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Portal hypertension:A disease better controlled than cured.

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Portal hypertension:A disease better controlled than cured.

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Portal hypertension is one of the common causes of upper gastrointestinal bleeding. It is a very lethal condition. Prompt diagnosis and commencement of early medical treatment can help keeping the disease under control. Surgery is a very useful adjunct in uncontrollable bleeding and in long term prevention in certain selected cases.

Portal hypertension is one of the common causes of upper gastrointestinal bleeding. It is a very lethal condition. Prompt diagnosis and commencement of early medical treatment can help keeping the disease under control. Surgery is a very useful adjunct in uncontrollable bleeding and in long term prevention in certain selected cases.

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Portal hypertension:A disease better controlled than cured.

  1. 1. PORTAL HYPERTENSION By Dr. Ketan Vagholkar MS, DNB, MRCS, FACS. Professor of Surgery & Consultant General Surgeon
  2. 2. Surgical Anatomy of portal venous circulation
  3. 3. Sites of portosystemic anastomosis • Lower oesophagus – Anatomical considerations • Umbilicus • Rectum & anal canal • Bare areas of the liver • Surgically created raw areas
  4. 4. Definition of portal hypertension • Portal venous pressure above 12 mm of Hg. is designated as portal hypertension.
  5. 5. Etiology of portal hypertension • Prehepatic • Intrahepatic – Portal vein thrombosis – Alcoholic cirrhosis – Splenic vein – Schistosomiasis thrombosis – Non cirrhotic portal – Cong. Atresiaof portal fibrosis vein – Hepatic metastasis – Extrinsic compression • Post hepatic – Venooclusive disease – Bud Chiari syndrome
  6. 6. Pathophsiology
  7. 7. Surgical implications • Upper GI bleed from oesophageal varices • Ascites due to liver cell dysfunction • Congestive splenomegaly
  8. 8. Clinical features • Haematemesis(differentia • Jaundice te from haemoptysis) – Duration – Volume – Treatment taken – Color – Mental status – No. of bouts – Blood transfusions – Treatment taken – Hepatitis B – Hospitalization – Family history of hereditary – Procedures performed disease – Duration of hospital stay – Mental status – Malaena
  9. 9. Clinical features • Ascites • Splenomegaly – Sudden distension of – Lump in the left abdomen hypochondrium – Cardiorespiratory – Bleeding tendencies embarrassment – Feeling of heaviness – Tapping in the left – Medical treatment hypochondrium – Features of spontaneous bacterial peritonitis
  10. 10. Clinical features • h/o alcoholism – Volume consumed per day – Duration of consumption
  11. 11. Physical examination • General examination – Level of consciousness – Vital parameters – Signs of hepatocellular failure • Ascites • Jaundice • Gynaecomastia • Spider angiomas • Palmer erythema • Dupuytrens contractures • Asterixis • Foetor hepaticus • Parotid swelling • Paper money skin
  12. 12. Clinical examination • Abdominal examination – Distension due to ascites – Signs for ascites (fluid thrill,shifting dullness,horseshoe shaped dullness,poodle’s sign) – Puncture marks over the abdomen – splenomegaly
  13. 13. Investigations • Laboratory – Cbc – Lft – Coagulation profile – Hepatitis markers (HbsAg) – Serum levels of bun,creatinine.electrolytes – Blood grouping and cross matching
  14. 14. Investigations • Endoscopy – Oesophageal varices – Blood clot over the varix – Varix over varix – Cherry red spots – Salmon patches – Fundic varices – Gastritis – Chronic duodenal ulcer
  15. 15. Investigations • Radiology • Barium – USG oesophagogram • Status of liver • Status of spleen • Free fluid • Portal cavernoma – Duplex doppler – Venous phase of superior mesenteric angiogram – Barium oesophagogram – Splenoportogram
  16. 16. Investigations • Splenoportogram • Performed before shunt surgery • Findings – Splenic pulp pressure – Splenic/portal vein callibre or thrombosis – Cavernomas – Natural shunts – Proximity of splenic vein to left renal vein in late films
  17. 17. Treatment • Preliminary • Resuscitation procedures – Crystalloids – Venesection – Colloids – Urinary catheterisation – Blood – Passage of Ryle’s tube
  18. 18. Treatment • Ryle’s tube washes with • If Ryle’s tube does not cold saline or saline clear then adrenaline • Vasopressin drip • Metoclopromide • 20IU in 200 cc of 5% • Vit k dextrose over 20 mins • Rantac 50mgm 8hyrly foll. 0.4IU/hr till RT clears • If Ryle’s tube clears then • Complications endoscopy – Abdominal cramps – Chest pain – Dilutional hyponatremia
  19. 19. Treatment • It Ryle’s tube clears • If Ryle’s tube does • Endoscopy not clear • Balloon tamponade with Sengstaken Blakemore tube
  20. 20. Treatment • Sengstaken Blakmore tube • Insertion • Traction • Precautions • Limitations • Modifications
  21. 21. Treatment • If effluent clears • If bleeding continues • Then endoscopy • Then surgical • Endoscopy is intervention is diagnostic and required therapeutic • Sclerotherapy • Intravariceal or paravariceal • Complications • Protocols
  22. 22. Surgical Treatment • Ablative procedures • Shunt procedures – Splenectomy with • Principles& selection of devascularization patients (Child’s criteria) – Oesophageal transection with • Types stapling(Johnstone’s ) – Oesophageal transection with • Selective hand sewn – DSRS anastomosis(Tanner’s) – Coronary caval shunt – Suguira procedure – Advantages • Splenectomy – Disadvantages • Devascularization • Non selective • Oephageal transection – Portocaval • Reanastomosis • Truncal vagotomy – Mesocaval • pyloroplasty – H grafts – Under running of – Advantages varices(Boerema crile) – Disadvantages
  23. 23. Shunt procedures
  24. 24. Other modalities • Medical treatment (propranolol therapy) • TIPS(transjugular intrahepatic portosytemic shunt) • Liver transplant
  25. 25. Treatment • Ascites • Left sided portal • Daily weighing hypertension • Salt restricted diet • Hypersplenism • Diuretics – Splenomegaly – Pancytopenia • Le Veen – Splenectomy causes shunts(peritoneoveno the counts to us shunts) normalise.

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