treatment of portal hypertension

TREATMENT OF PORTAL HYPERTENSION

TREATMENT OF PORTAL HYPERTENSION

SANTOSH K

RAGIV GANGHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA , INDIA

SANTOSH K

RAGIV GANGHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA , INDIA

TREATMENT OF PORTAL HYPERTENSION INCLUDESTREATMENT OF PORTAL

HYPERTENSION INCLUDES

TREATMENT OF VARICEAL BLEEDING

TREATMENT OF ASCITES

TREATMENT OF SPLEENOMEGALY

Portal pressure

Portal pressure

Resistance to portal flowResistance

to portal flow

CirrhosisCirrhosis

VaricesVarices Variceal GrowthVariceal Growth

VARICES AND VARICEAL HEMORRHAGEVARICES AND VARICEAL HEMORRHAGE

Small varicesSmall varices Large varicesLarge varicesNo varicesNo varices

VARICES INCREASE IN DIAMETER PROGRESSIVELY

VARICES INCREASE IN DIAMETER PROGRESSIVELY

VARICES INCREASE IN DIAMETER PROGRESSIVELYVARICES INCREASE IN DIAMETER PROGRESSIVELY

TREATMENT OF VARICES / VARICEAL HEMORRHAGE

TREATMENT OF VARICES / VARICEAL HEMORRHAGE

No varicesNo varices

VaricesNo hemorrhage


Varicealhemorrhage

Varicealhemorrhage

RecurrenthemorrhageRecurrent

hemorrhage

Prevention of variceal

development

Prevention of variceal

development

PREVENTION OF VARICEAL DEVELOPMENTPREVENTION OF VARICEAL DEVELOPMENT

PRE-PRIMARY PROPHYLAXISPRE-PRIMARY PROPHYLAXIS

· MULTICENTER, RANDOMIZED, PLACEBO-CONTROLLED TRIAL OF TIMOLOL (NON-SELECTIVE BETA-BLOCKER) VS. PLACEBO IN PATIENTS

· BETA-BLOCKERS DID NOT PREVENT THE DEVELOPMENT OF VARICES AND WERE ASSOCIATED WITH A HIGHER RATE OF SERIOUS ADVERSE EVENTS

· HEPATIC VENOUS PRESSURE GRADIENT WAS THE STRONGEST PREDICTOR OF THE DEVELOPMENT OF VARICES

· MULTICENTER, RANDOMIZED, PLACEBO-CONTROLLED TRIAL OF TIMOLOL (NON-SELECTIVE BETA-BLOCKER) VS. PLACEBO IN PATIENTS

· BETA-BLOCKERS DID NOT PREVENT THE DEVELOPMENT OF VARICES AND WERE ASSOCIATED WITH A HIGHER RATE OF SERIOUS ADVERSE EVENTS

· HEPATIC VENOUS PRESSURE GRADIENT WAS THE STRONGEST PREDICTOR OF THE DEVELOPMENT OF VARICES

NON-SELECTIVE BETA BLOCKERS DO NOT PREVENT DEVELOPMENT OF VARICESNON-SELECTIVE BETA BLOCKERS DO NOT PREVENT DEVELOPMENT OF VARICES

Treatment of Varices / Variceal Hemorrhage





Varicealhemorrhage

Varicealhemorrhage


hemorrhage

No specific therapyRepeat endoscopy in every

2-3 yrs

No specific therapyRepeat endoscopy in every

2-3 yrs

MANAGEMENT OF PATIENTS WITHOUT VARICESMANAGEMENT OF PATIENTS WITHOUT VARICES






Varicealhemorrhage

Varicealhemorrhage


hemorrhage

Prevention of first variceal

hemorrhage

Prevention of first variceal

hemorrhage

PREVENTION OF FIRST VARICEAL HEMORRHAGEPREVENTION OF FIRST VARICEAL HEMORRHAGE




hemorrhage

Varicealhemorrhage

Varicealhemorrhage




Management depends on the size of varicesManagement depends on the size of varices

