PORT AL HYPE RT E NSI ON An I ntro duc tio n to the Culprit - - PDF document

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PORT AL HYPE RT E NSI ON

An I ntro duc tio n to the Culprit o f Ma ny L ive r F a ilure Co mplic a tio ns

E dy G. T rujillo , RN, MSN, ACNP-BC L ive r T ra nspla nt RRUCL A Me dic a l Ce nte r July 31, 2018

Wha t Do We All L

• ok F
• rwa rd

to E ve ryda y?

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OBJE CT I VE S

1. Ide ntify o ne ke y diffe re nc e b e twe e n the Syste mic Circ ula tio n a nd Po rta l Circ ula tio n Syste ms. 2. De fine Po rta l Hype rte nsio n. 3. Ide ntify the ma in c o mplic a tio n c a use d b y Po rta l Hype rte nsio n o n Syste mic Circ ula tio n 4. Ide ntify two ma in c ha ng e s tha t o c c ur in the po rta l syste m tha t le a d to Po rta l Hype rte nsio n 5. Ide ntify two o r mo re c o mplic a tio ns o f Po rta l Hype rte nsio n in L ive r Dise a se

SYST E MI C CI RCUL AT I ON

L e ft Ve ntric le Aorta Arte ry Arte riole s Ca pilla rie s Ca pilla rie s Ve nule s Ve in Ve na Ca va Rig ht Ve ntric le

Syste mic VS Po rta l Circ ula tio n

Porta l Circ ula tion

I nflo w vs Ouflo w L ive r

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SYST E MI C VS PORT AL CI RCUL AT I ON

Syste mic Circ ula tio n Po rta l Circ ula tio n

PORT AL SYST E M

Circ ula tion of blood to the live r fro m sma ll inte stine , pa rt o f the c o lo n, a nd sple e n thro ug h the porta l ve in.

Re fe rre d to a s he pa tic porta l c irc ula tion

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PORT AL HYPE RT E NSI ON

Gre a te r tha n 5mmHg Clinic a lly Sig nific a nt whe n it re a c he s 10mmHg

T his Pho to b y Unkno wn Autho r is lic e nse d und e r CC BY- SA

He pa to Va sc ula r Re sista nc e (c o ng e stio n)

I N C R E

A S I

N G PORT AL HYPE RT E NSI ON

T he Culprit o f Ma ny L ive r F a ilure Co mplic a tio ns

• GI Ble e ding : E

so pha g e a l a nd Ga stric Va ric e s

• Hypo te nsio n
• Asc ite s
• He pa tic E

nc e pha lo pa thy

• He pa to re na l Syndro me
• He pa tic Hydro tho ra x
• He pa to pulmo na ry Syndro me

DI SRUPT I ON I N PORT AL SYST E M

Pre He pa tic

Ve sse l Oc c lusio n

Sple nic Ve in o r Me se nte ric Ve in T hro mb o sis E xtra he pa tic Po rta l Ve in

I ntra He pa tic L ive r Dise a se s

Infe c tio ns Auto immune Dz T

• xins

90%

Po stHe pa tic

Outflo w Ob struc tio n

Budd-Chia ri

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HE PAT OVASCUL AR RE SI ST ANCE

Struc tura l Arc hite c ture

• No dule F
• rma tio n
• Re mo de ling o f Sinuso ids
• F

ib ro sis

• Ang io g e ne sis
• Va sc ula r Oc c lusio n

Inc re a se in He pa tic Va sc ula r T

• ne
• Sinuso ida l E

ndo the lia l Dysfunc tio n

• De fe c tive pro duc tio n o f va so dila to rs
• De fe c tive Pro duc tio n o f Va so c o nstric to rs
• Oxida tive Stre ss
• L
• ss o f No rma l Phe no type o f live r sinuso ida l

e ndo the lia l c e lls

• Pro thro mb o tic
• Pro infla mma to ry
• Inc re a se De po sitio n o f Co lla g e n
• F

ib ro g e ne sis

• Inc re a se HVR

PORT AL HYPE RT E NSI ON

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PORT AL HYPE RT E NSI ON

• Spla nc hnic Va so dila tio n
• Syste mic Hypo te nsio n
• Asc ite s
• He pa tic E

nc e pha lo pa thy

• GI Ble e ding : E

so pha g e a l a nd Ga stric Va ric e s

• He pa to re na l Syndro me
• He pa tic Hydro tho ra x / He pa to pulmo na ry Syndro me

PORT AL HYPE RT E NSI ON

Hypo te nsio n E le va te d Ammo nia

L a c tulo se Rifa ximin

He pa tic E nc e pha lo pa thy

T re a t o nly if Sympto ma tic Mido drine ? ? F luids a lb umin

Va ric e a l Ble e ding

Pre ve ntio n GI Co nsult fo r E GD fo r b a nding PRBC, Pla te le ts, F F P

86/ 52

PORT ALHYPE RT E NSI ON

Asc ite s

Diure tic s Alb umin 25% Pa ra c e nte sis T I PS

He pa to re na l Syndro me

Alb umin Cha lle ng e 25% Mido drine T I D Oc tre o tide SQ T I D

He pa to pulmo na ry Syndro me

Oxyg e n Ga rlic

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CASE F OR T HOUGHT

58 F PMHx E SL D se c o nda ry to Auto I mmune He pa titis a dmitte d to ho spita l with MS c ha ng e s o the r sig nific a nt PMHx He pa to pulmo na ry Syndro me use s o xyg e n a t ho me VS: T : 38.1 HR 86 BP 90/ 58 RR 16 O2 Sa ts: 88% o n RA 96% o n 2L O2 via NC PE : A a nd O x 1 (pe rso n o nly), BS c le a r, ne g o rtho sta tic BP, + BS, + Asc ite s, la rg e no nte nde r a b do me n, no o b vio us b le e ding , L a b s: Ammo nia 80 H/ H 7.8/ 22.5 Plt 48 I NR 2.2 Na 128 Cr 2.2 T e mp 37.8 37.4 37.6 HR 90 110 88 BP 82/ 48 86/ 52 84/ 56 RR 20 20 18 Sa ts 90% 90% 88%

RE F E RE NCE S

_fig2_224038128

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