门静脉高压症(英文)课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,门静脉高压症,Portal Hypertension,门静脉高压症,Questions,Where is the portal vein?,What is portal hypertension?,How do we handle with the patient of portal hypertension?,QuestionsWhere is the portal v,Recently a talent artist died of the severe complication of liver cirrhosis combined with portal hypertension.,Recently a talent artist died,50 year old male, with history of hepatitis and liver cirrhosis,upper digestive tract bleeding recently,presenting with massive ascites,A typical case,50 year old male, with histor,History of portal hypertension,In 1882 an Italian pathologist Banti first described this disease with unknown etiology named Banti Syndrome.,In 1902 Gilbert first named this disease as portal hypertension.,History of portal hypertension,Definition,Portal hypertension is defined as a portal vein pressure above the normal range, with clinical syndrome.,Normal pressure of PV is 13-24cmH,2,O, and the average is about 18cmH,2,O,DefinitionPortal hypertension,The anatomy is relatively constant.,By the confluence of the superior mesenteric and splenic veins behind the neck of the pancreas.,The inferior mesenteric vein most often joins the splenic vein before PV is formed, but 1/3 of the inferior mesenteric vein joins the superior mesenteric vein.,Anatomy,The anatomy is relatively cons,a dual supply from both the HA and the PV.,PV system is entirely devoid of valves.,PV normally carries 75 per cent of the blood supply of the liver, with an average flow of 1200 ml/min.,Anatomy,a dual supply from both the H,Anatomy,Anatomy,Arteries,Portal Veins,Hepatic Veins,Arteries,门静脉高压症(英文)课件,Potential venous collaterals that develop with portal hypertension,Anatomy,Potential venous collaterals t,The colleteral network through the coronary and short gastric veins to the azygos vein is,the most important,one clinically because it results in formation of esophagogastric varices.,Other sites include a recanalized umbilical vein from the left portal vein to the epigastric venous system (caput medusae), retroperitoneal colleteral vessels, and the hemorrhoidal venous plexus.,The colleteral network through,Etiology,1. Intrahepatic occlusion,Presinusoidal: Schistosomiasis,Sinusoidal, post-sinusoidal: liver cirrhosis (alcoholic hepatitis, viral hepatitis, Wilson disease),2. Extraheptic diseases,PV occlusion: stenosis, thrombosis, extrinsic compression, trauma,inflammation,HV occlusion: Budd-Chiari Syndrome,Increased volume of PV: HA-PV,、,SA-SV ateriovenous fistula,Etiology1. Intrahepatic occlus,Backward theory vs. Forward theory,High resistance,Ohm Law, P = QR,High volume,It is currently believed that,the principle and initial,abnormality is,increased vascular resistance,to portal flow and that portal hypertension is then,maintained,by,increased blood flow,into the portal circulation.,Backward theory vs. Forwa,Hyperdynamic circulation of portal hypertension,Hyperdynamic circulation of po,门静脉高压症(英文)课件,门静脉高压症(英文)课件,PATHOLOGIC CHANGES,PATHOLOGIC CHANGES,Cirrhosis was first described in a fourth century B.C., Hippocratic aphorism: “In cases of jaundice it is a bad sign when liver becomes hard.”,Lannec introduced the term,cirrhosis, which was derived from the Greek word,kirrhos,meaning “orange-yellow”.,Liver cirrhosis,Cirrhosis was first described,Although the mechanisms causing liver cirrhosis are diverse, the pathologic response is uniform: hepatocellular necrosis followed by fibrosis and nodular regeneration.,Each of these three elements may exist alone, but all three are required for the development of cirrhosis.,Cirrhosis causes two major phenomena:,- hepatocellular failure,- portal hypertension,Although the mechanisms causin,The spleen is enlarged from the normal 300 grams or less to between 500 and 1000 gm,.,Sensitivity: PLCWBC RBC (Hypersplenism),Splenomegaly,&,Hypersplenism,The spleen is enlarged from th,Dilation of collateral,Esophagus varices,Rectal varices,Gastric varices,Dilation of collateralEsophagu,The increased pressure is transmitted to