MANAGEMENT OF PATIENTS WITH VARICES WHO HAVE NEVER BLEDMANAGEMENT OF PATIENTS WITH VARICES WHO HAVE NEVER BLED




hemorrhage

Varicealhemorrhage

Varicealhemorrhage

Medium/ large varicesNo hemorrhage


Small varicesNo hemorrhage Small varices

No hemorrhage


1) -blockers (propranolol 1-2 mg/kg/day) indefinitely

2) Endoscopic variceal ligation/Sclerotherapy in patients intolerant to -blockers

1) -blockers (propranolol 1-2 mg/kg/day) indefinitely

2) Endoscopic variceal ligation/Sclerotherapy in patients intolerant to -blockers

MANAGEMENT OF PATIENTS WITH MEDIUM/LARGE VARICES WITHOUT PRIOR HEMORRHAGEMANAGEMENT OF PATIENTS WITH MEDIUM/LARGE VARICES WITHOUT PRIOR HEMORRHAGE

PROPRANOLOLPROPRANOLOL

DECREASES CARDIAC OUTPUT RESULTING IN DECREASED PORTAL PRESSURE AND VARICEAL SIZE.

REDUCES THE INTRAHEPATIC PORTAL VASCULAR RESISTANCE.

PRODUCES SPLANCHNIC VASOCONSTRICTION WHICH LEASD TO DECREASE IN PORTAL BLOOD FLOW.

USED ALONG WITH SCLEROTHERAPY.BENIFICIAL RESULTS IN TERMS OF LOWER REBLEEDING RATES & LOWER VARICEAL RECURRENCE.

MOST WIDELY USED β

BLOCKER.

ENDOSCOPIC LIGATION OF VARICES

ENDOSCOPIC LIGATION OF VARICES

· RECENT DEVELOPMENT IN THE TREATMENT OF VARICES

· BASED ON PRINCIPLES OF BAND LIGATION TECHNIQUE FOR HEMORRHOIDS.

· OESOPHAGEAL VARICES ARE MECHANICALLY ENSNARED WITH SMALL ELASTIC RINGS CAUSING NECROSIS WITHIN 4-7 DAYS FOLLOWED BY RE-EPITHELIALIZATION AND SCAR FORMATION.

· ENDOSCOPIC THERAPY IS A LOCAL THERAPY THAT HAS NO EFFECT ON THE PATHOPHYSIOLOGIC MECHANISMS THAT LEAD TO PORTAL HYPERTENSION AND VARICEAL RUPTURE.

· RECENT DEVELOPMENT IN THE TREATMENT OF VARICES

· BASED ON PRINCIPLES OF BAND LIGATION TECHNIQUE FOR HEMORRHOIDS.

· OESOPHAGEAL VARICES ARE MECHANICALLY ENSNARED WITH SMALL ELASTIC RINGS CAUSING NECROSIS WITHIN 4-7 DAYS FOLLOWED BY RE-EPITHELIALIZATION AND SCAR FORMATION.

· ENDOSCOPIC THERAPY IS A LOCAL THERAPY THAT HAS NO EFFECT ON THE PATHOPHYSIOLOGIC MECHANISMS THAT LEAD TO PORTAL HYPERTENSION AND VARICEAL RUPTURE.

Endoscopic Variceal Band Ligation

Endoscopic Variceal Band Ligation

· BLEEDING CONTROLLED IN 90%

· REBLEEDING RATE 30%

· COMPARED WITH SCLEROTHERAPY:

Less rebleeding

Lower mortality

Fewer complications

Fewer treatment sessions

· BLEEDING CONTROLLED IN 90%

· REBLEEDING RATE 30%

· COMPARED WITH SCLEROTHERAPY:

Less rebleeding

Lower mortality

Fewer complications

Fewer treatment sessions

ENDOSCOPIC VARICEAL BAND LIGATIONENDOSCOPIC VARICEAL BAND LIGATION




hemorrhage

Varicealhemorrhage

Varicealhemorrhage




No hemorrhage


? Prevention of variceal growth

? Prevention of variceal growth

MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGEMANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE




hemorrhage

Varicealhemorrhage

Varicealhemorrhage


No hemorrhage


· Repeat endoscopy in 1-2 years

· Beta-blockers?

