2. ANATOMY AT GLANCE
Potential collaterals………!
Are not merely passively dilated
vessels.
These are also hypertrophied and
hyperplastic
Reason is the role of angiogenic factors
rather than just the pressure
3.
4.
5. COLLATERALS
Short gastric and coronary veins with esophageal azygous and intercostal veins
Result…… esophageal and gastric varices
Superior hemorrhoidal with middle and inferior hemorrhoidal
Result……anorectal varices ( not hemorrhoids)
Portal with epigastric veins through umbilical veins( caput medusae; cruvelheir
Baumgarten syndrome)
Liver capsule
Spontaneous splenorenal shunt
Ectopic varices in duodenum
8. PORTAL PRESSURE
Normally 9 mm Hg
Symptomatic at 12 mm Hg
In between is Latent or pre clinical portal htn
9. MOST COMMON CAUSE WORLDWIDE
Cirrhosis
Most common noncirrhotic cause is
schistosomiasis
10. IDIOPATHIC PORTAL HTN
INDIA and JAPAN
30 % of HTNsives in INDIA
HOW TO DIFFERENTIATE ?
BIOPSY OF LIVER
11. PATHOPHYSIOOGY OF BLEED
Damage to varices vs increased pressure ?
Varices don’t bleed before 12 mm Hg
BUT REMEMBER………. Not all those
above 12 mm Hg would bleed !!
12. REASONS FOR INCREASED PORTAL PRESSURE
Pre hepatic
Post hepatic
Hepatic
Our concern is hepatic………i.e……….
cirrhosis
13. CIRRHOSIS
Damaged architecture is not all causing
portal htn
Its more than that
It’s the vasodynamics
Dilator (NO)--------------- Constrictors
Result HTN
14. IN SPLANCHNIC CIRCULATION….!
NO increases !!! due to local regulation
And thus causes increased flow in portal vein
So increased flow plus constriction of portal vein causes htn
GUESS: WHY WE USE BETA BLOCKERS TO TREAT PORTAL
HTN ?
ANS: to constrict splanchnic vessels and reduce the flow into the
portal…….
Same is the mechanism of vasopressin, terlipressin,
somatostatins.
15. PRECAUTION
Don’t give Isosorbide mononitrate
Alpha agonists (prazosin or clonidine)
Anti endothelins
WHY???
Dilators
If necessary,,,, give with beta blockers
16. WHEN TO INTERVENE
When varices are more than 5 mm diameter
For Indefinite time
OR BAND LIGATE
17. WHAT TO DO IN CASE OF ACTIVE BLEED ??
Drugs or Endoscopy ?
Drugs are safer to start with. No
specialization is required.
TIPS is life saving for child class C……
But only child pugh <8 can undergo surgery
18. TECHNIQUE
HEPATIC CATH……
Difference between
Wedge pressure (WHVP) and free
pressure(FHVP) of hepatic vein
Called as hepatic venous pressure gradient (
HVPG)
19. POINT TO PONDER
ONCE BLEED………………. IS an indication
for liver transplant
