PORTAL HYPERTENSION

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PORTAL HYPERTENSION

• PRESENTER KRITHIKA KRISHNAN
• MODERATOR DR.R.PANDEY

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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• Mr. Anil Kumar Rai
• 36yrs / male
• Vendor
• New Delhi
• Presenting complaints

• Vomiting of blood
• Black tarry stools 1 month back
• Loss of consciousness

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History of presenting complaints

• Vomiting of blood.
• 2 episodes.
• 50 ml each.
• Dark colour mixed with fresh blood.
• Not associated with cough.
• Passage of black tarry stools.
• 2 episodes.

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• H/O Loss of consciousness.
• 1 episode.
• Not associated with trauma.
• Lasted for 30 seconds.
• H/O abdominal distension.
• 1 month.
• Progressively increasing.
• Uniform.
• Not associated with abdominal pain.

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• H/O yellowish discolouration of the body and
  mucous membrane
• 1 month.
• Progressively deepening.
• Not associated with clay stools or dark urine.
• H/O fever 1 month
• Low grade.
• Intermittent.
• Relieved with drugs.

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• H/O wakefulness in night and day time sleepiness.
• 15 days back.
• Improved with medications.
• H/O loss of weight.
• 15 kgs over past 2 years.
• H/O loss of appetite.

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• No H/O.
• Pedal edema.
• Breathlessness on exertion.
• Chest pain.
• Palpitation.
• Decreased urine output.
• Bruising/ gum bleed .

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• Personal History
• Consumes mixed diet.
• Chronic alcoholic since 15 years of age, stopped
  one year back (8-10 pegs of country liquor/day).
• H/O smoking since 15 years of age, stopped one
  year back about 15 pack- years.
• No H/O drug abuse.

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• Treatment History
• H/O upper GI endoscopy and sclerotherapy.
• Repeated paracentesis for the ascites.
• Antibiotics.
• T. Aldactone 100mg OD.
• T. Methyl cobalamine1500mg OD.
• T. Thiamine 100mg OD.
• Syrup. Lactulose 30ml TDS.

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• Past History
• H/O similar episodes of hemetemesis present 2
  years
• 4 such episodes.
• UGI endoscopy done.diagnosed as oesophageal
  varices and sclerotherapy done.
• Evaluated and diagnosed as cirrhosis with ESLD.
• H/O spontaneous bacterial peritonitis.
• 6 months back.
• Treated with antibiotics.

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• No H/O any other systemic illness.
• No H/O any surgery in the past.
• Family History
• No H/O any similar illness in the family.

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General examination

• 55 kg, 5 feet 7 inches.
• Average built .
• Pallor ve.
• Icteric.
• No clubbing.
• No cyanosis.

• No pedal edema.
• No other sign of liver cell failure.
• No significant lymphadenopathy.
• Venous access - good

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Vital Signs

• Pulse rate
• 72 beats/ min,
• regular in rhythm,
• normal in volume and character.
• Blood pressure
• 120/60 mm Hg
• measured in right upper limb ,in the supine
  posture.
• Jugular venous pulsations visible, pressure not
  elevated.
• Temperature - 37ºC.

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Airway Examination

• MMP II.
• Mouth opening and neck movements adequate.
• No loose tooth/ artificial denture.
• TMD gt3 fingers.

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Systemic examination

• Abdomen
• On inspection
• Distended uniformly.
• All quadrants moving equally with respiration.
• No dilated veins.
• Needle prick scars made out in the flanks.
• Umbilicus inverted.
• Divarication of recti present.

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• On palpation
• Soft.
• No tenderness.
• Spleen palpable below the left costal margin up
  to the umbilicus.
• Liver not palpable.
• On percussion
• Shifting dullness present.
• Liver span 7 cm.

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• Cardiovascular System
• S1 S2 heard - normal, no murmurs.
• Respiratory System
• B/L vesicular breath sounds present, no added
  sounds.
• Central Nervous System
• Clinically normal.

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Provisional diagnosis

• Decompensated chronic liver disease with portal
  hypertension with ascites.

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• Investigation
• Hemogram
• Hb 9 g/dl
• TLC 3700/cumm
• DLC P 74, L 23, M 2
• Platelet 71000/cumm
• PT 12/16.2

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• Biochemistry
• Blood sugar (R) 152 mg/dl
• B.Urea 103 mg/dl
• S. Creatinine 1.9 mg/dl
• Na/K 141/4.1 meq/L

• S.Bilirubin 3 mg/dl
• 0.8mg/dl 2.2mg/dl
• SGOT/PT 76/56
• ALKPO4 222
• T.Proteins/ Albumin/globulin 7.7/4.0/3.7

Unconjugated
Conjugated
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• CXR WNL
• ECG WNL
• Echo Normal study
• USG abdomen Liver small in size with slightly
  coarse echotexture.
• UGI endoscopy Grade III esophageal varices.
• CECT atrophy of R lobe of liver , spleen
  enlarged with infarct.
• HBsAg -ve.
• Anti HCV antibodies ve.

