Portal Hypertension (With Ascites) PDF

PORTAL HYPERTENSION (WITH ASCITES)  N portal v pressure: 5-8mmHg. When >10-12mmHg, considered PHT.  Portal v formed by union of sup mesenteric & splenic vv  Causes are outlines in the Ddx for Ascites CLINICAL MANIFESTATIONS  Pts are often asymptomatic  Splenomegaly is the most...

PORTAL HYPERTENSION (WITH ASCITES)  N portal v pressure: 5-8mmHg. When >10-12mmHg, considered PHT.  Portal v formed by union of sup mesenteric & splenic vv  Causes are outlines in the Ddx for Ascites CLINICAL MANIFESTATIONS  Pts are often asymptomatic  Splenomegaly is the most common manifestation  Ascites o Pathological fluid collection w/in peritoneal cavity. o Signs  Inspection  Distended abdomen w bulging flanks  Everted/ shallow, downward pointing umbilicus (in pregnancy, umbilicus points up d/t uterus growing from pelvis)  Palpation  Depending on the volume, may feel tense  Percussion  Shifting dullness  Fluid thrill (in large, tense ascites)  Puddle sign (in small vol ascites) o The DDx can quickly be narrowed down by abdominal paracentesis & ascitic fluid analysis, esp by comparing fluid albumin to serum albumin o Serum albumin – Ascites albumin = Serum albumin ascites gradient (SAAG) o Ascitic fluid was previously categorised as transudate/ exudate, but the SAAG is now used as it makes more pathophysiological sense. All high SAAG pts have portal hypertension. Prehepatic causes Portal v obstruction Presinusoidal Schistosomiasis High SAAG Hepatic (>=11,1mmol/L) Cirrhosis (PHT) Post-sinusoidal Veno-occlusive dz RHF Post-hepatic Dec intake malnutrition Ascites Budd-Chiari Dec production CLD N peritoneum Hypoalbuminaemia Nephrotic sd Inc losses Low SAAG (=33u/l is highly suggestive of abdominal TB Albumin Used to assess SAAG to narrow down Ddx  Venous dilation @ sites of portosystemic anastomosis o In healthy individuals, these sites don’t exchange significant volumes of blood, as the pressures in each system are approx. equal o In dzs that cause portal HT → shunting of blood from prtal vv to caval (systemic) vv o The ffw are sites of portosystemic anastomosis of clinical interest: Region Name of clinical sign Portal circulation Caval circulation Oesophageal Oesophageal varices Oesophageal branch of Oesophageal branches L gastric v of azygous v Rectal Rectal varices (painless Sup rectal v Middle & inf rectal vv haemorrhoids) Paraumbilical Caput Medusae Paraumbilical vv Superficial epigastric v o Caput medusa – dilated periumbilical vv  Assess direction of blood flow to differentiate IVC obstruction from PHT a) Occlude v w finger b) Empty v below occluding finger w 2nd finger c) Remove 2nd finger d) If v refills, flow is occurring towards occluding finger  The main vv of interest are those BELOW the umbilicus, because  In PHT, direction of blood flow is away from the umbilicus, ie, will drain inferiorly below the umbilicus  In IVC obstruction, vv drain up, towards the IVC, ie, will drian superiorly below the umbilicus o Oesophageal varices  Oesophageal varices occur in 90% of pts w PHT over 10y  Only 1/3 will bleed  Bleeding varices is an emergency  Likelihood of bleeding is increased when the varices are large/ when there are RED SIGNS on endoscopy  Red signs: o Red wale marks: longitudinal red streaks on varices o Cherry-red spots: red, discreet, flat spots on varices o Haematocystic spots: red, discreet, raised spots o Diffuse erythema