variceal haemorrhage with special attention to portal hypertension
TRANSCRIPT
Dr. Sadia Nazneen22.02.2017, MALDA MEDICAL COLLEGE
Gasatroesophageal varices > 90% Hypertensive portal gastropathy <5% Isolated gastric varices – rare.
Portal hypertension is defined as a hepatic venous pressure gradient equal to or greater than 10 mm of Hg.
Normal 6-8mm Hg In cirrhosis >10mm Hg HVPG <12 mm Hg unlikely to develop
variceal bleeding. Useful for assessing medical
treatment.
Block to portal flow increased portal pressure
Splanchnic vascular bed response : (a) Initial increased vasoconstrictor and decreased
vasodialator response intrahepatic response
(b)Secondarily vasodialator response dominates with increase in splanchnic inflow
Collaterals develop. Plasma volume expansion Systemic
hyperdynamic circulation
Portal inflow Systemic outflow Collaterals
Left gastric veinsShort gastric veins
Intercostal, diaphragmatic and oesophageal veins
Gastro-oesophagealvarices
Superior haemorrhoidal vein
Middle haemorrhoidal veinInferior haemorrhoidal vein
haemorrhoids
Left portal vein via falciform ligament
Umbilicus and abdominal wall veins
Caput medusa
Liver via lienorenalligament
Left renal vein Retroperitoneal collaterals
Pre hepatic: Portal vein thrombosis Splenic vein thrombosis Congenital thrombosis of Portal vein Arteriovenous fistula
Intra hepatic: Primary biliary cirrhosis Cirrhosis Infiltrative liver disease Congenital hepatic fibrosis Polycystic liver disease Veno – occlusive disease
Post hepatic: Budd – Chiari syndrome Inferior vena cava webs or thrombosis Congenital heart failure Constrictive pericarditis Tricuspid valve diseases
Splenomegaly Oesophageal varices Caput medusa. Haemorrhoids.
Complications : Ascites. Spontaneous bacterial peritonitis. End-stage renal disease. Hepatopulmonary syndrome. Encephalopathy
Assessment of the liver function. Assessment of the portal circulation. Upper GI endoscopy.
Assessment of liver function: Hypoalbuminaemia. ALT & AST are moderately raised. Prothrombin time and INR are disturbed.
Blood picture anaemia, leucopenia, thrombocytopenia or pancytopenia.
Assessment of portal circulation:
Duplex scan or Doppler ultrasound:
To assess the hepatic artery, hepatic vein and portal vein.
Patency of portal vein.
Upper GI Endoscopy or EGD
To detect gatroesophagealvarices
Gold standard for diagnosing varicealbleeding
Diagnosis of the aetiology of liver disease is performed by:
(a) Immunological tests for hepatitis markers.
Other specific serological markers are alpha foetoprotein, ceruloplasmin,alpha 1 antitrypsin, antimitochondrial antibodies,and iron studies.
(b) Liver biopsy.
CT ANGIOGRAPHY MR ANGIOGRAPHY
Points
1 2 3
Bilirubin (mg/dL) < 2 2 – 3 > 3
Albumin (g/dL) > 3.5 2.8 – 3.5 < 2.8
Prothrombin time (seconds)
1 – 3 4 – 6 > 6
Ascites None Slight Moderate
Encephalopathy None Minimal Advanced
Grade A, 5-6 points; Grade B, 7-9 points; Grade C, 10-15 points
Score = 0.957 × loge creatinine (mg/dL) + 0.378 × loge bilirubin (mg/dL) + 1.120 loge INR
Prophylaxis – Pharmacotherapy and endoscopic therapy
Acute variceal bleedingResuscitaion and pharmacotherapy Endoscopic therapyDecompressive shuntsDevascularisation Liver transplantation
Prevention of rebleedingLevel I evidence
Pharmacotherapy: Non-cardioselective beta blockers
Endoscopic variceal ligation
Admit patient in ICU
Fluids and blood products judiciously administered
Somatostatin or its analogues octreotide or terlipressinadministered and continued for 3-5 days
Non-selective beta blockers like propanol or nadolol
Current recommendation is to administer an antibiotic prophylaxis upto 7days, specifically a fluoroquinolones.