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Final diagnosis

• Decompensated chronic liver disease, probably
  alcohol in etiology, with portal hypertension
  with ascites.

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• Portal hypertension(gt10mmHg) and its consequences
• Gastroesophageal varices
• Ascites
• Hepatic encephalopathy
• SBP
• Hepatorenal syndrome
• HCC

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• Laboratory findings (minimal or absent)
• Anemia (a frequent finding)
• Coagulation abnormalities
• Increased AST, ALP, bilirubin, gamma globulins
• Decreased albumin

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• Imaging
• Spleen and hepatic enlargment
• Barium / endoscopic studies- presence of varices
• USG/ CT/ MRI for liver size, ascitis, hepatic
  nodules
• Doppler- for assessing the patency of splenic,
  portal hepatic veins

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• Portal Hypertension
• Hemorrhage from varices.
• Splenomegaly with hypersplenism.
• Ascites.
• Acute and chronic hepatic encephalopathy.

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• Diagnosis
• Fibreoptic esophagoscopy -for confirming varices.
• MRI and contrast CT- tool for detecting the
  collateral circulation.
• Percutaneous transhepatic catheterisation-Portal
  venous pressure.

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• Management of acute bleed
• Prompt replacement of fluid loss
• Replacement of clotting factors with fresh frozen
  plasma
• Monitoring of CVP or cap.wedge pressure
• Vasoconstrictors
• Balloon tamponade
• Endosopic variceal ligation
• Sclerotherapy
• Gastric devascularisation

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• Pathological feaures in advanced liver disease
• 1.Hyperdynamic circulation
• ? peripheral vascular resistance
• ? cardiac output
• Other CVS changes
• Increased SV HR.
• Normal filling pressures.
• Decreased sensitivity to vasopressors.
• Cardiomyopathy.

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• 2. Hypoxemia
• Intrapulmonary shunting
• Precapillary sphincter dilatation (HPS I).
• AV shunting (HPS II).
• V-Q abnormality in the lung.
• Exacerbated in the upright position.
• Pleural effusion.
• Pulmonary infection.
• Diaphragmatic dysfunction.
• Dysfunction of HPV.
• Rightward shift of O2 dissociation curve.

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• 3. Metabolic alkalosis
• High aldosterone state.
• 4. Coagulation abnormalities
• Deficiency of plasma clotting factors.
• ? platelet count.
• ? platelet function.
• Abnormal fibrinolytic factors.

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• 5. Hepatic blood flow
• Summation of hepatic arterial portal venous
  blood flow
• Effect of anesthetic drugs
• Ventilation IPPV, CO2
• Effect of surgery
• 6. Ascites
• 7. Renal impairment
• 8. Hepatic encephalopathy

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Ascites

• Underfill hypothesis
• Overflow hypothesis
• Treatment
• Spirnolactone
• Paracentesis, large volume albumin
• Frusemide
• Peritoneovenous shunt

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Hepatopulmonary syndrome

• HPS
• Presence of chronic disease
• Absence of intrinsic cardiopulmonary disease
• Pulmonary gas exchange abnormality
• Intrapulmonary vascular dilatation
• PPH
• PAP gt25mmHg
• PCWP lt15mmHg
• PVR gt120 dynes/s/cm5

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Hepatorenal syndrome
International ascites club criteria 1.
S.creatinine gt1.5mg/dl (133 µmol/l), GFR
lt40ml/min. 2. Absence of on going bact infection,
fluid loss, treatment with nephrotoxic drugs. 3.
No sustained improvement after diuretic
withdrawal and plasma volume expansion. 4.
Proteinuria lt 0.5g/dl. 5. No USG evidence of
parenchymal renal disease.

• U. Na lt10
• U.sediments N
• U.osmolality exceeds pl osmolality by atleast
  100mosm/l
• U/Pl cr. ratio gt301

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Hepatic encephalopathy
CNS Asterixes EEG
Grade I Sleep inversion euphoria /- Triphasic
II Lethargy Triphasic
III Confusion Triphasic
IV Coma, initially responds to noxious stimulus - Delta activity
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Precipitating factor

• Hypoxia.
• Hypovolemia.
• Hypoglycemia.
• Anemia.
• Infection, pneumonia sepsis.
• UGI bleed.
• Increased protein intake.
• Constipation.
• Large volume parcentesis.
• Diarrhea and vomiting.
• Diuretic.
• Sedatives.
• Shunts.