· Repeat endoscopy in 1-2 years

· Beta-blockers?



MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGEMANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE



Control of hemorrhageControl of

hemorrhage


hemorrhage

Varicealhemorrhage

Varicealhemorrhage




No hemorrhage


CONTROL OF ACUTE VARICEAL HEMORRHAGECONTROL OF ACUTE VARICEAL HEMORRHAGE

TREATMENT OF ACUTE VARICEAL HEMORRHAGE

TREATMENT OF ACUTE VARICEAL HEMORRHAGE

GENERAL MANAGEMENT: · IV ACCESS AND FLUID RESUSCITATION· DO NOT OVERTRANSFUSE (HEMOGLOBIN

~ 8 G/DL)· ANTIBIOTIC PROPHYLAXIS (IV

CEFTRIAXONE 50-100 MG/KG/DAY)

SPECIFIC THERAPY:· PHARMACOLOGICAL THERAPY:

TERLIPRESSIN, SOMATOSTATIN AND ANALOGUES, VASOPRESSIN + NITROGLYCERIN

· ENDOSCOPIC THERAPY: BAND LIGATION, SCLEROTHERAPY

· SHUNT THERAPY: TIPS, SURGICAL SHUNT

GENERAL MANAGEMENT: · IV ACCESS AND FLUID RESUSCITATION· DO NOT OVERTRANSFUSE (HEMOGLOBIN

~ 8 G/DL)· ANTIBIOTIC PROPHYLAXIS (IV

CEFTRIAXONE 50-100 MG/KG/DAY)

SPECIFIC THERAPY:· PHARMACOLOGICAL THERAPY:

TERLIPRESSIN, SOMATOSTATIN AND ANALOGUES, VASOPRESSIN + NITROGLYCERIN

· ENDOSCOPIC THERAPY: BAND LIGATION, SCLEROTHERAPY

· SHUNT THERAPY: TIPS, SURGICAL SHUNT

PHARMACOLOGIC THERAPY

PHARMACOLOGIC THERAPY

· SOMATOSTATIN-DECREASES PORTAL FLOW, SPLANCHNIC VASOCONSTRICTION.

· OCTREOTIDE- 50MCG/H SHOWN TO REDUCE COMPLICATIONS OF BLEEDING AFTER SCLEROTHERAPY.

· VASOPRESSIN- REDUCES BLOOD FLOW TO ALL SPLANCHNIC ORGANS, DECREASES PORTAL PRESSURE, VENOUS BLOOD FLOW. USE NITROGLYCERIN WITH IT! IT’S THE MOST POTENT SPLANCHNIC VASOCONSTRICTOR.

· ANTIBIOTICS TO PREVENT INFECTION.

· SOMATOSTATIN-DECREASES PORTAL FLOW, SPLANCHNIC VASOCONSTRICTION.

· OCTREOTIDE- 50MCG/H SHOWN TO REDUCE COMPLICATIONS OF BLEEDING AFTER SCLEROTHERAPY.

· VASOPRESSIN- REDUCES BLOOD FLOW TO ALL SPLANCHNIC ORGANS, DECREASES PORTAL PRESSURE, VENOUS BLOOD FLOW. USE NITROGLYCERIN WITH IT! IT’S THE MOST POTENT SPLANCHNIC VASOCONSTRICTOR.

· ANTIBIOTICS TO PREVENT INFECTION.

BALLONON TAMPONADEBALLONON TAMPONADE

· BALLOON TAMPONADE ONLY IN MASSIVE

BLEEDING AS A TEMPORARY MEASURE.

SENGSTAKEN TUBE

HAS 3 LUMENS, 1 FOR GASTRIC

ASPIRATION, 2TO INFLATE THE

GASTRIC BALLOON AND THE

OESOPHAGEAL BALLOON.

