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Section II General Surgery P203Surgical Recall Sixth > Portal Hypertension, C53 P357-363 > Flashcards

Portal Hypertension, C53 P357-363 Flashcards

1
Q

Identify the anatomy of the
portal venous system:
P357 (picture)

A
  1. Portal vein
  2. Coronary vein
  3. Splenic vein
  4. IMV (inferior mesenteric vein)
  5. SMV (superior mesenteric vein)
  6. Superior hemorrhoidal vein
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2
Q

Describe drainage of
blood from the superior
hemorrhoidal vein.
P358

A

To the IMV, the splenic vein, and then

the portal vein

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3
Q

Where does blood drain into
from the IMV?
P358

A

Into the splenic vein

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4
Q

Where does the portal vein
begin?
P358

A

At the confluence of the splenic vein and

the SMV

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5
Q 
What are the (6) potential
routes of portal–systemic
collateral blood flow (as seen
with portal hypertension)?
P358
A
  1. Umbilical vein
  2. Coronary vein to esophageal venous
    plexuses
  3. Retroperitoneal veins (veins of Retzius)
  4. Diaphragm veins (veins of Sappey)
  5. Superior hemorrhoidal vein to middle
    and inferior hemorrhoidal veins and
    then to the iliac vein
  6. Splenic veins to the short gastric
    veins
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6
Q

What is the pathophysiology
of portal hypertension?
P358

A

Elevated portal pressure resulting from

resistance to portal flow

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7
Q

What level of portal
pressure is normal?
P358

A

<10 mm Hg

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8
Q

What is the etiology?

P358

A 
Prehepatic—Thrombosis of portal vein/
    atresia of portal vein
Hepatic—Cirrhosis (distortion of
    normal parenchyma by regenerating
    hepatic nodules), hepatocellular
    carcinoma, fibrosis
Posthepatic—Budd-Chiari syndrome:
    thrombosis of hepatic veins
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9
Q

What is the most common
cause of portal hypertension
in the United States?
P358

A

Cirrhosis (>90% of cases)

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10
Q

How many patients with
alcoholism develop
cirrhosis?
P358

A

Surprisingly, < 1 in 5

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11
Q

What percentage of patients
with cirrhosis develop
esophageal varices?
P359

A

≈40%

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12
Q

How many patients with
cirrhosis develop portal
hypertension?
P359

A

Approximately two thirds

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13
Q

What is the most common
physical finding in patients
with portal hypertension?
P359

A

Splenomegaly (spleen enlargement)

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14
Q

What are the associated
CLINICAL findings in
portal hypertension (4)?
P359 (picture)

A
  1. Esophageal varices
  2. Splenomegaly
  3. Caput medusae (engorgement of
    periumbilical veins)
  4. Hemorrhoids
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15
Q

What other physical findings
are associated with cirrhosis
and portal hypertension?
P359

A

Spider angioma, palmar erythema,
ascites, truncal obesity and peripheral
wasting, encephalopathy, asterixis (liver
flap), gynecomastia, jaundice

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16
Q

What is the name of the
periumbilical bruit heard
with caput medusae?
P359

A

Cruveilhier-Baumgarten bruit

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17
Q 
What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Esophageal varices?
P360
A

Coronary vein backing up into the

azygous system

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18
Q 
What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Caput medusae?
P360
A 
Umbilical vein (via falciform ligament)
draining into the epigastric veins
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19
Q 
What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Retroperitoneal varices?
P360
A

Small mesenteric veins (veins of Retzius)

draining retroperitoneally into lumbar veins

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20
Q 
What constitutes the portal–
systemic collateral circulation
in portal hypertension in the
following conditions:
Hemorrhoids?
P360
A

Superior hemorrhoidal vein (which
normally drains into the inferior mesenteric
vein) backing up into the middle
and inferior hemorrhoidal veins

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21
Q

What is the etiology?

P360

A 
Cirrhosis (90%), schistosomiasis,
hepatitis, Budd-Chiari syndrome,
hemochromatosis, Wilson’s disease,
portal vein thrombosis, tumors, splenic
vein thrombosis
22
Q

What is the most common
cause of portal hypertension
outside North America?
P360

A

Schistosomiasis

23
Q

What is Budd-Chiari
syndrome?
P360

A

Thrombosis of the hepatic veins

24
Q

What is the most feared
complication of portal
hypertension?
P360

A

Bleeding from esophageal varices

25
Q

What are esophageal
varices?
P360

A

Engorgement of the esophageal venous
plexuses secondary to increased collateral
blood flow from the portal system as a
result of portal hypertension

26
Q

What is the “rule of 2/3” of
portal hypertension?
P360

A 
2/3 of patients with cirrhosis will develop
    portal hypertension
2/3 of patients with portal hypertension
    will develop esophageal varices
2/3 of patients with esophageal varices
    will bleed from the varices
27
Q 
In patients with cirrhosis and
known varices who are
suffering from upper GI
bleeding, how often does that
bleeding result from varices?
P361
A

Only ≈50% of the time

28
Q

What are the signs/symptoms?

