HIPERTENSIUNEA PORTALA

SINDROMUL ICTERIC
SINDROMUL ASCITIC
ENCEFALOPATIA HEPATICA
SINDROMUL HEPATORENAL

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 Portal hypertension (PH) - haemodynamic
abnormality associated with the most severe
complications of cirrhosis
 ascites
 hepatic encephalopathy
 bleeding from gastroesophageal varices.
 Sinusoidal portal hypertension (PH)
 pressure in the portal vascular system ≥ 10 mmHg
 hepatic venous pressure gradient (HVPG) ≥ 5mmHG

 Clinically significant portal hypertension (CSPH)

 hepatic venous pressure gradient (HVPG) ≥ 10mmHG

 The introduction of transient elastography (TE) - early identification

of patients with chronic liver disease (CLD) at risk of developing
(CSPH) =
 “compensated advanced chronic liver disease” (cACLD)
 “compensated cirrhosis”
Criteria to suspect cACLD:

 values >15 kPa - highly suggestive of cACLD

 values between 10-15 kPa are suggestive of cACLD but need
further test for confirmation
 TE values <10 kPa in the absence of other known clinical -
signs rule out cACLD

Criteria to confirm cACLD:

 Upper GI endoscopy - gastroesophageal varices

 Hepatic venous pressure gradient (HVPG) ≥ 5 mmHg
 Liver biopsy - severe fibrosis or established cirrhosis
 Clinically significant portal hypertension (CSPH)

 HVPG measurement is the gold-standard method to assess the

presence of CSPH (≥ 10mmHg)

 Imaging showing collateral circulation - sufficient to rule-in

CSPH in patients with cACLD of all aetiologies

 Liver stiffness by TE ≥ 20-25kPa at least two measurements on

different days in fasting condition alone or combined to
platelets and spleen size

 patients without CSPH have no gastroesophageal varices, and

have a low five year risk of developing them a
 v. splenica

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Componenta mecanica Componenta dinamica (VC) Vasodilatatie arteriolara
- fibroza - miofibroblasti splahnica
- noduli de regenerare - celule endoteliale - vasodilatatoare endog
- colagenizare spatii Disse - sdr. cardiac hiperkinetic

(ingustarea lumenului vascular)

Cresterea rezistentei vasculare Cresterea debitului portal

HIPERTENSIUNE PORTALA

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 HTP

PREHEPATICA INTRAHEPATICA POSTHEPATICA

PRESINUSOIDALA SINUSOIDALA POSTSINUSOIDALA

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Malformatii ale trunchiului port
Pileflebita, piletromboza (neoplazii, hipercoagulabilitate, pancreatita acuta)
Cavernom portal
Compresiuni sau invazii ale VP (HCC, colangiocc)
Tromboza venei splenice
Cresterea fluxului splenic ( splenomegalia din boli hematologice)
Cresterea fluxului hepatic (fistule arteriovenoase hepatoportale)

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 PRESINUSOIDALE SINUSOIDALE POSTSINUSOIDALE

Schistostomiaza Ciroza hepatica B. venoocluziva

Fibroza hepatica congenit
Boli mieloproliferative
Sarcoidoza
Factori toxici (arsen, cl vinil)
Sdr. Felty
Fibroza perisinusoidala Hepatita alcoolica
Hiperplazia nodulara (scleroza hialina centroven.
regenerativa
Hepatita acuta fulminanta

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 Sdr. Budd Chiari ( idiopatic, boli autoimune, traumatisme,
radioterapie, neoplasme invadante in v. hepatice)
Malformatii congenitale si tromboza VCI
Pericardita constrictiva
Afectiuni ale valvei tricuspide

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1. Dezvoltarea colateralelor portosistemice

Mai multe teritorii: - varice - esofagiene – principala complicatie a HTP = HDS

- gastrice
- duodenale
- veziculei biliare
- caii biliare principale
- jejunoileale
- colonice
- rectale
- anorectale
- intraperitoneale