· BALLOON TAMPONADE ONLY IN MASSIVE

BLEEDING AS A TEMPORARY MEASURE.

SENGSTAKEN TUBE

HAS 3 LUMENS, 1 FOR GASTRIC

ASPIRATION, 2TO INFLATE THE

GASTRIC BALLOON AND THE

OESOPHAGEAL BALLOON.

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT

· TIPS IS RESCUE THERAPY FOR RECURRENT VARICEAL HEMORRHAGE

· IT IS ONLY USEFUL IN PORTAL HYPERTENSION OF HEPATIC ORIGIN.

· TIPS IS INDICATED IN PATIENTS WHO REBLEED ON COMBINATION ENDOSCOPIC PLUS PHARMACOLOGIC THERAPY

· IN PATIENTS WITH CIRRHOSIS, THE DISTAL SPLENO-RENAL SHUNT IS AS EFFECTIVE AS TIPS.

· TIPS IS RESCUE THERAPY FOR RECURRENT VARICEAL HEMORRHAGE

· IT IS ONLY USEFUL IN PORTAL HYPERTENSION OF HEPATIC ORIGIN.

· TIPS IS INDICATED IN PATIENTS WHO REBLEED ON COMBINATION ENDOSCOPIC PLUS PHARMACOLOGIC THERAPY

· IN PATIENTS WITH CIRRHOSIS, THE DISTAL SPLENO-RENAL SHUNT IS AS EFFECTIVE AS TIPS.

TIPS IN THE TREATMENT OF VARICEAL HEMORRHAGETIPS IN THE TREATMENT OF VARICEAL HEMORRHAGE

ACCEPTED INDICATIONSACCEPTED INDICATIONS

· ACTIVE BLEEDING DESPITE ENDOSCOPIC OR PHARMACOLOGIC TREATMENT

· RECURRENT VARICEAL BLEEDING DESPITE ADEQUATE ENDOSCOPIC TREATMENT.

· POTENTIAL INDICATIONS INCLUDE BLEEDING GASTRIC FUNDIC VARICES, REFRACTORY ASCITES.

· A BRIDGE TO TRANSPLANTATION.

· ACTIVE BLEEDING DESPITE ENDOSCOPIC OR PHARMACOLOGIC TREATMENT

· RECURRENT VARICEAL BLEEDING DESPITE ADEQUATE ENDOSCOPIC TREATMENT.

· POTENTIAL INDICATIONS INCLUDE BLEEDING GASTRIC FUNDIC VARICES, REFRACTORY ASCITES.

· A BRIDGE TO TRANSPLANTATION.

PROCEDUREPROCEDUREINSERTION OF AN EXPANDABLE METALLIC STENT FROM THE HEPATIC TO THE PORTAL VEIN THROUGH THE PERCUTANEOUS TRANSJUGULAR ROUTE UNDER RADIOLOGICAL GUIDANCE.

UNDER FLUOROSCOPIC CONTROL, A GUIDEWIRE IS PASSED INTO A HEPATIC VEIN. A NEEDLE IS THEN ADVANCED OVER A GUIDEWIRE INTO THE HEPATIC VEIN AND THEN TO THE PORTAL VEIN.

A BALLOON CATHETER IS SUBSEQUENTLY USED TO DILATE THE INTRAHEPATIC TRACT AND THE STENT IS DEPLOYED

INSERTION OF AN EXPANDABLE METALLIC STENT FROM THE HEPATIC TO THE PORTAL VEIN THROUGH THE PERCUTANEOUS TRANSJUGULAR ROUTE UNDER RADIOLOGICAL GUIDANCE.

UNDER FLUOROSCOPIC CONTROL, A GUIDEWIRE IS PASSED INTO A HEPATIC VEIN. A NEEDLE IS THEN ADVANCED OVER A GUIDEWIRE INTO THE HEPATIC VEIN AND THEN TO THE PORTAL VEIN.

