Portal Hypertension & TIPS

Transcriptie

1 Portal Hypertension & TIPS Joost PH Drenth Department of Gastroenterology and Hepatology Radboud University Medical Center The Netherlands

2 Opzet Lever Anatomie Functie Cirrhose Wat is dat? Portale Hypertensie Fysiologie Pathofysiologie Klinische uitingen van portale hypertensie/ cirrhose Therapie Chirurgie TIPS

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4 Liver 1.5 kg, wedge shape 4 lobes, Right, left, Caudate, Quadrate. Double blood supply Hepatic arteries Portal Venous blood

5 Laparoscopic view of the liver

6 Computer Tomografie Lever Maag Wervel Milt

7 Post-Mortem vet Lever Maag Wervel Milt

8 Liver Function Metabolism Carbohydrate, Fat & Protein Secretory Bile, Bile acids, salts & pigments Excretory Bilirubin, drugs, toxins Synthesis Albumin, coagulation factors Storage Vitamins, carbohydrates Detoxification toxins, ammonia

9 Liver Cirrhosis Cirrhosis is common end result of many chronic liver disorders Inflammation healing with fibrosis - Liver tissue is replaced by connective tissue Regeneration of remaining hepatocytes form regenerating nodules Loss of normal architecture & function. The damage is irreversible but witholding / treating causative agent can slow or stop further damage

10 Causes Alcohol induced cirrhosis One of two common causes of cirrhosis in the United States Occurs in 15% of all alcoholics ~ 3-4 /day in Men ~ 2-3 / day in Women Hepatitis B Most common cause of cirrhosis world wide Passed through blood or bodily secretions 100 more infectious than HIV United States 1.5m World 300m infected Hepatitis C Second of two common causes of cirrhosis in USA USA 6.5m Mostly passed through needle use (not sexually)

11 Normal Liver - Microscopy

12 Cirrhosis Fibrosis Regenerating Nodule

13 Liver Biopsy Cirrhosis

14 Normal Liver vs. Cirrhosis

15 Portal Hypertension Has everything to do with the blood supply of the liver

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17 Portal Hypertension Portal hypertension is an increase in pressure in the portal vein which is caused by obstructed blood flow through the liver Normal pressure 5-10mm Hg Anything over 10mm Hg is considered high Problems Blood will find a way to bypass the liver to reach the heart or there is too much pressure upstream Major cause of portal hypertension is cirrhosis of the liver Alcohol Hepatitis B and C

18 Ven a gast rica UMC S t Radboud Vena hepatica Lever Vena porta Vena mesenterica superior Normale situatie Vena cava Maag/Oesophagus Vena lienalis Milt Vena mesenterica inferior

19 Ven a gast rica UMC S t Radboud Vena hepatica Lever Vena porta Vena mesenterica superior Lever Cirrhose Druk in vena porta Vena cava Maag/Oesophagus 1. Vertraging van de bloedstroom Vena lienalis Milt Vena mesenterica inferior

20 Ven a gast rica UMC S t Radboud Vena hepatica Lever Vena porta Vena mesenterica superior Lever Cirrhose Druk in vena porta Vena cava Maag/Oesophagus Vena lienalis 1. Vertraging van de bloedstroom 2. Venen zetten uit 3. Milt wordt groter Milt Vena mesenterica inferior

21 Ven a gast rica UMC S t Radboud Vena hepatica Lever Vena porta Vena mesenterica superior Vena cava Vena lienalis Vena mesenterica inferior Maag/Oesophagus 1. Omkering van de bloedstroom 2. Venen zetten uit 3. Milt wordt groter Milt

22 Ven rica UMC S t Radboud Vena hepatica Lever Vena cava Vena lienalis Maag/Oesophagus 1. Omkering van de bloedstroom 2. Venen zetten uit 3. Milt wordt groter 4. Esophagus varices Milt a gast Vena porta Vena mesenterica superior Vena mesenterica inferior

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25 Symptoms of Portal Hypertension Esophageal Varices Ascites Hepatic encephalopathy Palmar erythema Spider Clubbing Caput Medusae

26 Esophageal Varices Chronic Liver Disease - 8% per year for the first two years 30% by the sixth year Risk of bleeding is 30% in the first year after Diagnosis 70% chance of rebleeding and some 30% of the episodes are fatal Treatment: Banding tying rubber band around bleeding veins Sclerotherapy injection of sclerosing agent which causes them to shrink

27 Esophageal Varices Extreme dilation of the sub-mucosal veins in the lower mucosa of the esophagus and sometimes upper part of the stomach Life threatening shock Diagnosis by endoscopy Two main inflows for esophageal varices are left coronary vein or splenic hilus through the short gastric veins Responsible for 5-11% of gastrointestinal bleeding

28 Esophageal Varices

29 Bleeding Esophageal Varices

30 Esophageal Varices Banding Banding

31 Ascites Accumulation of fluid in the peritoneal cavity Not deadly but can lead to further complications Can cause fluid retention by the kidneys Diuretics are used in treatment and safer than drainage