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1. Obstructia venei porte - HTP = dilatare completa s sitemului port si
afluentilor cu dezvolatre de anastomoze portosistemice

1. Obstructia unui segment periferic = HTP segmentara

- obstructia v. splenice – dilatarea v. gastrice (varice gastrice)

- obstructia v. omentale

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2. Gastropatia portal hipertensiva
 gastropatie congestiva
ectazie vasculara cu cresterea comunicarilor arteriovenoase
submucoase si din musculara mucoasei
Se poate accentua dupa sleroterapia varicelor esofagiene
Risc de HDS (dupa consum de AINS)
3. entero-colopatia portal hipertensiva
 dilatare a circulatiei intramurale digestive

4. splenomegalia
Cresterea volumului splinei ( ecografic> 120/60mm)
Poate fi asociata cu hipersplenismul
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5. scaderea debitului portal efectiv hepatic
Scadere a debitului sanguin hepatic total
Agravarea insuficientei hepatice

6. sdr. hepatopulmonar
La 1/3 din pacientii cu ciroza decompensta
Sunturi intrapulmonare prin fistule arteriovenoase
Perturbarea schimburilor gazose, hipoxemie arteriala si vasodilatatie
intrapulmonara, fara boala primara pulmonara
Dispare dupa transplant

7. hipertensiunea arteriala pulmonara

 la 2% din cirotici
consecinta sunturilor portopulmonare
Distensia capilarelor pulmonare, cu tulburarea de difuziune a oxigenului
Contraindica
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 8. ascita

9. sdr. hepatorenal

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 1. Hemoragia digestiva superioara
2. Ascita
3. Encefalopatia hepatica
4. Sdr. hepatorenal

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CLINIC

Simptome si semne comune: - circulatia colaterala

- varicele esofagiene
- splenomegalia

Ascita
Encefalopatia hepatica

Simptome si semne ale bolii de baza : ex- ciroza hepatica: modificari

hepatice, icter, stelute vascular, eritem palmar

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Circulatia colaterala
- tip portocav: “ capul de meduza”, omfalofug
- tip cavo cav : in flacuri, sens cranial
- sdr. Cruveilhier- Baumgarten = HTP+permeabilitatea v. ombilic,
= suflu continuu;
= hepatocarcinom, hepatita acuta
etanolica

Varicele esofagiene cu/fara HDS

HDS - cea mai redutabila complicatie a HTP
- 80-90% - ruptura varicelor esofagiene
- risc mare: varice voluminoase, cu semne rosii, insuficienta hepatica

Splenomegalia

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PARACLINIC
ECOGRAFIA ABDOMINALA:

- dilatarea VP>12-14mm
- dilatarea VS>9mm, VM>9mm
- reducerea compliantei respiratorii
- scaderea debitului si vitezei de flux in VP
- inversarea fluxului, aparitia fluxului bidirectional
- colaterale porto sistemice: recanaliz lig rotund, circul colat
perigastrica, perisplenica, in patul vezicii biliare

- modificarea ficatului
- splenomegalia
- ingrosare peretelui digestiv
- ascita
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PARACLINIC
ENDOSCOPIA:
- vizualizarea varicelor esofagiene, gastrice, duodenale, rectale,
gastropatiei portal hipertensiva
- prezenta varicelor, dimensiuni, localizare, aspectul mucoasei
- semnul “rosu” - semn predictiv pt hemoragie, risc crescut la gradient
>12mmHg

COMPUTER TOMOGRAFIA

REZONANTA MAGNETICA NUCLEARA

MASURAREA PRESIUNII PORTALE – tehnica invaziva

EXPLORAREA FUNCTIEI HEPATICE

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THERAPEUTIC OPTIONS IN PATIENTS
WITH PORTAL HYPERTENSION

1. PRE-PRIMARY PROPHYLAXIS (prevention

of the formation of varices)

2. PRIMARY PROPHYLAXIS (prevention of the

first bleeding episode)

3. TREATMENT OF ACUTE BLEEDING

4. PREVENTION OF RE-BLEEDING