4.WK 4 PORTAL HYPERTENSION Year 4 Internal Medicine Notes

4.WK 4 PORTAL HYPERTENSION Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.1 / ALEX -- Slide 1 Portal Hypertension Dr. Alex Mogere Consultant Physician\nMKU Slide 2 QUIZZ A 69-year-old man present with a 2-week history of abdominal pain which has worsened over the last few days. On examination, the patient is jaundiced and the abdomen is distended with tenderness in the epigastric region. In addition, there is a smooth hepatomegaly and shifting dullness. Which of the following is the most likely cause of the hepatomegaly?\nA. Iron deficiency anaemia\nB. Budd–Chiari syndrome\nC. Ulcerative colitis\nD. Crohn’s disease\nE. Left-sided heart failure Slide 3 Outline Definition of portal Hypertension Classification\nClinical Presentation Treatment\nComplications. Slide 4 Defn Portal Hypertension is one of the long term complications of liver cirrhosis. It is defined as the elevation of hepatic venous pressure gradient (HVPG) to 5mmHg. HVPG is the best surrogate marker in portal hypertension and should be measured in every trial involving pharmacologic tx Slide 5 Pathophysiology Increased resistance to blood flow in the cirrhotic liver and also increased blood flow in the splanchnic bed due to vasodilatation. Portal HT is responsible for the varices and ascites seen in liver cirrhosis. Slide 6 Anatomy. the portal venous system normally drains blood from the stomach, intestines, spleen, pancreas, gall bladder.\n\nPortal vein is formed by the joining of superior mesenteric and splenic veins Slide 10 Causes of portal Hypertension They are divided into: prehepatic, intrahepatic and post hepatic. Prehepatic: These affect the portal venous system before it enters the liver; Include: portal vein thrombosis, splenic vein thrombosis,trauma,pancreatitis, Bantis syndrome.\n(chronic congestive enlargement of the spleen resulting in premature destruction of RBCs by the spleen)\nIntrahepatic causes: cause 95% of Portal HT and Liver cirrhosis is the commonest cause. Post hepatic: causes that affect the hepatic vein and venous drain to the heart: include- Budd Chari syndrome, Chronic RHF, venoocclusive disease. Slide 15 Cont. clinical presentation;Varices In the developed world, cirrhotic patients are routinely screened for varices. 1/3 have them\n5-15% of cirrhotics develop varices per year. Estimated that majority of cirrhotic patients will develop varices over time. 1/3 of patients with varices will bleed. HVPG above 12mmHg is the threshold Pa for variceal rupture. Factors which predict bleeding include: severity of cirrhosis, portal pressure, size of varices, location of varices, tense ascites and other endoscopic findings. Slide 16 Cont.clinical presentation Hepatic insufficiency s/s: jaundice,ascites,coma, hemorrhagic tendency,anemia hyperestrenism: palmar erythema,testicular atrophy,spider naevi, gynaecomastia Hypersplenism: bone marrow changes, leucopenia, thrombocytopenia,anemia Slide 17 Diagnosis of Portal HT Most of our cirrhotic patients present with features of P/HT Developed world, cirrhosis can be diagnosed on routine check ups before patients develop clinically evident P/HT. In such patients, P/HT is suspected by development of ascites, low platelets, splenomegally, encephalopathy, GIT bleeding, abdominal collaterals. Radiological procedures can be used to determine the wedged and free-hepatic vein pressures: U/S,MRI, liver angiography,splenic protogram,coeliac-mesenteric arteriography Slide 19 MX Directed towards treatment of the 3 main presentations of Portal HT- Variceal hemorrhage, Ascites and Hypersplenism Variceal Haemorrhage Include 2 approaches- Primary prophylaxis and secondary prophylaxis.\nPrimary prophylaxis- do routine endoscopy screening for varices in cirrhotic patients Slide 20 Mx:Bleeding varices Admit into ICU 2 widebore iv access,administer ivf-lactated ringers Monitor vital signs, urine output Blood transfusion Prevent hypercoagulopathy Prevent hepatic encephalopathy Slide 21 Cont; Mx variceal bleed Those with varices and high risk of bleedingCan use medical treatment with Beta blockers-non selective eg propranolol and nadolol. Studies have shown reduced variceal bleed, reduced mortality from variceal bled compared to patients who were given placebo over a 1-2 yr follow up. Non Medical- variceal band ligation, sclerotherapy Slide 22 Severe variceal bleed Esophageal balloon tamponade(SengstakenBlakemore tube), for temporary hemostasis before endoscopy is available Slide 23 Cont. Secondary prophylaxis For those who have had a bleed, treat the acute bleed, stabilize the pt and carry out repeated band ligation to obliterate the varices for 2nd prophylaxis Slide 24 Pharmacologic Tx vasoconstricting agents like: Vasopressin: 20-40units iv in 200mls 5% dextrose over 10mins,may repeat every 2-4 hrs until bleeding stops Octreotide:50ug iv bolus followed by 50ug/hr infusion for 5/7 Slide 27 Mx of Splenomegaly and hypersplenism No significant Tx is advanced though splenectomy may