32 Ascites Every 2-3 weeks: liter drainage

33 Ascitis & Umbilical hernia

34 Spider naevi

35 Hepatic Encephalopathy Hepatic encephalopathy Impairment of brain cells because of toxic substances in the blood Impaired cognition, tremors, and decreased levels of consciousness Subtle signs are usually observed in 70% of people with cirrhosis

36 Palmar Erythema Palmar erythema reddening of the skin on the hands because of capillary congestion Therapy treat portal hypertension

37 Clubbing Clubbing deformity of the fingers and fingernails Thought to cause vasodilation in the fingers and therefore hypertrophy of the nailbeds

38 Caput Medusae Appearance of distended or engorged umbilical veins radiating from umbilicus Blood trying to circumvent the liver because of pressure

39 Caput Medusae

40 Caput Medusae

41 Other signs of Cirrhosis Gynaecomastia Jaundice

42 Gynaecomastia

43 Jaundice

44 Portal Hypertension

45 Treatment of Portal Hypertension Beta adrenergic blocking agents Propanolol start when varices > grade 3 Portacaval Shunts pass blood from portal vein to inferior vena cava Splenorenal Shunts Pass blood from splenic vein to renal vein

46 Portal Hypertension

47 End-to-side portocaval shunt

48 Porto-caval shunt

49 Side-to-side portocaval shunt

50 Mesocaval C shunt

51 Various portocaval shunts

52 Splenorenal shunt

53 Various Splenorenal shunts

54 Portocaval shunts Difficult for the surgeon; requires a lot of experience High death rate 24-53% show debilitating symptoms of hepatic encephalopathy High rate of non-functioning shunts

55 Treatment of Portal Hypertension Transjugular T Intrahepatic I Portosystemic P Shunt S catheter is extend from portal vein across liver and connects to the hepatic vein

56 Transjugular Intrahepatic Porto-systemic Shunt TIPS

57 TIPS

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59 TIPS functional side-to-side shunt

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61 Insertion of TIPS (3)

62 Insertion of TIPS (2)

63 Insertion of TIPS (1)

64 Dhr FvH 61 jaar 1993: Stembandknobbels verwijderd. Preoperatief onderzoek hepatomegalie en verhoogde Gamma GT, ASAT en ALAT. 2000: Niet insuline afhankelijk Diabetes Mellitus en verhoogd Gamma GT. 2002: Diabetes Mellitus met nefropathie, opname in verband met ascites, hypertensie. 2004: Second opinion in verband met refractaire ascites bij alcoholische levercirrose.

65 Anamnese & Onderzoek Onderzoek Icterus Abdomen: bolle buik met versterkte vaattekening. Palpabele lever (drie vingers). Demping in de flanken met shifting dulness. Geen clubbing fingers of erythema palmare. Anamnese Sinds augustus 2002 ascites Pijnlijke druk in de buik en steken Toename van de buikomvang Moeheid & jeuk

66 Beloop Therapie resistente ascites diuretica geen effect Diverse drainages geen effect Geen spontane bacteriele peritonitis Patiënt komt in aanmerking voor een TIPS procedure

67 TIPS 1

68 TIPS 2

69 TIPS 3

70 TIPS 4

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73 TIPS Technically feasible Complications 9-50% Infection Intraperitoneal Bleeding Congestive Failure Subcapsular Hematoma Acute Renal Failure Hemobilia Mortality (30 day) 3-13%

74 Problems With TIPS Encephalopathy minimum 15% Occlusion one year Rebleeding one year 4.7 months

75 What to do with TIPS? Occlusion rate well above 50% (one year) Multiple revisions!!! Polytetrafluoroethylene (PTFE) covered stents

76 Polytetrafluoroethylene = Teflon non-sticking non-reactive Implants

77 UMC S Polytetrafluoroethylene t Radboud (PTFE) covered stents Viatorr

78 Covered TIPS (Viatorr) vs uncovered stents Shunt dysfunction Primary patency Complications portal hypertension Encephalopathy Teflon 15* 76* 19* 33* Uncovered

79 Covered TIPS (Viatorr) vs uncovered stents Teflon covered stents improve long-term patency of TIPS fewer reprocedures prevent clinical relapses decrease rate of encephalopathy

80 The Role For Tips Indication Refractory bleeding Bridge to transplant Child C livercirrhosis Refractory ascites Relative contraindication Unreliable patient

81 Preventing Portal Hypertension Preventing portal hypertension = preventing cirrhosis Treat infectious hepatitis!!! No alcohol < 1/day for women < 2/day for men

82 Beloop patient 2004: Na TIPS afname maar niet verdwijnen van ascitis: situatie acceptabel 2005: Slikklachten: scopie esophagus carcinoom; Radiotherapie; remissie 2005: Opname elders ivm koorts: spontane bacteriele peritonitis? 2006: Recidief esophagus carcinoom: overlijden

83 References Familypracticenotebook.com Wikipedia EMedicine

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85 Alcoholic Fatty Liver

86 Jaundice

87 Alcoholic Fatty Liver

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89 Normal Liver Histology PT CV

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92 TIPS