15肝胆外科-门脉高压症（教学）

1、门脉高压症The Portal Hypertension贺志军 教授中南大学湘雅二医院普外器官移植科贺志军教授简介1982 1987 衡阳医学院医疗系，获学士学位1987 1991 耒阳市人民医院外科，住院医生1991 1996 湘雅医院普外科硕博连读研究生，获博士学位1996 1998 芬兰Tampere大学医院普外科博士后，临床外科 访问学者1998 2000 青岛大学医学院附属烟台毓璜顶医院肝胆外科 主任，副教授，硕士生导师2000 2003 美国西北大学腹部器官移植中心、德州大学医 学院、匹兹堡大学器官移植中心访问学者2003 现在 湘雅二医院器官移植中心教授，外科副主任授课主要内容什

2、么是门脉高压？What is the portal hypertension?门脉高压如何产生？How dose it happen?门脉高压的危害？What is its results?如何诊断门脉高压？Diagnosis如何治疗门脉高压？Treatment解剖 Anatomy什么是门脉高压症？ The definition of portal hypertensionPortal hypertension is defined as a portal vein pressure above the normal range of 5 to 8 mm Hg. Portal hyperten

3、sion may also be defined by the hepatic vein-portal vein pressure gradient, which is greater than 5 mm Hg in portal hypertensive states. 病因 Etiology宏观肝前性、肝性、肝后性 prehepatic, hepatic and posthepatic conditions.微观窦前性、窦性、窦后性 presinusoidal, sinusoidal, or postsinusoidal conditions.病理生理 pathophysiology增加门

4、脉压力的因素 the factors of portal hypertensionincreased resistance: cirrhosis, portal vein thrombosis, or hepatic venous obstruction.increase in splanchnic flow: splanchnic vasodilation by various cytokines and hormonesArteriovenous shunts：nitric oxide, prostacyclins, endotoxins, and glucagon第一章 肝硬化门静脉高压

5、症 The portal hypertension with cirrhosis病因 Etiology肝炎 hepatitis血吸虫 schistosomiasis 病理生理 pathophysiologyWhen his portal vein pressure increased more than 25-50 cm H2O.静脉曲张 varices脾大、脾亢 hypersplenotrophy腹水 ascites肝性脑病 hepatic encephalopathy腹水形成的机制腹水肝内血管阻力低蛋白血症胶体渗透压淋巴液组织静水压毛细血管通透性门静脉压全身水负荷临床表现 clinical

6、 manifestation脾大、脾亢 Hypersplenotrophy, Hypersplenia呕血、 Gastroenterological Bleeding腹水Ascites 诊断和鉴别诊断Diagnosis and differential diagnosis病史及临床表现实验室检查 Lab. Test影像学检查 ImagesX光照片 X-rayB超 B-UltrasonographyCT, MRI and portal angiography临床评估目标 Clinical Evaluation (1) to determine the cause of portal hypert

7、ension .(2) to estimate hepatic functional reserve.(3) to define the portal venous anatomy and assess hemodynamic status. (4) to identify the site of GI hemorrhage (if present). CHILD-TURCOTTE CRITERIA FOR HEPATIC FUNCTIONAL RESERVE门脉高压症的治疗食道静脉破裂出血脾亢、脾大腹水原发病-肝硬化1.食道静脉曲张破裂出血的治疗 Treatment of Variceal

8、bleeding非手术治疗 expectant treatment输血 bleed transfusion生长抑素 Sandostatin三腔二囊管压迫内镜套扎 endoscopic esophageal variceal ligation硬化剂注射 endoscopic esophageal variceal sclerotherapy食道静脉曲张破裂出血的手术治疗 Surgical treatment分流术 shunt operation断流术 devascularization operation 经颈静脉肝内门腔支架分流术Transjugular intrahepatic portos

9、ystemic stent shunt, TIPS门腔分流术 portocaval shunt operation部分门腔分流术 partial portacaval shunt operation 肠腔分流术 mesocaval operation 选择性远端脾肾静脉分流术 Warren operation断流术 devascularization operation 内镜及药物处理失败后的食道静脉曲张破裂出血的手术处理方案2. 脾亢的外科治疗脾切除术 或 脾切除+断流术3. 腹水的外科治疗腹腔静脉转流术TIPS肝移植4. 终末期肝病的根治性处理方案-liver transplantatio

10、n手术步骤器官修整病肝切除供肝植入切除的病肝良好的肝移植效果肝癌和胆汁淤积性肝硬化患者原发性胆汁淤积症患者肝移植术后其它各类疾病患者肝移植术后状态再次肝移植我中心开展的腹部联合器官移植肝肾联合移植肝胰联合移植（省内首例，国内第二例）胰肾联合移植（省内首位成功病例）（省内首例）第二节 肝前型门脉高压症 Prehepatic portal hypertension病因 etiology先天畸形 congenital malformation脐静脉炎 omphalophlebitis门静脉海绵样变 cavernous transformation of portal vein动静脉瘘 A-V fis

11、tula肝前型门脉高压症 Prehepatic portal hypertension临床表现 clinical manifestation处理 treatment第三节 肝后型门脉高压症Budd-Chiari SyndromeThe Budd-Chiari syndrome is caused by hepatic venous obstruction. The obstruction may occur at the level of the inferior vena cava, the hepatic veins, or the central veins within the liv

12、er itself.病因Etiologycongenital webs (most common in Africa and Asia), acute/chronic thrombosis (most common in the West): hypercoagulable states associated with polycythemia vera, myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, and defects in the coagulation cascade, as in conditi

13、ons associated with high estrogen levels (e.g., pregnancy and administration of birth control pills) .malignancy.obliterative endophlebitis of the intrahepatic veins分型 TypingI型：57% 下腔静脉隔膜II型：38% 下腔静脉弥漫性狭窄或阻塞III型：5% 肝静脉阻塞症状 SymptomsAcute symptoms include hepatomegaly, right upper quadrant abdominal p

14、ain, nausea, vomiting, and ascites.Chronic symptoms include variceal bleeding, ascites, spontaneous bacterial peritonitis, fatigue, and encephalopathy. 诊断 DiagnosisUltrasonographic evaluation has a sensitivity of 85% to 95%. CT Angiography is the “gold standard” for the diagnosis, which provides detailed information on the location and degree of obstruction. 治疗 Treatmentinterventionportosystem