PORTALHYPERTENSION By Dr. Ketan Vagholkar MS, DNB, MRCS, FACS. Professor of Surgery & Consu...
Surgical Anatomy of portal venous circulation
Sites of portosystemic anastomosis• Lower oesophagus – Anatomical considerations• Umbilicus• Rectum & anal canal• ...
Definition of portal hypertension• Portal venous pressure above 12 mm of Hg. is designated as portal hypertension.
Etiology of portal hypertension• Prehepatic • Intrahepatic – Portal vein thrombosis – Alcoholic cirrh...
Pathophsiology
Surgical implications• Upper GI bleed from oesophageal varices• Ascites due to liver cell dysfunction• Congestive splenome...
Clinical features• Haematemesis(differentia • Jaundice te from haemoptysis) – Duration – Volu...
Clinical features• Ascites • Splenomegaly – Sudden distension of – Lump in the left abdomen ...
Clinical features• h/o alcoholism – Volume consumed per day – Duration of consumption
Physical examination• General examination – Level of consciousness – Vital parameters – Signs of hepatocellular fail...
Clinical examination• Abdominal examination – Distension due to ascites – Signs for ascites (fluid thrill,shifting du...
Investigations• Laboratory – Cbc – Lft – Coagulation profile – Hepatitis markers (HbsAg) – Serum levels of bun,creati...
Investigations• Endoscopy – Oesophageal varices – Blood clot over the varix – Varix over varix – Cherry red spots – S...
Investigations• Radiology • Barium – USG oesophagogram • Status of li...
Investigations• Splenoportogram• Performed before shunt surgery• Findings – Splenic pulp pressure – Splenic/portal ve...
Treatment• Preliminary • Resuscitation procedures – Crystalloids – Venesection ...
Treatment• Ryle’s tube washes with • If Ryle’s tube does not cold saline or saline clear then adrenaline ...
Treatment• It Ryle’s tube clears • If Ryle’s tube does• Endoscopy not clear ...
Treatment• Sengstaken Blakmore tube• Insertion• Traction• Precautions• Limitations• Modifications
Treatment• If effluent clears • If bleeding continues• Then endoscopy • Then surgical• Endoscopy is inte...
Surgical Treatment• Ablative procedures • Shunt procedures – Splenectomy with • Princi...
Shunt procedures
Other modalities• Medical treatment (propranolol therapy)• TIPS(transjugular intrahepatic portosytemic shunt)• Liver tran...
Treatment• Ascites • Left sided portal• Daily weighing hypertension• Salt restricted diet ...
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Portal hypertension:A disease better controlled than cured.

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.
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Portal hypertension:A disease better controlled than cured.

  • 1. PORTALHYPERTENSION 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
  • 6. Pathophsiology
  • 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.

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