Initial bolus 100 microgram continuous infusion of 25 microgram / h for 24 hrs.
Dose 20-60 mg bid
Sclerotherapy
Intra- or Para- Variceal.
1-3 ml sclerosant
(ethanolamine oleate).
Multiple sessions (2 weekly).
Control bleeding in 80-95 %.
About 50% rebleed.
Intravariceal
Paravariceal
Endoscopic BandingOccludes venous
channels
Sessions <
sclerotherapy
Same results as
sclerotherapy
Endoscopic
treatment of
choice
Transjugular intrahepatic portosystemicshunt or (TIPS) is a procedure that involves the creation of an artificial anastomosisbetween the hepatic and portal veins under fluoroscopic guidance with the use of a covered stent, shunting away blood from the hepatic sinusoids and relieving portal pressure.
Indications for TIPSS: Refractory bleeding Prior to transplant Child C Refractory ascites
Porta – systemic shunts. Non Shunt surgery – Devascularisation. Liver transplantation.
Classification:
Non-selective shunts: Total shunts:
PortacavalMesocavalProximal spleno-renal
Partial shunts: Small diameter porta-caval (Sarfeh)
Selective shunts: Distal spleno renal shunt
Portal blood is completely redirected into IVC below the liver.
Two types: end to side and side to side
Side to side shunt is useful in preventing portal hypertension in Budd – Chiari syndrome .
Anastomosis of the side of the SMV to the proximal end of the divided IVC, for control of portal hypertension;
The incidence of thrombosis is high.
Indication: EHPVO.Advantage: The incidence of
encephalopathy is less than after porta cavalshunt.
Disadvantage: Less effective In
rebleeding. If the splenic vein is less
than 1 cm the anastmosisis liable to thrombosis.
A small diameter interposition
(8-10 mm) porta – cavalshunt.Advantage: Partially decompress the
portal venous system. Hepatic portal flow is
preserved.Drawback: Increasaed incidence of
thrombosis. Recurrence of bleeding.
Types :•The distal splenorenal shunt (Dean Warren shunt)•Inokuchi splenocaval shunt (IMV to IVC)•Interposition shunts with the left gastric vein to IVC
An anastomosis of the splenic vein and the left renal vein, created to lower portal hypertension
Merits:•The incidence of encephalopathy is low •Liver functions remain normal.
Devascularisation:Aim: Direct disconnection between the portal and azygos vein done by disconnecting the varices from their bleeding vessels.Components:SplenectomyGastric and oesophagealdevascularisationOesophagealtransection
Good-risk patients—Child’s A patients or MELD less than 10.
Pharmacotherapy +/- Banding If they rebleed or have failure to obliterate
their varices banding, they may be a candidate for decompression with TIPS or DSRS.
Indeterminate patients—Child’s B or MELD 10–16. Majority of patients Initial treatment is with endoscopic banding
and a beta-blocker. Subsequent treatment depends on the course
of their liver disease.
End-stage liver disease—Child’s C or MELD greater than16.
Liver transplantation
Patients with any of the above scenarios, who also have advanced liver disease, are candidates for liver transplantation, possibly using TIPS as a bridge.
Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension
Most common cause of this is cirrhosisof the liver.
Investigations: Endoscopy Treatment: Medications: o Non-selective beta blockers (such as propranolol and nadolol)o Octreotide Procedural:o Argon plasma coagulation.o TIPS.o Cryotherapy.
Most commonly found in patients with portal hypertension. Gastric varices may also be found in patients with
thrombosis of the splenic vein.
Clinical features: Hematemesis, melena, shock
Treatment: Injecting cyanoacrylate glue, TIPS. Intravenous octreotide Splenectomy Liver transplantation.
Variceal bleeding has high morbidity and mortality rate.
Endoscopy is both diagnostic and therapeutic. Beta blockers and EVL are first line of treatment. TIPSS and DSRS are used as bridge to Liver
Transplant. Liver transplant though last resort may be
curative.
THANK YOU.