A BALLOON CATHETER IS SUBSEQUENTLY USED TO DILATE THE INTRAHEPATIC TRACT AND THE STENT IS DEPLOYED

PORTOSYSTEMIC SHUNTSPORTOSYSTEMIC SHUNTS

· SHUNT OPERATIONS ARE THE ONLY MODALITIES THAT EFFECTIVELY REDUCE PORTAL PRESSURE AND THUS DEFINATIVELY TREAT THE UNDERLYING CAUSE OF VARICEAL BLEEDING.

· SHUNT OPERATIONS ARE THE ONLY MODALITIES THAT EFFECTIVELY REDUCE PORTAL PRESSURE AND THUS DEFINATIVELY TREAT THE UNDERLYING CAUSE OF VARICEAL BLEEDING.

TYPES OF SHUNT OPERATIONSTYPES OF SHUNT OPERATIONS

· NON SELECTIVE SHUNTS

PORTOCAVAL SHUNTS

MESOCAVAL SHUNTS

SPLENORENAL SHUNTS• SELECTIVE SHUNTS

DISTAL SPLENORENAL SHUNT

· NON SELECTIVE SHUNTS

PORTOCAVAL SHUNTS

MESOCAVAL SHUNTS

SPLENORENAL SHUNTS• SELECTIVE SHUNTS

DISTAL SPLENORENAL SHUNT

DISTAL SPLEENORENAL SHUNTDISTAL SPLEENORENAL SHUNT


hemorrhage




No hemorrhage




Varicealhemorrhage

Varicealhemorrhage

1) Safe vasoactive drug + endoscopic therapy + balloon tamponade+antibiotic prophylaxis

2) TIPS / Shunt (rescue therapy)

1) Safe vasoactive drug + endoscopic therapy + balloon tamponade+antibiotic prophylaxis

2) TIPS / Shunt (rescue therapy)

MANAGEMENT OF PATIENTS WITH ACUTE VARICEAL HEMORRHAGEMANAGEMENT OF PATIENTS WITH ACUTE VARICEAL HEMORRHAGE






Varicealhemorrhage

Varicealhemorrhage


hemorrhage

1) -blockers + EVL

2)TIPS / shunt surgery

1) -blockers + EVL

2)TIPS / shunt surgery

PREVENTION OF RECURRENT VARICEAL HEMORRHAGEPREVENTION OF RECURRENT VARICEAL HEMORRHAGE

Evolution of Varices


Level of Intervention

Level of Intervention Management RecommendationsManagement Recommendations

Cirrhosis with no varices


· Repeat endoscopy in 2-3 years· No specific therapy· Repeat endoscopy in 2-3 years· No specific therapy

Pre-primary prophylaxisPre-primary prophylaxis

SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE







Small varicesNo hemorrhageSmall varices

No hemorrhage

Medium / large varices

No hemorrhage


No hemorrhage


Small varices· Repeat endoscopy in 1-2 years· No specific therapy· ? beta-blocker to prevent

enlargement

Medium/Large varices· Non-selective beta-blockers· EVL in those who are intolerant to

drugs


enlargement


drugs


Primary prophylaxis

Primary prophylaxis

SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGESUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE








No hemorrhage


No hemorrhage


No hemorrhage

Variceal hemorrhage

Variceal hemorrhage



enlargement


drugs


enlargement


drugs· Endoscopic/pharmacologic therapy· Antibiotics in all patients· TIPS or shunt surgery as rescue

therapy

· Endoscopic/pharmacologic therapy· Antibiotics in all patients· TIPS or shunt surgery as rescue

therapy


Primary prophylaxis

Primary prophylaxis









No hemorrhage


No hemorrhage


No hemorrhage

Variceal hemorrhage

Variceal hemorrhage

Recurrent variceal

hemorrhage

Recurrent variceal

hemorrhage


Primary prophylaxis

Primary prophylaxis

Secondary prophylaxisSecondary prophylaxis



enlargement

Medium/Large varices· Non-selective beta-blockers· EVL in those intolerant to drugs


enlargement

Medium/Large varices· Non-selective beta-blockers· EVL in those intolerant to drugs


therapy


therapy

· Beta-blockers + EVL· TIPS or shunt surgery as rescue

therapy

· Beta-blockers + EVL· TIPS or shunt surgery as rescue

therapy


MANAGEMENT OF ASCITESMANAGEMENT OF ASCITES• SODIUM RESTRICTION AND

PROMOTION OF SODIUM EXCRETION ARE THE CORNER STONES OF ASCITES MANAGEMENT.

