Portal hypertension - increased pressure in the portal vein (normal pressure - 7 mmHg), developing as a result of blood flow difficulties on any part of the vein.
Increase over 12-20 mmHg It leads to expansion of portal vein. Varicose veins rupture easily, resulting in bleeding.
Causes
Intrahepatic causes of portal hypertension
- Cirrhosis of the liver
- The node proliferation (at rheumatoid arthritis, Felty's syndrome)
- Acute alcoholic hepatitis
- Receiving cytostatics (methotrexate, azathioprine, mercaptopurine)
- Intoxication with vitamin A
- schistosomiasis
- sarcoidosis
- alveococcosis
- Caroli's disease
- Wilson's disease
- Congenital hepatic fibrosis (portal and hepatic sclerosis)
- Gaucher's disease
- polycystic liver
- liver tumors
- hemochromatosis
- myeloproliferative disease
- Exposure to toxic substances (vinyl chloride, arsenic, copper)
Predpechenochnye reasons
- Impaction stem portal or splenic vein
- Surgical interventions on the liver, biliary tract; seoezenki removal
- Damage to the portal vein as a result of trauma or injury
- The increase seleznki with polycythemia, osteomyelofibrosis, hemorrhagic thrombocythemia
- Congenital anomalies of the portal vein
Postpechenochnye causes of portal hypertension
- Budd-Chiari syndrome
- constrictive pericarditis (E.g., with pericardium calcification) causes a pressure increase in the inferior vena cava, increasing the resistance of the venous blood flow in the liver
- Thrombosis or compression of the inferior vena cava.
The main importance is the veins of the lower third of the esophagus and gastric fundus, as varicose veins rupture easily, resulting in bleeding.
Manifestations of portal hypertension
- The expansion of the saphenous veins of the anterior abdominal wall ( "Head of Medusa"), veins of the lower 2/3 of the esophagus, stomach, hemorrhoidal veins
- Bleeding from varices - esophageal-gastric bleeding (vomiting "coffee grounds", black stool), bleeding hemorrhoids
- Pain in the pit of the stomach, a feeling of heaviness in the upper quadrant, nausea, constipation etc.
- swelling
- Maybe jaundice
survey
- The general analysis of blood - decrease platelet, Leukocytes, erythrocytes
- In functional tests of liver - changes characteristic for hepatitis and cirrhosis
- Determination of markers viral hepatitis
- Detection of autoantibodies
- Determination of iron concentration in serum and liver
- Determining the activity of alpha-1-antitrypsin in the blood serum
- Determination of tserulloplazmina and daily excretion of copper in the urine, and quantitative determination of the copper content in the liver tissue.
- esophagographic
- Fibrogastroduodenoscopy reveals varicose veins of the esophagus and the stomach
- sigmoidoscopy: Under the mucous membrane of rectum and sigmoid colon are clearly visible varicose veins
- US allows estimating the diameter of the portal vein and splenic diagnose portal vein thrombosis.
- Doppler
- venography
- Angiography
Treatment of portal hypertension
In the treatment of portal hypertension, it is important to address the causes of underlying disease. Also used:
- Propranolol 20-180 mg 2 times a day in combination with sclerotherapy and variceal ligation of vessels
- Hemostasis: terlipressin 1 mg / bolus followed by 1 mg every 4 hours for 24 hours - operates more stably and permanently than vasopressin. Somatostatin in portal hypertension 250mg i.v. bolus, followed by 250 mg i.v. infusion over hours (infusion can be continued up to 5 days) reduces the frequency of rebleeding in 2 times. Somatostatin impairs blood flow in the kidney and the water-salt exchange, so the ascites it should be used cautiously.
- Endoscopic sclerotherapy ( "gold standard" treatment) carried out previously tamponade and administered somatostatin. Sclerosing drug introduced into varicose veins, leads to blockage. Manipulation effective in 80% of cases.
- esophageal tamponade with a probe Sengsteykena-Blakemore. After insertion of the probe into the stomach in the cuff is pumped air, pressing the veins of the stomach and the lower esophagus. Esophageal balloon should not be kept in the inflated state for more than 24 hours.
- Endoscopic ligation of varices of the esophagus and stomach by elastic rings. The effectiveness is the same as with sclerotherapy, but the procedure is complex in terms of continued bleeding. It prevents re-bleeding, but no effect on survival.
- Elective surgery varicose veins of the esophagus and stomach is performed to prevent rebleeding in case of failure or bleeding prophylaxis propranolol sclerotherapy. Survival is determined by the functional state of the liver. After the operation, it reduces the likelihood of ascites, peritonitis, Hepatorenal syndrome
- Liver transplantation is a patients with cirrhosis who had undergone at least 2 episodes of bleeding that required blood transfusion
Forecast
The prognosis of portal hypertension depends on the underlying disease. When it is determined the severity of cirrhosis of liver failure. Mortality in each bleeding is 40%.
