different time points in managing variceal bleeding Company Logo Surgical treatment Anastomose the portal vein or its main branches (splenic vein and superior mesenteric vein) to

43、vena cava or its main branches(renal vein)by use of operative procedures, and put the hypertensive portal blood flow into the low-pressured inferior vena cava. To reduce the portal vein pressure and thus decrease the blood flow through collateral venous beds Company Logo Surgical shunts Surgical tre

44、atment Total shunts splenorenal shunt portacaval shunt end-to-side, side-to-side, H-graft mesocaval shunt Selective shunts distal splenorenal shunt(Warrensoperation) TIPSS Company Logo Surgical shunts Therapeutic effects on portal flow, resistance, and pressure of different therapies for portal hype

45、rtension Company Logo Surgical treatment Company Logo Splenorenal Shunt Surgical treatment Company Logo Splenorenal Shunt Surgical treatment Company Logo Portacaval Shunt Surgical treatment Company Logo Superior Mesenteric and Inferior Vena Cava Shunt Surgical treatment Company Logo Superior Mesente

46、ric and Inferior Vena Cava Shunt Surgical treatment Company Logo Transjugular Intrahepatic Portosystemic Stent Shut (TIPSS) Surgical treatment vTIPS is a minimally invasive means for patients with advanced liver disease to create a direct communication between the portal and hepatic venous systems w

47、ithin the liver parenchyma vThis technique is of great value in controlling portal hypertension and variceal bleeding and can be used to stop acute bleeding or to prevent rebleeding in a patient who has recovered from an acute episode Company Logo Transjugular Intrahepatic Portosystemic Stent Shut (

48、TIPSS) Surgical treatment vTIPS is used most commonly as a salvage procedure in patients who continue to bleed after treatment with pharmacologic agents and endoscopic banding or sclerotherapy Company Logo Transjugular Intrahepatic Portosystemic Stent Shut (TIPSS) Surgical treatment Devascularizatio

49、n: the purpose is to block the anomalous flow between the azygos and portal vein, and remove the spleen at the same time in order to achieve hemostasis Company Logo Surgical devascularization procedures Surgical treatment Pericardial vessels can be divided into four groups: Gastric Coronary Vein ： S

50、hort Gastric Vein ； Posterior Gastric Vein ； Left Inferior Phrenic Vein Company Logo Surgical devascularization procedures Surgical treatment v Surgical devascularization procedures Company Logo Company Logo Comparing the shunt with devascularization Company Logo Evaluation and Selection of Surgical Procedures Shunt：decrease portal flow and portal pressure significantly. higher incidence of hepatic encephalopathy Devascularization： reducing inflow to varices, The more extensive the devas- cularization, the lower the subse