P361

A

Hematemesis, melena, hematochezia

29
Q

What is the mortality rate
from an acute esophageal
variceal bleed?
P361

A

≈50%

30
Q

What is the initial treatment
of variceal bleeding?
P361

A 
As with all upper GI bleeding: large
bore IVs x 2, IV fluid, Foley catheter,
type and cross blood, send labs, correct
coagulopathy (vitamin K, fresh frozen
plasma), +/ – intubation to protect from
aspiration
31
Q

What is the diagnostic test
of choice?
P361

A

EGD (upper GI endoscopy)
Remember, bleeding is the result of
varices only half the time; must rule
out ulcers, gastritis, etc.

32
Q

If esophageal varices cause
bleeding, what are the EGD
treatment options?
P361

A
  1. Emergent endoscopic
    sclerotherapy: a sclerosing substance
    is injected into the esophageal varices
    under direct endoscopic vision
  2. Endoscopic band ligation: elastic
    band ligation of varices
33
Q

What are the pharmacologic
options?
P361

A

Somatostatin (Octreotide) or IV
vasopressin (and nitroglycerin, to
avoid MI) to achieve vasoconstriction of the
mesenteric vessels; if bleeding continues,
consider balloon (Sengstaken-Blakemore
tube) tamponade of the varices, -blocker

34
Q

What is a Sengstaken-
Blakemore tube?
P361

A

Tube with a gastric and esophageal
balloon for tamponading an esophageal
bleed (see page 268)

35
Q

What is the next therapy after
the bleeding is controlled?
P361

A

Repeat endoscopic sclerotherapy/banding

36
Q 
What are the options
if sclerotherapy and
conservative methods fail to
stop the variceal bleeding or
bleeding recurs?
P362
A 
Repeat sclerotherapy/banding and treat
    conservatively
TIPS
Surgical shunt (selective or partial)
Liver transplantation
37
Q

What is a “selective” shunt?

P362

A

Shunt that selectively decompresses the
varices without decompressing the portal
vein

38
Q

What does the acronym
TIPS stand for?
P362

A

Transjugular Intrahepatic Portosystemic

Shunt

39
Q

What is a TIPS procedure?

P362

A

Angiographic radiologist places a small
tube stent intrahepatically between the
hepatic vein and a branch of the portal
vein via a percutaneous jugular vein route

40
Q

What is a “partial shunt”?

P362

A

Shunt that directly decompresses the

portal vein, but only partially

41
Q

What is a Warren shunt?

P362 (picture)

A

Distal splenorenal shunt with ligation of the
coronary vein—elective shunt procedure
associated with low incidence of
encephalopathy in patients postoperatively
because only the splenic flow is diverted
to decompress the varices

42
Q

What is a contraindication to
the Warren “selective”
shunt?
P363

A

Ascites

43
Q

Define the following shunts:
End-to-side portocaval shunt
P363

A

“Total shunt”—portal vein (end) to IVC

side

44
Q

Define the following shunts:
Side-to-side portocaval
shunt
P363

A

Side of portal vein anastomosed to side of
IVC—partially preserves portal flow
(“partial shunt”)

45
Q

Define the following shunts:
Synthetic portocaval
H-graft
P363

A 
“Partial shunt”—synthetic tube graft
from the portal vein to the IVC
(good option for patients with alcoholism;
associated with lower incidence
of encephalopathy and easier
transplantation later)
46
Q

Define the following shunts:
Synthetic mesocaval
H-graft
P363

A

Synthetic graft from the SMV to the IVC

47
Q

What is the most common
perioperative cause of death
following shunt procedure?
P363

A

Hepatic failure, secondary to decreased
blood flow (accounts for two thirds of
deaths)

48
Q

What is the major
postoperative morbidity
after a shunt procedure?
P363

A 
Increased incidence of hepatic
encephalopathy because of decreased
portal blood flow to the liver and
decreased clearance of toxins/metabolites
from the blood
49
Q 
What medication is infused
to counteract the coronary
artery vasoconstriction of IV
vasopressin?
P363
A

Nitroglycerin IV drip

50
Q

What lab value roughly
correlates with degree of
encephalopathy?
P363

A

Serum ammonia level (Note: Thought
to correlate with but not cause
encephalopathy)

51
Q

What medications are used to
treat hepatic encephalopathy?
P363

A

Lactulose PO, with or without

neomycin PO

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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