Portal Hypertension PDF

1 Portal Hypertension By Prof. Hoda El Aggan Professor of Internal Medicine (Hepato-Biliary Pancreatic Unit) Faculty of Medicine, Alexandria University I...

1 Portal Hypertension By Prof. Hoda El Aggan Professor of Internal Medicine (Hepato-Biliary Pancreatic Unit) Faculty of Medicine, Alexandria University ILOs At the end of this session, the student will be able to: ▪ Revise the anatomy and physiology of the portal venous system. ▪ Know the definition and the classification of causes of portal hypertension (PH). ▪ Understand the pathogenesis of PH and portosystemic collateral development. ▪ Summarize the clinical manifestations and diagnosis of PH. ▪ Recognize the different therapeutic options for the management of portal hypertension- related bleeding. The portal venous system The portal vein is formed by the union Liver Spleen of the splenic vein and the superior mesenteric vein, which drain veins Portal vein from the intra-peritoneal viscera, Umbilical including the gastrointestinal (GI) tract, vein spleen, gallbladder, and pancreas Splenic vein (Figure 1). Inferior The portal vein enters the liver at the Pancreas mesenteric vein porta hepatis and divides into the left Superior mesenteric vein and right branches, one to each lobe and has a segmental intrahepatic Figure 1: The portal circulation. distribution. The portal venous blood and the hepatic arterial blood pour into the sinusoids and the mixed blood flows to the central veins, which subsequently drains into El Aggan H  2 the hepatic veins and then into the inferior vena cava (IVC) to end in the right atrium (Figure 2). Interlobular The total hepatic blood flow is about portal vein 1600 ml of blood each minute, two thirds of which is provided by the portal venous blood. The normal portal venous pressure is generally considered to be between 5 and 10 mmHg. Figure 2: The hepatic blood flow. The hepatic venous pressure gradient (HVPG) is the difference between the wedged hepatic venous pressure (WHVP) and the free hepatic vein pressure (FHVP), both of which are measured by hepatic venous catheterization. The WHVP measures the hepatic sinusoidal pressure. The HVPG is normally ≤5 mmHg. The portal pressure gradient (PPG) is the difference between the portal vein pressure and the hepatic vein (or inferior vena cava) pressure. It reflects the hepatic perfusion pressure. Normal PPG is ≤5 mmHg. Definition Portal hypertension (PH) represents an increased pressure within the portal venous system. A rise of portal venous pressure >15 mmHg or in HVPG >5 mmHg indicates the presence of PH. Clinically significant portal hypertension - Clinically significant portal hypertension (CSPH) is defined as HVPG ≥10 mmHg and is marked by the appearance of clinical manifestations of PH such as varices, variceal bleeding, portal hypertensive gastropathy (PHG), other portosystemic collaterals, ascites, hepatorenal syndrome, hyponatremia, hepatic encephalopathy (HE), and cardiopulmonary complications. CSPH is associated with a higher risk of decompensation. - A HVPG > 5 mmHg to