• Portal hypertension is defined by a portal pressure higher than 5 mm Hg.

Portal hypertension

Type

• prehepatic portal hypertension

• intrahepatic portal hypertension

• posthepatic portal hypertension

Prehepatic portal hypertension

• portal vein thrombosis: the most common

• Infection in the abdominal cavity

• omphalophlebitis

• A-V fistula between HA and PV

Intrahepatic portal hypertension

• Type:the presinusoidal levelthe sinusoidal levelthe postsinusoidal level

• Cause:schistosomiasishepatitis B and hepatitis C hepatocellular carcinoma

Postsinusoidal portal hypertension

• Cause: Budd-Chiari syndrome (hepatic vein thrombos

is) constrictive pericarditis heart failure. massive splenomegaly (idiopathic portal hype

rtension) a splanchnic arteriovenous fistula

Anatomy of portal hypertension

• The portal vein is formed from the confluence of the superior mesenteric inferior mesenteric and splenic veins

The extrahepatic portal venous circulation

Four collateral pathways

• Esophageal and gastric venous plexus

• umbilical vein from the left portal vein to the epigastric venous system

• retroperitoneal collateral vessels

• the hemorrhoidal venous plexus

Portosystemic collateral pathways

Pathophysiology of portal hypertension

• The portal vein contributes two thirds of the total hepatic blood flow

• Indirectly regulated by vasoconstriction and vasodilation of the splanchnic arterial bed.

Pathophysiology of portal hypertension

portal venous resistance portal venous pressure inc

rease hyperdynamic systemic cir

culation splanchnic hyperemia portal hypertension collateral pathways establi

shed

Clinical manifestation

• Upper gastrointestinal hemorrhage

• Ascite

• Enlarged spleen 、 hypersplenia

• Hepatic coma

Ascite

Laboratory tests

• Blood test• Hepatic function: aminotransferase alkaline phosphatase

serum bilirubin level • α-fetoprotein level • CT CTA• Magnetic resonance imaging• ultrasound Doppler ultrasonography

A three-dimensional reconstruction of a CT angiogram

Liver Biopsy

• A useful technique for establishing the cause of cirrhosis and for assessing activity of the liver disease.

• Laparoscopic biopsy

Pressure test

• portal pressure can be indirectly estimated by measurement of hepatic venous wedge pressure (HVWP)

Child-Pugh criteria for hepatic functional reserve

Clinical and Laboratory Measurement Patient Score for Increasing Abnormality 1 2 3

• Encephalopathy (grade) None 1 or 2 3 or 4• Ascites None Mild Moderate• Bilirubin (mg/dL) 1–2 2.1–3 ≥3.1• Albumin (g/dL) ≥3.5 2.8–3.4 ≤2.7• Prothrombin time (increase, sec) 1–4 4.1–6 ≥6.1

• Grade A, 5 and 6; grade B, 7–9; grade C, 10–15.

Diagnosis

• History

• Symptom and Physical examination

• Laboratory examination

Hematology exam

CT 、 CTA

USG

Endoscopic examination

Treatment

• Nonoperative treatments

• operative treatments

Nonoperative treatments

• Pharmacotherapy

• Endoscopic treatment

• Balloon Tamponade

• Transjugular intrahepatic portosystemic shunt （ TIPS ）

Pharmacotherapy

• Vasopressin: a bolus dose of 20 units over 20 minutes and a continuous infusion of 0.2 to 0.4 unit/minute

• Somatostatin is a250-μg intravenous bolus and a continuous infusion of 250 μg/hour for 2 to 4 days

• Octreotide :an intravenous bolus of 50 μg and an infusion of 25 to 50 μg/hour for a similar length of time

• β-adrenergic blockade

Endoscopic treatment

• Sclerosis

• Ligation

Sclerosis

Ligation

Balloon Tamponade

• Complications

esophageal perforation

ischemic necrosis of the esophagus

Transjugular intrahepatic portosystemic shunt （ TIPS ）

• Access is gained to a major intrahepatic portal venous branch through puncture through a hepatic vein. A parenchymal tract between hepatic and portal veins is then created with a balloon catheter,and a 10-mm expandable metal stent is inserted, thereby creating the shunt

Operative treatments

• operative mortality rates for Child-Pugh classes A, B, and C

• patients are in the range of 0 to 5%, 10% to 15%, and greater than 25%, respectively.

Operative method

• a shunt procedure

• a nonshunt operation

• hepatic transplantation

Nonselective shunts

• The end-to-side portacaval shunt

• The side-to-side portacaval shunt

• The large-diameter interposition shunts

• The conventional splenorenal shunt

Nonselective shunts

Selective shunts

• the distal splenorenal shunt

• the left gastric vena caval shunt

• a vein graft between the left gastric (coronary) vein and the inferior vena cava

The distal splenorenal shunt

Partial shunts

• a small-diameter interposition portacaval shunt

Partial shunts

Nonshunt Operations

• esophagogastric devascularization procedures

Hepatic Transplantation

Removal

New liver implantation

Schematic of completed liver

Piggyback TechniquePiggyback Technique

Thank you