醫(yī)藥衛(wèi)生門靜脈高壓癥治療課件

SurgicalComplicationofCirrhosisandPortalHypertension第二軍醫(yī)大學東方肝膽外科醫(yī)院馬優(yōu)鋼SurgicalComplicationofCirrh1[Mechanism]SomecausesHepatocellular

injuryNecrosisfibrosisnodularregenerationcirrhosis

[Mechanism]SomeHepatocellul2alteredhepaticarchitectureperisinusoidalfibrosisIncreasedhepaticvasecularresistanceportalhypertensionalteredhepaticIncreasedportal3[Somecauses]Toxins:alcoholViruses:hepatitisB,hepatitisCProlongedcholestasis:extrahepatic,intrahepaticAutoimmunity:lupoidhepatitisMetabolicdisorders:hemochromatosis,Wilson’sdiseasealpha1-antitrypsindeficiency[Somecauses]Toxins:alcohol4[Anatomy][Anatomy]5[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件6[Classificationofportalhypertension]

PrehepaticportalhypertensionIntrahepaticportalhypertensionPosthepaticportalhypertension[Classificationofportalhyp7PrehepaticportalhypertensionIsolatedsplenicveinthrombosisLeftsidedportalhypertension

PancreaticinflammationorneoplasmThemostcommoncauseisportalveinthrombosis.(Halfinchildren)Prehepaticportalhypertension8IntrahepaticportalhypentensionPresinusoidalleverschistomiasisposthepatitisSinusoidalleveralcoholicposthepatitisPostsinusoidalleveralcoholic,Budd-chiari’ssyndromerareIntrahepaticportalhypentensi9PosthepaticportalhypertensionBudd-Chiari’ssyndrome:hepaticveinthrombosis,obstructionofvenacavaConstrictivepericarditisHeartfailurePosthepaticportalhypertensio10[Pathophysiologyofportalhypertension]

Aportalpressureabovethenormalleverof5to8mmHgstimulatesportosystemiccollateraligation.CoronaryveinEsophagogastricShortgastricvein

varicesAzygosvein[Pathophysiologyofportalhy11[Evaluationofthepatientwithcirrhosis]

DiagnosisoftheunderlyingliverdiseaseEstimationsoffunctionalhepaticreserveIdentificationofthesiteofupperGIhemorrhage,ifpresent(esophagealvarices,gastricvarices,ectopicvarices,portalhypertensivegastropathy)Definitionofportalvenousanatomyandhepatichemadynamicevaluation[Evaluationofthepatientwi12[MeasurementofHepaticFunctionalReserve]Child-PughCriteriaforHepaticFunctionalReserveMeasureABCSerumbulirubin<22-3>3(mgper100ml)

Serumalbumin>3.52.8-3.5<2.8(gper100ml)Prothrombosistime1-34-6>6AscitesNoneSlightModerateNeurologicdisorderNoneMinimalAdvanced,”coma”[MeasurementofHepaticFunct13[OtherLaboratoryTests]

Anemia(bleeding,nutritionaldeficiency,hemolysis,orbonemarrowdepressing)LeukopeniaThromhocytopeniaProthrombintimeAlpha-fetoproteinleverLiverbiopsy(causeofcirrhosis,activityoftheliverdisease)[OtherLaboratoryTests]

Ane14[HepaticHemodynamicAssessment]PresinusodalSinusodialPostsinusoidalPortalHypertensionHepaticvenouswedgepressureTranshepaticvenouscannulationUmbilicalvenouscannulationPercutaneouspleenpuncure[HepaticHemodynamicAssessme15Casestodoshuntoperation

SelectivevisceralangiographyDuplexultrasonographyPortalvenoussystemRenalveinHepaticportalperfusionCasestodoshuntoperation

Se16[Treatment]NonoperativeColchicinePenicillamine

DefinitivetreatmentOperativeLiverTransplantation

[Treatment]NonoperativeDefi17PharmacotherapyEndoscopictherapyTIPSPalliativetreatment

