Treatment of portal hypertension

1. TREATMENT OF PORTAL HYPERTENSION SANTOSH K RAGIV GANGHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA , INDIA

2. TREATMENT OF PORTAL HYPERTENSION INCLUDES

3. Portal pressure Resistance to portal flow Cirrhosis Varices Variceal Growth VARICES AND VARICEAL HEMORRHAGE

4. Small varices Large varices No varices VARICES INCREASE IN DIAMETER PROGRESSIVELY VARICES INCREASE IN DIAMETER PROGRESSIVELY

5. TREATMENT OF VARICES / VARICEAL HEMORRHAGE No varices Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage Prevention of variceal development PREVENTION OF VARICEAL DEVELOPMENT

6. PRE-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 NON-SELECTIVE BETA BLOCKERS DO NOT PREVENT DEVELOPMENT OF VARICES

7. Treatment of Varices / Variceal Hemorrhage No varices Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage No specific therapy Repeat endoscopy in every 2-3 yrs MANAGEMENT OF PATIENTS WITHOUT VARICES

8. Treatment of Varices / Variceal Hemorrhage No varices Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage Prevention of first variceal hemorrhage PREVENTION OF FIRST VARICEAL HEMORRHAGE

9. Treatment of Varices / Variceal Hemorrhage Recurrent hemorrhage Variceal hemorrhage Varices No hemorrhage No varices Management depends on the size of varices MANAGEMENT OF PATIENTS WITH VARICES WHO HAVE NEVER BLED

10. Treatment of Varices / Variceal Hemorrhage Recurrent hemorrhage Variceal hemorrhage Medium/ large varices No hemorrhage Small varices No hemorrhage No varices 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 HEMORRHAGE

11. PROPRANOLOL

12. 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.

13. Endoscopic Variceal Band Ligation BLEEDING CONTROLLED IN 90% REBLEEDING RATE 30% COMPARED WITH SCLEROTHERAPY : Less rebleeding Lower mortality Fewer complications Fewer treatment sessions ENDOSCOPIC VARICEAL BAND LIGATION

14. Treatment of Varices / Variceal Hemorrhage Recurrent hemorrhage Variceal hemorrhage Medium/ large varices No hemorrhage Small varices No hemorrhage No varices ? Prevention of variceal growth MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE

15. Treatment of Varices / Variceal Hemorrhage Recurrent hemorrhage Variceal hemorrhage Small varices No hemorrhage No varices Repeat endoscopy in 1-2 years Beta-blockers? Medium/ large varices No hemorrhage MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE

16. Treatment of Varices / Variceal Hemorrhage Control of hemorrhage Recurrent hemorrhage Variceal hemorrhage Medium/ large varices No hemorrhage Small varices No hemorrhage No varices CONTROL OF ACUTE VARICEAL HEMORRHAGE

17. 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

18. 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.

19. BALLONON 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.

20. 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 IN THE TREATMENT OF VARICEAL HEMORRHAGE

21. ACCEPTED 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.

22. PROCEDURE 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

23. PORTOSYSTEMIC SHUNTS SHUNT OPERATIONS ARE THE ONLY MODALITIES THAT EFFECTIVELY REDUCE PORTAL PRESSURE AND THUS DEFINATIVELY TREAT THE UNDERLYING CAUSE OF VARICEAL BLEEDING. TYPES OF SHUNT OPERATIONS NON SELECTIVE SHUNTS PORTOCAVAL SHUNTS MESOCAVAL SHUNTS SPLENORENAL SHUNTS SELECTIVE SHUNTS DISTAL SPLENORENAL SHUNT

24. DISTAL SPLEENORENAL SHUNT

25. Recurrent hemorrhage Medium/ large varices No hemorrhage Small varices No hemorrhage No varices Treatment of Varices / Variceal Hemorrhage Variceal hemorrhage 1) Safe vasoactive drug + endoscopic therapy + balloon tamponade+antibiotic prophylaxis 2) TIPS / Shunt (rescue therapy) MANAGEMENT OF PATIENTS WITH ACUTE VARICEAL HEMORRHAGE

26. Treatment of Varices / Variceal Hemorrhage No varices Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage 1)  -blockers + EVL 2)TIPS / shunt surgery PREVENTION OF RECURRENT VARICEAL HEMORRHAGE

27. Evolution of Varices Level of Intervention Management Recommendations Cirrhosis with no varices Repeat endoscopy in 2-3 years No specific therapy Pre-primary prophylaxis SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE

28. Evolution of Varices Level of Intervention Management Recommendations Cirrhosis with no varices Small varices No hemorrhage Medium / large varices No hemorrhage Repeat endoscopy in 2-3 years No specific therapy 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 Pre-primary prophylaxis Primary prophylaxis SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE

29. Evolution of Varices Level of Intervention Management Recommendations Cirrhosis with no varices Small varices No hemorrhage Medium / large varices No hemorrhage Variceal hemorrhage Repeat endoscopy in 2-3 years No specific therapy 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 Endoscopic/pharmacologic therapy Antibiotics in all patients TIPS or shunt surgery as rescue therapy Pre-primary prophylaxis Primary prophylaxis SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE

30. Evolution of Varices Level of Intervention Management Recommendations Cirrhosis with no varices Small varices No hemorrhage Medium / large varices No hemorrhage Variceal hemorrhage Recurrent variceal hemorrhage Pre-primary prophylaxis Primary prophylaxis Secondary prophylaxis Repeat endoscopy in 2-3 years No specific therapy 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 intolerant to drugs Endoscopic/pharmacologic therapy Antibiotics in all patients TIPS or shunt surgery as rescue therapy Beta-blockers + EVL TIPS or shunt surgery as rescue therapy SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE

31. MANAGEMENT OF ASCITES

32. 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.

33. TREATMENT 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.

34. LIVER 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.