• SODIUM RESTRICTION TO 1 TO 2 meq/Kg/day.

• FLUID RESTRICTION.• SPIRONOLACTONE IS THE DIURETIC

OF CHOICE BECAUSE OF ITS ADDITIONAL ANTI ALDOSTERONE ACTIVITY.

• INITIATE AT 2-3mg/kg/day IN DIVIDED DOSES. CAN BE SAFELY DOUBLED IF NO INCREASE IN URINE OUTPUT OCCOURS IN 3-4 DAYS.• FUROSEMIDE CAN BE ADDED IF THERE IS NO RESPONSE TO HIGH DOSES OF SPIRONOLACTONE.

• HYPONATREMIA ASSOCIATED WITH FUROSEMIDE ADMINISTRATION SHOULD BE CORRECTED.

• INTRAVENOUS ALBUMIN 1g/kg WITH FUROSEMIDE CAN BE GIVEN TO PREVENT RECOLLECTION OF ASCITIC FLUID.

• IN VERY LARGE ASCITES PARACENTESIS MAY BE DONE.

DENVER AND LEVEEN SHUNTS

DENVER AND LEVEEN SHUNTS

· SUBCUTANEOUS SHUNTS THAT DRAIN ASCITIC FLUID FROM THE ABDOMEN INTO THE CENTRAL VENOUS SYSTEM.

· DIC IS A KNOWN COMPLICATION OF PERITONEOVENOUS SHUNTING OF ASCITIC FLUID.

· SUBCUTANEOUS SHUNTS THAT DRAIN ASCITIC FLUID FROM THE ABDOMEN INTO THE CENTRAL VENOUS SYSTEM.

· DIC IS A KNOWN COMPLICATION OF PERITONEOVENOUS SHUNTING OF ASCITIC FLUID.

TREATMENT FOR HYPER SPLEENISMTREATMENT FOR

HYPER SPLEENISM

· SELECTIVE SPLEENIC INFARCTION EFFECTIVELY CONTROLS HYPERSPLEENISM, REDUCES INCIDENCES OF REBLEEDING & CONSERVES SPLEENIC IMMUNE FUNCTION.

· MUST BE DONE IN CONJUNCTION WITH PNEUMOCOCCAL VACCINATION AND LONG TERM ANTIBIOTIC PROPHYLAXIS TO THE AGE OF 6 YEARS.

· SELECTIVE SPLEENIC INFARCTION EFFECTIVELY CONTROLS HYPERSPLEENISM, REDUCES INCIDENCES OF REBLEEDING & CONSERVES SPLEENIC IMMUNE FUNCTION.

· MUST BE DONE IN CONJUNCTION WITH PNEUMOCOCCAL VACCINATION AND LONG TERM ANTIBIOTIC PROPHYLAXIS TO THE AGE OF 6 YEARS.

LIVER TRANSPLANTATIONLIVER TRANSPLANTATION

· LIVER TRANSPLANTION IS THE LAST CHOICE OF SURGERY FOR TREATMENT OF PORTAL HYPERTENSION.

· IT IS DONE IN REFRACTORY CASES NOT IMPROVING WITH OTHER METHODS.

· LIVER TRANSPLANTION IS THE LAST CHOICE OF SURGERY FOR TREATMENT OF PORTAL HYPERTENSION.

· IT IS DONE IN REFRACTORY CASES NOT IMPROVING WITH OTHER METHODS.

treatment of portal hypertension

Health & Medicine

oesophageal varices

mediumlarge varices

thedevelopment of varices

variceal size

variceal rupture

lower variceal recurrence

management of patients

treatment of varicesbased