Hipertensión Portal

Dr. Michel Baró A

Hipertensión portalHipertensión portal

Várices esofágicasVárices esofágicas Hemorragia digestivaHemorragia digestiva

ascitisascitisPeritonitis bacteriana Peritonitis bacteriana espontáneaespontánea

Insuficiencia renalInsuficiencia renal

Patogenia de la cirrosis hepáticaPatogenia de la cirrosis hepática

Patogenia de la HT portal: Fístulas de EckPatogenia de la HT portal: Fístulas de Eck

The portal venous system

(1) the gastroesophageal junction; (2) the anal canal (3) the falciform ligament (4) the splenic venous bed and the left renal vein(5) the retroperitoneum

Shunts:

Measurement of portal hypertension

Presión del sinusoide hepático y vena porta = WHVP – FHVP (5 mmHg)Presión del sinusoide hepático y vena porta = WHVP – FHVP (5 mmHg)

Flujo hepático = 1350 mL/min (27% del gasto cardíaco)Flujo hepático = 1350 mL/min (27% del gasto cardíaco)Contenido sanguíneo hepático = 450 mL (función de reservorio)Contenido sanguíneo hepático = 450 mL (función de reservorio)

Natural history of esophageal varices

Endoscopic images of esophageal varices (A)

Endoscopic images of esophageal varices (B)

Large varices of stigmata of recent bleeding (A)

Factors affecting risk of esophageal variceal hemorrhage (A)

Classification of gastric varices (C)

Active hemorrhage from an esophageal varix

Portal hypertensive gastropathy (B)

Cardiovascular and renal physiology in cirrhosis: renal sodium and water retention

HT portal pre-hepática raramente da lugar al desarrollo de ascitis

Continuation of the cirrhotic process (A)

Continuation of the cirrhotic process (B)

The peripheral arterial vasodilatation hypothesis

The importance of nitric oxide or endothelial-derived relaxing factor as vasodilator (A)

The importance of nitric oxide or endothelial-derived relaxing factor as vasodilator (B)

Vasodilatación

Hepatic dysfunction and sodium retention

Excreción Na urinario

The role of cirrhotic cardiomyopathy HipertrofiaDisfunción diastólica en reposoDisfunción sistólica de stress

EndotoxinasNOAc. biliares

Tono simpático

Retención de Na

Retención de Na

Effector mechanisms of renal sodium retention in cirrhosis

Antinatriuretic and antidiuretic factors

Natriuretic and diuretic factors

Schematic representation of the hepatic sinusoidal bed

Schematic representation of sinusoidal portal hypertension

900 mL/día máx

Outline of stages of renal sodium retention

ANF—atrial natriuretic factor PNE—plasma norepinephrinePRA—plasma renin activity

Patient with ascites

Ascites-related hernia

Umbilical hernia due to ascites

Scrotal and penile edema

Pleural effusion

Chylous ascitic fluid

Peritoneal carcinomatosis

Cirrhotic patient with tense ascites

Large complicated umbilical hernia

Bulging of flanks

Abdominal ultrasound

Sampling of ascitic fluid

Ascitic fluid analysis

Table 10-39. Ascitic Fluid Analysis

Polymorphonuclear count

> 250 per μL is diagnostic of SBP Ascitic fluid albumin concentration

Serum-ascitic fluid albumin concentration > 1.1 g/dL is suggestive of cirrhotic, rather than malignant, ascites

Ascitic fluid protein concentration

Patients with ascitic fluid protein < 1.0 g/dL should be considered for prophylaxis against SBP

Differential diagnosis of ascites

Table 10-40. Differential Diagnosis of Ascites

Cirrhosis Constrictive pericarditis

Hepatoma Nephrotic syndrome Tuberculous peritonitis in the malnourished alcoholic Pancreatitis

Peritoneal carcinomatosis Malignant chylous ascites, especially lymphoma

Right-sided cardiac failure

Sodium balance in cirrhosis with ascites

Diuretic therapy

Diuretics used in ascites

Table 10-43. Diuretics Used in Ascites

Type of diuretic Name Side effects

Distal Spironolactone Gynecomastia

Hyperkalemia

Renal tubular acidosis Amiloride Hyperkalemia

Triamterene

Loop Furosemide Hyponatremia

Ethacrynic acid Hypokalemia

Azotemia Proximal Metolazone Hyponatremia

Hypokalemia

Azotemia

Definition of refractory ascites

Table 10-44. Definition of Refractory Ascites

Prolonged history of ascites unresponsive to 400 mg of spironolactone or 30 mg of amiloride plus up to 160 mg of furosemide daily for 2 wk while on a sodium-restricted diet (? 50 mmol/d) Patients who cannot tolerate diuretics because of side effects are also regarded as diuretic resistant

The development of ascites in patients with cirrhosis is associated with a poor prognosis (A)

Survival of patients with progressive functional renal failure (B)

Pathogenesis of Spontaneous Bacterial Peritonitis

Clinical features of spontaneous bacterial peritonitis

Table 10-73. Clinical Features of Spontaneous Bacterial Peritonitis

Significant fever Worsening encephalopathy

Chills Worsening of ascites Abdominal pain Hypotension

Abdominal tenderness Asymptomatic

Reduced bowel sounds

Gram stain of ascitic fluid (A)

Gram stain of ascitic fluid (B)

Organisms isolated in spontaneous bacterial peritonitis

Table 10-76. Organisms Isolated in Spontaneous Bacterial Peritonitis

Gram-negative bacilli (70&percnt;) Anaerobes (5&percnt;) Gram-positive organisms (25&percnt;)

Escherichia coli Bacteroides Streptococcus viridans

Klebsiella Clostridia Group D Streptococcus

Citrobacter freundii Lactobacillus Streptococcus pneumoniae Proteus Staphylococcus aureus

Enterobacter

Deterioration of renal function and the course of spontaneous bacterial peritonitis

Recurrence of spontaneous bacterial peritonitis (A)

Recurrence of spontaneous bacterial peritonitis (B)

Recurrence of spontaneous bacterial peritonitis (C)

Recurrence of spontaneous bacterial peritonitis (D)

Norfloxacin for reducing risk of spontaneous bacterial peritonitis recurrence

Prognosis