Portal hypertension:A disease better controlled than cured.
•
28 gefällt mir•6,579 views
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.
Empfohlen
Weitere ähnliche Inhalte
Was ist angesagt?
Was ist angesagt? (20)
Andere mochten auch
Andere mochten auch (19)
Ähnlich wie Portal hypertension:A disease better controlled than cured.
Ähnlich wie Portal hypertension:A disease better controlled than cured. (20)
Mehr von KETAN VAGHOLKAR
Mehr von KETAN VAGHOLKAR (20)
Kürzlich hochgeladen
Kürzlich hochgeladen (20)
Portal hypertension:A disease better controlled than cured.
- 1. PORTAL HYPERTENSION By Dr. Ketan Vagholkar MS, DNB, MRCS, FACS. Professor of Surgery & Consultant General Surgeon
- 2. Surgical Anatomy of portal venous circulation
- 3. Sites of portosystemic anastomosis • Lower oesophagus – Anatomical considerations • Umbilicus • Rectum & anal canal • Bare areas of the liver • Surgically created raw areas
- 4. Definition of portal hypertension • Portal venous pressure above 12 mm of Hg. is designated as portal hypertension.
- 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
- 7. Surgical implications • Upper GI bleed from oesophageal varices • Ascites due to liver cell dysfunction • Congestive splenomegaly
- 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. 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. Clinical features • h/o alcoholism – Volume consumed per day – Duration of consumption
- 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. 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. Investigations • Laboratory – Cbc – Lft – Coagulation profile – Hepatitis markers (HbsAg) – Serum levels of bun,creatinine.electrolytes – Blood grouping and cross matching
- 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. 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. 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. Treatment • Preliminary • Resuscitation procedures – Crystalloids – Venesection – Colloids – Urinary catheterisation – Blood – Passage of Ryle’s tube
- 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. Treatment • It Ryle’s tube clears • If Ryle’s tube does • Endoscopy not clear • Balloon tamponade with Sengstaken Blakemore tube
- 20. Treatment • Sengstaken Blakmore tube • Insertion • Traction • Precautions • Limitations • Modifications
- 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. 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. Shunt procedures
- 24. Other modalities • Medical treatment (propranolol therapy) • TIPS(transjugular intrahepatic portosytemic shunt) • Liver transplant
- 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.