1. Critical Care Aspects of Chronic Hepatic Failure Aditya N. Dubey, MD Peter K. Linden, MD University of Pittsburgh Medical Center Department Critical Care Medicine

5. Causes of Portal Hypertension LIVER Pre-sinusoidal PV thrombosis PV extrinsic comp. Schistosomiasis Sarcoidosis PBC Sinusoidal Cirrhosis Alcoholic hepatitis Post Sinusoidal Budd – Chiari Veno-occlusive dis. Severe CHF Restrictive heart dis. BLOOD FLOW

8. Hierarchal Treatment for Variceal Bleeding Pharmacologic Endoscopic Radiologic shunt TIPSS Surgical Shunt Balloon Tamponade Pharmacologic and endoscopic therapy are the usual 1 st and 2 nd interventions

13. Banding of Esophageal Varix

20. Malposition of the Gastric Balloon of a Minnesota Tube Retroverted in the Distal Esophagus

22. Summary of Trials Comparing TIPSS to Endoscopic Therapy for Variceal Bleeding Stanley. Lancet. 1997;350(9086):1235-1239. Generally, higher rates of rebleeding were more common after Endoscopy treatment, while encephalopathy rates were higher in the TIPSS groups

24. Conditions Which May Contraindicate TIPSS This venogram shows an occlusive thrombus of the portal vein, which may make safe TIPSS placement impossible. This abdominal CT demonstrates a large hypodense hepatic lesion due to hepatocellular carcinoma in a very shrunken cirrhotic liver. Other contraindications include hepatic vein occlusion, heart failure or pulmonary hypertension, biliary obstruction, and poorly controlled systemic infection.

26. Trans-TIPSS Embolization of Persistent Varices Persistent variceal bleeding due to high flow collaterals despite a patent TIPS shunt may be coil-embolized radiologically via the TIPS shunt itself.

28. Relative Effectiveness of Available Therapies for the Prevention of Recurrent Variceal Bleeding Beta-blockers are the single most effective and safest strategy to prevent the recurrence of variceal Bleeding. More aggressive strategies such as banding, TIPSS, or shunt surgery may decrease bleeding but are associated with higher risks and costs. Sharara A, et al. N Engl J Med. 2001.

44. Tc Labeled Sulfur Colloid Showing Fluid Passage From Peritoneal to Pleural Space 99 Bhattacharya, et al. J Gastroenterol Hepatol. 2001.

45. Right Hydrothorax Managed with Plerual Catheter Drainage Before After

47. Hepatorenal Syndrome Pere Ginès, et al. N Engl J Med. 2004;350:1646-1654.

50. Vasoconstrictor Studies in HRS Or – orlipressin NE – norepinephrine Te - terlipressin OC - octreotide Mi - midodrine A - albumin These results, although encouraging, need to be validated by a large, prospective randomized trial. 30 (18%) 73 (44%) 104 (63%) 165 TOTAL 13 36 58 99 Te ± A Moreau 3 6 10 12 NE + A Duvoux 2 4 4 5 Mi,Oc,A Angeli 5 9 10 13 Te ± A Ortega 2 4 7 12 Te + A Mulkay 2 4 4 7 Or, D, A Gulberg 3 5 7 9 Te + A Uriz - 5 4 8 Or + A Guevara Liver Tx Survival HRS Reversal # Pts Treatment STUDY

53. Pathophysiology of Hypoxemia in Hepatopulmonary Syndrome Hoeper MM, et al. Lancet.2004;363(9419):1461-8.

55. Liver Transplantation