collateral venous channels. Sometimes these venous collaterals are dilated. Seen here is caput medusae which consists of dilated veins seen on the abdomen of a patient with cirrhosis of the liver.,caput medusae,The increased pressure is tran,Ascites,1. FPP,（,1,）,elevated filtrating pressure of,capillary bed,（,2,）,disable of lymph refluence,2. deteriorated liver function,（,1,）,decreasing albumin production,（,2,）,inactivation of aldosterone and,vasopressin,Ascites 1. FPP,门静脉高压症(英文)课件,门静脉高压症(英文)课件,Portal hypertensive gastropathy,Hepatic encephalopathy,asterixis,Portal hypertensive gastropa,CLINIC MANESTATION &DIAGONOSIS,CLINIC MANESTATION &DIAGONOS,Diagnosis,Medical history: Hepatits, Schistosomiasis,Splenomegaly, Hypersplenism,Bleeding,Ascites,Lab Testing,Blood testing,Liver function,Abdomen US, Duplex US,X- ray, CT,angiography,Diagnosis,门静脉高压症(英文)课件,Child Classification,Child Classification,MELD score as an allocation system in United States since Feb 28, 2002.,MELD score = 10, ( 0.957 ln creatinine, mg/dL +0.378 ln bilirubin, mg/dL +1.12 ln INR +0.643),Where laboratory values less than 1.0 are set to 1.0 for purpose of the MELD score calculation and the maximum serum creatinine is 4.0mg/dL.,Euro-transplant plans to switch form MUC to MELD within 2 years.,MELD (Model for end-stage liver disease),MELD score as an allocation,MELD score: 29,分；,3,月死亡率为,58,Child-Pugh: 10,分；,Child C,MELD score: 29分；3月死亡率为58Child,门静脉高压症(英文)课件,门静脉高压症(英文)课件,门静脉高压症(英文)课件,门静脉高压症(英文)课件,3D CT Scan,3D CT Scan,Eyes-icterus,Skin-spider,Eyes-icterusSkin-spider,A major challenge to the physician or surgeon managing patients with cirrhosis is to determine when definite treatment (transplantation) rather than palliative treatment (e.g., intervention to prevent recurrent variceal hemorrhage) should be applied.,Treatment,A major challenge to the physi,Treatment,Conventional surgical treatment is aimed at the complication of portal hypertension,No prophylactic operation,Various interventions depending on liver function,New horizon is liver transplantation,Treatment Conventional surgica,门静脉高压症(英文)课件,Acute Upper GI Hemorrhage,Endoscopy,Bleeding esophageal varices,Bleeding gastric varices or portal gastropathy,Emergency Sclerotherapy,Bleeding stops,Elective management,Bleeding persist or recurs,Repeat Sclerotherapy,Bleeding persist,Balloon tamponade or phamacotherapy,phamacotherapy,Bleeding stops,Bleeding persist,Consider early definite therapy,Good risk patient,shunt or devascularization,Poor risk patient,TIPS,Liver Transplantation,Good risk patient,shunt or devascularization,Acute Upper GI HemorrhageEndos,Rupture of Gastroesophagus varices,Non-surgical treatment,Transfusion and preventing shock,Drug: vasopressin,Endoscopy,Sengstaken-Blakemore tube,TIPS (transjugular intrahepatic portosystemic shunt),Rupture of Gastroesophagus var,The highest priority,in emergency management is restoration of circulating blood volume, which should be accomplished before upper gastrointestinal endoscopy.,Volume status is assessed by central venous pressure measurements, urinary output, and a Swan-Ganz pulmonary artery catheter if necessary.,The highest priority in emerge,Vasopressin is usually administered intravenously as a bolus dose of 20 units over 20 minutes and then as a continuous infusion of 0.2 to 0.4 unit/min.,Because vasopressin also constricts systemic arterioles, it frequently causes hypertension, bradycardia, decreased cardiac output, and coronary vasoconstriction.,Randomized trial have shown that somatostatin and its longer-acting analogue octreotide are as efficacious as endoscopic treatment for control of acute variceal bleeding.,Vasopressin is usually adminis,Endoscopic Sclerotherapy & Variceal Ligation,Endoscopic Sclerotherapy & Var,To tamponade acutely bleeding gastroesophageal varices.,The tube has three luminaone to aspirate the stomach, another to inflate the gastric balloon, and a third to inflate the esophageal balloon.,Patients treated with balloon tamponade should be in an intensive care unit, and endotracheal tubes should