Portosystemicshunt(nonselective,selective,partial)NonshuntoperationPharmacotherapyPalliativePorto18Historically,thetreatmentofcirrhosishasbeenthetreatmentofthecomplicationsofportalhypertension..Amajorchallengeistodeterminewhendefinitivetreatmentratherthanpalliativetreatmentshoudbeapplied.Nosingletherapyisentirelysatisfactoryforallpatientsorclinicalsituations.Historically,thetreatmentof19[TreatmentofAcuteBleedingEpisode]DecompensatedhepaticfunctionEncephalopathyAscitesCoagulopathyMalnutritionHighrisk

Nonoperativetreatmentwheneverpossible[TreatmentofAcuteBleeding20ResuscitationandDiagnosisPharmacotherapy:Vasopressin+nitroglycerin,somatostatin/octreotideBalloontamponade:Sengstaken-BlackmoretubeEndoscopictreatment:varicealsclerosisorligationTransjugularintrahepaticportosystemicshunt(TIPS)ResuscitationandDiagnosisPha21[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件22[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件23[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件24EmergencySurgeryFailureofAcuteendoscopictreatmentLong-termendoscopictreatmentTIPSHemorrhagefromgastricvaricesPortalhypertensivegastropathy(PHG)EmergencyoperationEmergencySurgeryFailureofAcu25[TreatingforPreventionofRecurrentHemorrhage]First-linetreatmentPharmacotherapyEndoscopicTIPS(Satisfactoryhepaticfunction)[TreatingforPreventionofR26[Portosystemicshunts]

Advantages:themosteffectivedecompressionlowrebleedingrate.Shortages:highencephalopathyacceleratedhepaticfailure[Portosystemicshunts]

Advan27NonselectiveshuntsEnd-to-sideportacavalshunt(Eckfistula)Side-to-sideportacavalshuntLargediameterinterpositionshuntConventionalspleenorenalshuntNonselectiveshuntsEnd-to-sid28[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件29SelectiveshuntsWarren(1967)DistalsplenorenalshuntInokuchu(1984)LeftgastricrenacavalshuntLeftgastic(coronary)veinveingraftinferiorvenacavaSelectiveshuntsWarren(1967)30[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件31PatialShunts

Small-diametervein-to-veinanastomosesSmall-diameterinterpositionproacavalshunt

PatialShuntsSmall-diameterv32[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件33TheobjectiveofpartialselectiveshuntsEffectivedecompressionofvaricesPreservationofhepaticportalperfusionMaintenanceofsomeresidualportalhypertensionTheobjectiveofpartialselec34[NonshuntOperation]

Objectives:extensiveesophagogastricdevasculrigationsplenectomytransectionofthedistalesophagus

[NonshuntOperation]

Objecti35[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件36[LiverTransplantantion]AdefinitivetreatmentEnd-stagehepaticfailureNotindicatedforschistosomiasisNotindicatedforactivealcoholism(noncompliance)[LiverTransplantantion]Ade37[OveralltreatmentPlan][OveralltreatmentPlan]38[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件39SurgicalComplicationofCirrhosisandPortalHypertension第二軍醫(yī)大學東方肝膽外科醫(yī)院馬優(yōu)鋼SurgicalComplicationofCirrh40[Mechanism]SomecausesHepatocellular

injuryNecrosisfibrosisnodularregenerationcirrhosis

[Mechanism]SomeHepatocellul41alteredhepaticarchitectureperisinusoidalfibrosisIncreasedhepaticvasecularresistanceportalhypertensionalteredhepaticIncreasedportal42[Somecauses]Toxins:alcoholViruses:hepatitisB,hepatitisCProlongedcholestasis:extrahepatic,intrahepaticAutoimmunity:lupoidhepatitisMetabolicdisorders:hemochromatosis,Wilson’sdiseasealpha1-antitrypsindeficiency[Somecauses]Toxins:alcohol43[Anatomy][Anatomy]44[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件45[Classificationofportalhypertension]

PrehepaticportalhypertensionIntrahepaticportalhypertensionPosthepaticportalhypertension[Classificationofportalhyp46PrehepaticportalhypertensionIsolatedsplenicveinthrombosisLeftsidedportalhypertension

