門靜脈高壓癥治療英文課件

1、Surgical Complication of Cirrhosis and Portal HypertensionSurgical Complication of Cirrh Mechanism Some causesHepatocellular injuryNecrosis fibrosis nodular regenerationcirrhosis Mechanism Some Hepatocellulaltered hepatic architecture perisinusoidal fibrosisIncreased hepatic vasecular resistanceport

2、al hypertensionaltered hepaticIncreasedportal Some causes Toxins: alcoholViruses: hepatitis B,hepatitis CProlonged cholestasis: extrahepatic, intrahepaticAutoimmunity: lupoid hepatitisMetabolic disorders: hemochromatosis, Wilsons disease alpha1-antitrypsin deficiency Some causes Toxins: alcoholAnato

3、myAnatomy門靜脈高壓癥治療英文課件 Classification of portal hypertension Prehepatic portal hypertension Intrahepatic portal hypertension Posthepatic portal hypertension Classification of portal hypPrehepatic portal hypertensionIsolated splenic vein thrombosisLeft sided portal hypertension Pancreatic inflammation

4、 or neoplasmThe most common cause is portal vein thrombosis.( Half in children )Prehepatic portal hypertensionIntrahepatic portal hypentensionPresinusoidal lever schistomiasis posthepatitisSinusoidal lever alcoholic posthepatitisPostsinusoidal lever alcoholic, Budd-chiaris syndrome rareIntrahepatic

5、portal hypentensiPosthepatic portal hypertensionBudd-Chiaris syndrome: hepatic vein thrombosis, obstruction of vena cavaConstrictive pericarditisHeart failurePosthepatic portal hypertensio Pathophysiology of portal hypertension A portal pressure above the normal lever of 5 to 8 mmHg stimulates porto

6、systemic collateraligation.Coronary vein Esophagogastric Short gastric vein varicesAzygos vein Pathophysiology of portal hy Evaluation of the patient with cirrhosis Diagnosis of the underlying liver disease Estimations of functional hepatic reserve Identification of the site of upper GI hemorrhage,

7、if present (esophageal varices, gastric varices, ectopic varices, portal hypertensive gastropathy) Definition of portal venous anatomy and hepatic hemadynamic evaluation Evaluation of the patient wi Measurement of Hepatic Functional Reserve Child-Pugh Criteria for Hepatic Functional ReserveMeasure A

8、 B CSerum bulirubin 3 ( mg per 100 ml ) Serum albumin 3.5 2.8-3.5 6Ascites None Slight ModerateNeurologic disorder None Minimal Advanced,”coma” Measurement of Hepatic Funct Other Laboratory Tests Anemia ( bleeding, nutritional deficiency, hemolysis, or bone marrow depressing )LeukopeniaThromhocytope

9、nia Prothrombin timeAlpha-fetoprotein leverLiver biopsy(cause of cirrhosis, activity of the liver disease) Other Laboratory Tests Ane Hepatic Hemodynamic Assessment PresinusodalSinusodialPostsinusoidalPortal HypertensionHepatic venous wedge pressureTranshepatic venous cannulationUmbilical venous can

10、nulationPercutaneou spleen puncure Hepatic Hemodynamic AssessmeCases to do shunt operationSelective visceral angiography Duplex ultrasonographyPortal venous systemRenal veinHepatic portal perfusionCases to do shunt operationSe Treatment Nonoperative ColchicinePenicillamine Definitive treatmentOperat

11、iveLiver Transplantation Treatment Nonoperative DefiPharmacotherapyEndoscopic therapy TIPSPalliativetreatment Portosystemic shunt (nonselective, selective, partial)Nonshunt operationPharmacotherapyPalliativePortoHistorically, the treatment of cirrhosis has been the treatment of the complications of

12、portal hypertension.A major challenge is to determine when definitive treatment rather than palliative treatment shoud be applied.No single therapy is entirely satisfactory for all patients or clinical situations.Historically, the treatment of Treatment of Acute Bleeding Episode Decompensated hepati

13、c functionEncephalopathyAscitesCoagulopathyMalnutrition High risk Nonoperative treatment whenever possible Treatment of Acute Bleeding Resuscitation and DiagnosisPharmacotherapy: Vasopressin+ nitroglycerin, somatostatin/octreotideBalloon tamponade: Sengstaken-Blackmore tubeEndoscopic treatment: vari

14、ceal sclerosis or ligationTransjugular intrahepatic portosystemic shunt(TIPS)Resuscitation and DiagnosisPha門靜脈高壓癥治療英文課件門靜脈高壓癥治療英文課件門靜脈高壓癥治療英文課件Emergency SurgeryFailure ofAcute endoscopic treatmentLong-term endoscopic treatmentTIPSHemorrhage from gastric varicesPortal hypertensive gastropathy(PHG)Eme

15、rgency operationEmergency SurgeryFailure ofAcu Treating for Prevention of Recurrent Hemorrhage First-linetreatmentPharmacotherapyEndoscopicTIPS( Satisfactory hepatic function ) Treating for Prevention of R Portosystemic shunts Advantages: the most effective decompression low rebleeding rate.Shortage

16、s:high encephalopathy accelerated hepatic failure Portosystemic shunts AdvanNonselective shuntsEnd-to-side portacaval shunt(Eckfistula)Side-to-side portacaval shuntLarge diameter interposition shuntConventional spleenorenal shuntNonselective shuntsEnd-to-sid門靜脈高壓癥治療英文課件Selective shuntsWarren (1967)

17、Distal splenorenal shuntInokuchu (1984) Left gastric renacaval shuntLeft gastic(coronary) vein vein graft inferior vena cavaSelective shuntsWarren (1967) 門靜脈高壓癥治療英文課件Patial Shunts Small-diameter vein-to-vein anastomosesSmall-diameter interposition proacaval shunt Patial Shunts Small-diameter v門靜脈高壓癥

18、治療英文課件The objective of partial selective shuntsEffective decompression of varicesPreservation of hepatic portal perfusionMaintenance of some residual portal hypertension The objective of partial selec Nonshunt Operation Objectives: extensive esophagogastric devasculrigation splenectomy transection of the distal esoph