be placed in almost all to prevent aspiration.,Sengstaken-Blakemore tube,To tamponade acutely bleeding,TIPS,TIPS,At the present time, TIPS should not be recommended as initial therapy for acute variceal hemorrhage. Mortality is related to the status of hepatic function.,One clear indication for TIPS is as a short-term bridge to liver transplantation for patients in whom endoscopic treatment has failed.,TIPS,At the present time, TIPS shou,A similar frequency of,encephalopathy,after TIPS as has been previously reported after nonselective shunts.,Shunt stenosis or occlusion,develops in as many as half of patients within 1 year of TIPS insertion.,Absolute contradications,to TIPS include right-sided heart failure and polycystic liver disease.,Relative contradications,are portal vein thrombosis, hyper-vascular liver tumors, and encephalopathy, which can be worsened by diversion of portal flow.,TIPS,A similar frequency of encepha,Surgical treatment,Portosystemic shunts,Devascularization,Splenectomy,Surgical treatment,The portal vein is divided, the hepatic limb of the portal vein is ligated, and the splanchnic end of the portal vein is anastomosed end-to-side to the vena cava. All portal blood is necessarily diverted into the vena cava.,End-to-side portacaval shunt,The portal vein is divided, th,An anastomosis is made between the side of the portal vein and the side of the inferior vena cava. With a shunt of standard diameter, almost all splanchnic blood is diverted around the liver into the low-pressure vena cava.,Side-to-side portacaval shunt,An anastomosis is made between,A plastic prosthesis or an autogenous internal jugular vein is used for the shunt. One end is anastomosed to the inferior vena cava, and the other end is anastomosed to the trunk of the superior mesenteric vein. The shunt curves around the lower edge of the third portion of the duodenum and is sometimes called a,C-shunt.,Interposition mesocaval shunt,A plastic prosthesis or an aut,A vascular prosthesis measuring 8 to 10 mm in diameter is interposed between the side of the vena cava and the side of the portal vein.,Small-diameter interposition portacaval shunt,A vascular prosthesis measurin,Distal splenorenal Warren shunt,Distal splenorenal Warren shun,门静脉高压症(英文)课件,门静脉高压症(英文)课件,Splenorenal shunt,Splenorenal shunt,Transection and reanastomosis of the distal esophagus with the stapling device to control variceal hemorrhage.,(A),A stapling device is inserted through a small gastrotomy incision.,(B),When the device is fired, the esophagus is simultaneously transected and reanastomosed with staples.,(C),If the device fires correctly, a complete ring of esophageal tissue is excised.,Devascularization,Transection and reanastomosis,Ligation of grastric varices,Ligation of grastric varices,Sugiura esophageal transection and,devascularization operation,Sugiura esophageal transection,TIPS,LeVeen peritoneovenous shunt used for routing ascitic fluid into the systemic circulation. The shunt consists of fenestrated tubing for insertion into the peritoneal cavity, a one-way valve, and a length of venous tubing for insertion into the superior vena cava.,Treatment of poorly controlled ascites,TIPSTreatment of poorly contr,女性，,58,岁，肝硬化数年，近三月来二次上消化道出血。术前肝功能分级,Child A,级。,女性， 58岁，肝硬化数年，近三月来二次上消化道出血。术前肝,术中发现胃底迂曲成团的曲张静脉丛，与术前,CT,所示一致。,术中发现胃底迂曲成团的曲张静脉丛，与术前CT所示一致。,门静脉高压症(英文)课件,门静脉高压症(英文)课件,门静脉高压症(英文)课件,门静脉高压症(英文)课件,门静脉高压症(英文)课件,TIPS,LeVeen peritoneovenous shunt used for routing ascitic fluid into the systemic circulation. The shunt consists of fenestrated tubing for insertion into the peritoneal cavity, a one-way valve, and a length of venous tubing for insertion into the superior vena cava.,Treatment of poorly controlled ascites,TIPSTreatment of poorly contr,资料来源：北京、上海、长春、南京、武汉的 八所医院，床位均在,1000,张以上,我国门静脉高压症手术现状,资料来源：北京、上海、长春、南京、武汉的 八所医院，床位,Liver Transplantation,Liver Transplantation,Years after OLT,Log Rank: p = 0.0001,Survival rate after OLT,Univ. of Pittsburgh,Years after OLTLog Rank: p = 0,Classic OLT,Classic OLT,门静脉高压症(英文)课件,门静脉高压症(英文)课件,谢 谢,谢 谢,