[医药卫生]门静脉高压症治疗课件

1、Surgical Complication of Cirrhosis and Portal Hypertension第二军医大学东方肝胆外科医院马优钢 Mechanism Some causesHepatocellular injuryNecrosis fibrosis nodular regenerationcirrhosis altered hepatic architecture perisinusoidal fibrosisIncreased hepatic vasecular resistanceportal hypertension Some causes Toxins: alco

2、holViruses: hepatitis B,hepatitis CProlonged cholestasis: extrahepatic, intrahepaticAutoimmunity: lupoid hepatitisMetabolic disorders: hemochromatosis, Wilsons disease alpha1-antitrypsin deficiencyAnatomy Classification of portal hypertension Prehepatic portal hypertension Intrahepatic portal hypert

3、ension Posthepatic portal hypertensionPrehepatic portal hypertensionIsolated splenic vein thrombosisLeft sided portal hypertension Pancreatic inflammation or neoplasmThe most common cause is portal vein thrombosis.( Half in children )Intrahepatic portal hypentensionPresinusoidal lever schistomiasis

4、posthepatitisSinusoidal lever alcoholic posthepatitisPostsinusoidal lever alcoholic, Budd-chiaris syndrome rarePosthepatic portal hypertensionBudd-Chiaris syndrome: hepatic vein thrombosis, obstruction of vena cavaConstrictive pericarditisHeart failure Pathophysiology of portal hypertension A portal

5、 pressure above the normal lever of 5 to 8 mmHg stimulates portosystemic collateraligation.Coronary vein Esophagogastric Short gastric vein varicesAzygos vein Evaluation of the patient with cirrhosis Diagnosis of the underlying liver disease Estimations of functional hepatic reserve Identification o

6、f the site of upper GI hemorrhage, if present (esophageal varices, gastric varices, ectopic varices, portal hypertensive gastropathy) Definition of portal venous anatomy and hepatic hemadynamic evaluation Measurement of Hepatic Functional Reserve Child-Pugh Criteria for Hepatic Functional ReserveMea

7、sure A 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” Other Laboratory Tests Anemia ( bleeding, nutritional deficiency, hemolysis, or bone marrow depressing )LeukopeniaThromhocytopenia Prothrombin timeAlp

8、ha-fetoprotein leverLiver biopsy(cause of cirrhosis, activity of the liver disease) Hepatic Hemodynamic Assessment PresinusodalSinusodialPostsinusoidalPortal HypertensionHepatic venous wedge pressureTranshepatic venous cannulationUmbilical venous cannulationPercutaneou spleen puncureCases to do shun

9、t operationSelective visceral angiography Duplex ultrasonographyPortal venous systemRenal veinHepatic portal perfusion Treatment Nonoperative ColchicinePenicillamine Definitive treatmentOperativeLiver Transplantation PharmacotherapyEndoscopic therapy TIPSPalliativetreatment Portosystemic shunt (nons

10、elective, selective, partial)Nonshunt operationHistorically, the treatment of cirrhosis has been the treatment of the complications of portal hypertension.A major challenge is to determine when definitive treatment rather than palliative treatment shoud be applied.No single therapy is entirely satis

11、factory for all patients or clinical situations. Treatment of Acute Bleeding Episode Decompensated hepatic functionEncephalopathyAscitesCoagulopathyMalnutrition High risk Nonoperative treatment whenever possibleResuscitation and DiagnosisPharmacotherapy: Vasopressin+ nitroglycerin, somatostatin/octr

12、eotideBalloon tamponade: Sengstaken-Blackmore tubeEndoscopic treatment: variceal sclerosis or ligationTransjugular intrahepatic portosystemic shunt(TIPS)Emergency SurgeryFailure ofAcute endoscopic treatmentLong-term endoscopic treatmentTIPSHemorrhage from gastric varicesPortal hypertensive gastropat

13、hy(PHG)Emergency operation Treating for Prevention of Recurrent Hemorrhage First-linetreatmentPharmacotherapyEndoscopicTIPS( Satisfactory hepatic function ) Portosystemic shunts Advantages: the most effective decompression low rebleeding rate.Shortages:high encephalopathy accelerated hepatic failure

14、Nonselective shuntsEnd-to-side portacaval shunt(Eckfistula)Side-to-side portacaval shuntLarge diameter interposition shuntConventional spleenorenal shuntSelective shuntsWarren (1967) Distal splenorenal shuntInokuchu (1984) Left gastric renacaval shuntLeft gastic(coronary) vein vein graft inferior ve

15、na cavaPatial Shunts Small-diameter vein-to-vein anastomosesSmall-diameter interposition proacaval shunt The objective of partial selective shuntsEffective decompression of varicesPreservation of hepatic portal perfusionMaintenance of some residual portal hypertension Nonshunt Operation Objectives: extensive esophagogastric deva