PancreaticinflammationorneoplasmThemostcommoncauseisportalveinthrombosis.(Halfinchildren)Prehepaticportalhypertension47IntrahepaticportalhypentensionPresinusoidalleverschistomiasisposthepatitisSinusoidalleveralcoholicposthepatitisPostsinusoidalleveralcoholic,Budd-chiari’ssyndromerareIntrahepaticportalhypentensi48PosthepaticportalhypertensionBudd-Chiari’ssyndrome:hepaticveinthrombosis,obstructionofvenacavaConstrictivepericarditisHeartfailurePosthepaticportalhypertensio49[Pathophysiologyofportalhypertension]

Aportalpressureabovethenormalleverof5to8mmHgstimulatesportosystemiccollateraligation.CoronaryveinEsophagogastricShortgastricvein

varicesAzygosvein[Pathophysiologyofportalhy50[Evaluationofthepatientwithcirrhosis]

DiagnosisoftheunderlyingliverdiseaseEstimationsoffunctionalhepaticreserveIdentificationofthesiteofupperGIhemorrhage,ifpresent(esophagealvarices,gastricvarices,ectopicvarices,portalhypertensivegastropathy)Definitionofportalvenousanatomyandhepatichemadynamicevaluation[Evaluationofthepatientwi51[MeasurementofHepaticFunctionalReserve]Child-PughCriteriaforHepaticFunctionalReserveMeasureABCSerumbulirubin<22-3>3(mgper100ml)

Serumalbumin>3.52.8-3.5<2.8(gper100ml)Prothrombosistime1-34-6>6AscitesNoneSlightModerateNeurologicdisorderNoneMinimalAdvanced,”coma”[MeasurementofHepaticFunct52[OtherLaboratoryTests]

Anemia(bleeding,nutritionaldeficiency,hemolysis,orbonemarrowdepressing)LeukopeniaThromhocytopeniaProthrombintimeAlpha-fetoproteinleverLiverbiopsy(causeofcirrhosis,activityoftheliverdisease)[OtherLaboratoryTests]

Ane53[HepaticHemodynamicAssessment]PresinusodalSinusodialPostsinusoidalPortalHypertensionHepaticvenouswedgepressureTranshepaticvenouscannulationUmbilicalvenouscannulationPercutaneouspleenpuncure[HepaticHemodynamicAssessme54Casestodoshuntoperation

SelectivevisceralangiographyDuplexultrasonographyPortalvenoussystemRenalveinHepaticportalperfusionCasestodoshuntoperation

Se55[Treatment]NonoperativeColchicinePenicillamine

DefinitivetreatmentOperativeLiverTransplantation

[Treatment]NonoperativeDefi56PharmacotherapyEndoscopictherapyTIPSPalliativetreatment

Portosystemicshunt(nonselective,selective,partial)NonshuntoperationPharmacotherapyPalliativePorto57Historically,thetreatmentofcirrhosishasbeenthetreatmentofthecomplicationsofportalhypertension..Amajorchallengeistodeterminewhendefinitivetreatmentratherthanpalliativetreatmentshoudbeapplied.Nosingletherapyisentirelysatisfactoryforallpatientsorclinicalsituations.Historically,thetreatmentof58[TreatmentofAcuteBleedingEpisode]DecompensatedhepaticfunctionEncephalopathyAscitesCoagulopathyMalnutritionHighrisk

Nonoperativetreatmentwheneverpossible[TreatmentofAcuteBleeding59ResuscitationandDiagnosisPharmacotherapy:Vasopressin+nitroglycerin,somatostatin/octreotideBalloontamponade:Sengstaken-BlackmoretubeEndoscopictreatment:varicealsclerosisorligationTransjugularintrahepaticportosystemicshunt(TIPS)ResuscitationandDiagnosisPha60[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件61[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件62[醫(yī)藥衛(wèi)生]門靜脈高壓癥治療課件63EmergencySurgeryFailureofAcuteendoscopictreatmentLong-termendoscopictreatmentTIPSHemorrhagefromgastricvaricesPortalhypertensivegastropathy(PHG)EmergencyoperationEmergencySurgeryFailureofAcu64[TreatingforPreventionofRecurrentHemorrhage]First-linetreatmentPharmacotherapyEndoscopicTIPS(Satisfactoryhepaticfunction)[TreatingforPreventionofR65[Portosystemicshunts]

Advantages:themosteffectivedecompressionlowrebleedingrate.Shortages:highencephalopathyacceleratedhepaticfailure[Portosystemicshunts]