资源描述
,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,*,Surgical Complication of Cirrhosis and Portal Hypertension,Mechanism,Some,causes,Hepatocellular,injury,Necrosis,fibrosis,nodular,regeneration,cirrhosis,altered hepatic,architecture,perisinusoidal,fibrosis,Increased,hepatic,vasecular,resistance,portal,hypertension,Some causes,Toxins:alcohol,Viruses:hepatitis B,hepatitis C,Prolonged cholestasis:extrahepatic,intrahepatic,Autoimmunity:lupoid hepatitis,Metabolic disorders:hemochromatosis,Wilsons disease,alpha,1,-antitrypsin deficiency,Anatomy,Classification of portal hypertension,Prehepatic portal hypertension,Intrahepatic portal hypertension,Posthepatic portal hypertension,Prehepatic portal hypertension,Isolated splenic vein thrombosis,Left sided portal hypertension,Pancreatic inflammation or neoplasm,The most common cause is portal vein thrombosis.,(Half in children),Intrahepatic portal hypentension,Presinusoidal lever schistomiasis posthepatitis,Sinusoidal lever alcoholic posthepatitis,Postsinusoidal lever alcoholic,Budd-chiaris,syndrome,rare,Posthepatic portal hypertension,Budd-Chiaris syndrome:hepatic vein thrombosis,obstruction of vena cava,Constrictive pericarditis,Heart failure,Pathophysiology of portal hypertension,A portal pressure above the normal lever of 5 to 8 mmHg stimulates portosystemic collateraligation.,Coronary vein Esophagogastric,Short gastric vein,varices,Azygos vein,Evaluation of the patient with cirrhosis,Diagnosis of the underlying liver disease,Estimations of functional hepatic reserve,Identification of the site of upper GI hemorrhage,if present(esophageal varices,gastric varices,ectopic varices,portal hypertensive gastropathy),Definition of portal venous anatomy and hepatic hemadynamic evaluation,Measurement of Hepatic Functional Reserve,Child-Pugh Criteria for Hepatic Functional Reserve,Measure A B C,Serum bulirubin 3,(mg per 100 ml),Serum albumin 3.5 2.8-3.5 6,Ascites None Slight Moderate,Neurologic disorder None Minimal Advanced,”coma”,Other Laboratory Tests,Anemia(bleeding,nutritional deficiency,hemolysis,or bone marrow depressing),Leukopenia,Thromhocytopenia,Prothrombin time,Alpha-fetoprotein lever,Liver biopsy(cause of cirrhosis,activity of the liver disease),Hepatic Hemodynamic Assessment,Presinusodal,Sinusodial,Postsinusoidal,Portal,Hypertension,Hepatic venous wedge pressure,Transhepatic venous cannulation,Umbilical venous cannulation,Percutaneou spleen puncure,Cases to do shunt operation,Selective visceral angiography,Duplex ultrasonography,Portal venous system,Renal vein,Hepatic portal perfusion,Treatment,Nonoperative,Colchicine,Penicillamine,Definitive treatment,Operative,Liver Transplantation,Pharmacotherapy,Endoscopic therapy,TIPS,Palliative,treatment,Portosystemic shunt,(nonselective,selective,partial),Nonshunt operation,Historically,the treatment of cirrhosis has been the treatment of the complications of portal hypertension.,A major challenge is to determine when definitive treatment rather than palliative treatment shoud be applied.,No single therapy is entirely satisfactory for all patients or clinical situations.,Treatment of Acute Bleeding Episode,Decompensated hepatic function,Encephalopathy,Ascites,Coagulopathy,Malnutrition,High risk,Nonoperative treatment whenever possible,Resuscitation and Diagnosis,Pharmacotherapy:Vasopressin+nitroglycerin,somatostatin/octreotide,Balloon tamponade:Sengstaken-Blackmore tube,Endoscopic treatment:variceal sclerosis or ligation,Transjugular intrahepatic portosystemic shunt(TIPS),Emergency Surgery,Failure of,Acute endoscopic treatment,Long-term endoscopic treatment,TIPS,Hemorrhage from gastric varices,Portal hypertensive gastropathy(PHG),Emergency,operation,Treating for Prevention of Recurrent Hemorrhage,First-line,treatment,Pharmacotherapy,Endoscopic,TIPS,(Satisfactory hepatic function),Portosystemic shunts,Advantages:the most effective decompression low rebleeding rate.,Shortages:high encephalopathy accelerated hepatic failure,Nonselective shunts,End-to-side portacaval shunt(Eckfistula),Side-to-side portacaval shunt,Large diameter interposition shunt,Conventional spleenorenal shunt,Selective shunts,Warren(1967)Distal splenorenal shunt,Inokuchu(1984)Left gastric renacaval shunt,Left gastic(coronary)vein vein graft inferior vena cava,Patial Shunts,Small-diameter vein-to-vein anastomoses,Small-diameter interposition proacaval shunt,The objective of partial selective shunts,Effective decompression of varices,Preservation of hepatic portal perfusion,Maintenance of some residual portal hypertension,Nonshunt Operation,Objectives:,extensive esophagogastric,devasculrigation,splenectomy,transection of the distal,esophagus,Liver Transplantantion,A definitive treatment,End-stage hepatic failure,Not indicated for schistosomiasis,Not indicated for active alcoholism(noncompliance),Overall treatment Plan,
展开阅读全文