• Treatment
• Avoid ppt factors.
• Lactulose.
• Neomycin . Metronidazole.
• Liver transplantation.

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• Guidelines for anaesthetic management in patients
  with ESLD
• Common operative procedures
• Surgery for gastric/duodenal ulcer,
  cholecystectomy, colon carcinoma
• Various orthopedic procedures
• Portocaval shunts, Sclerotherapy, gastric
  devascularisation surgery

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• Preoperative instructions
• NPO gt 8 hours.
• High risk consent in the view of perioperative
  risk of renal and hepatic failure.
• Hydration of the patient with IV fluids
  _at_100ml/hour.
• CM S.electrolytes, PT and platelets.
• Premedication with T.Lorazepam 4mg HS CM and
  T.Ranitidine 150mg HS CM.

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• Induction Mod RSI
• Pre oxygenation for 3 minutes.
• Titrated dose of propofol (Thio can also be
  used).
• Intubate after giving scoline.
• Maintenance -
• Volatile agents Isoflurane, desflurane or
  sevoflurane.
• NMB Non depolarizing agents - Altered Vdss.

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• Opioids
• Fentanyl.
• Morphine.
• Pain Best controlled with epidural opioids if
  CNB is not contraindicated.

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Drugs Effect of liver disease Effect of liver disease Effect of liver disease Effect of liver disease Dose adjustment
T1/2 Vd Cl Fp
Thiopentone U U U I May need to
Morphine U U U U Frequency
Fentanyl U U U None
Alfentanil I U D I
Midazolam I I D
Lorazepam I I D I None
Propofol U U U I None/
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Risk assessment in patients with liver
diseaseChild Pugh score
C B A
gt3 2 - 3 lt2 Bilirubin
lt2.8 2.8 -3. 5 gt3.5 Albumin
Poorly controlled Well controlled None Ascites
Grade III-IV Grade I-II None Hepatic encepahalopathy
gt6/gt2.3 4 6/1.7-2.3 lt 4/lt1.7 PT/ INR
76 30 10 Surgical risk
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• MELD score
• MELD 3.8 x loge(bil ) 11.2 x loge(INR) 9.6
  x loge(creatinine)
• Causes of mortality in the periop period
• Sepsis, pneumonia.
• Renal failure.
• Non mechanical bleeding.
• Hepatic failure encephalopathy.

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Liver transplantation

• Indications
• Children.
• Adults.
• Contraindications
• Absolute.
• Relative.

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Preoperative preparation

• Central nervous system status.
• Encephalopathy grade.
• ICP.
• Coagulation status.
• Renal failure.
• Cardiopulmonary status.

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Phases of OLT

• Preanhepatic phase
• Monitor placement to clamping.
• Medications titrated.
• Lorazepam, morphine, oxazepam.
• Temperature monitoring and maintenance.
• Invasive monitoring.
• Defibrillator ready.
• Rapid infusor.
• Thromboelastography.
• Periodic blood sampling.

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• Anhepatic phase
• Occlusion of vascular supply to old liver to
  perfusion of new liver.
• Metabolic acidosis/ alkalosis.
• Hypocalcemia.
• Hypokalemia.

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• Postanhepatic phase
• After perfusion of the new liver.
• Ventricular fibrillation - hyperkalemia.
• Hypotension vasoactive amines.
• Air embolism.
• Paradox Hepatic congestion.

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Jaundice
Hemolytic Hepatocellular cholestasis
Transaminase N N
S. Albumin N N
PT N N
Bilirubin Unconju Conju Conju
ALP N N
GGT N N
BUN N N N
ICG N Retention N/ Retention
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Coagulation cascade
XII.XIIa
Intrinsic pathway
XIXIa
IX..IXa
IXaVIIIa
X..Xa
XaVa
II..IIa
IIa
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TF
Extrinsic pathway
VII..VIIa TF
X.Xa
V..Va
II.IIa
I.Ia
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ASRA guidelines

• Recommendation with heparin
• Sub cut heparin no CI
• S.C gt 4 d platelet count
• i.v heparin delay for 1 hr
• indwelling catheter remove after 2- 4 hrs of
  last dose, next dose after atleast 1 hr.
• syst heparinisation monitor neurologic status
  for 12 hr, dilute conc of LA
• bloody tap no mandatory cancellation

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• Preoperative LMWH
• LMWH thromboprophylaxis - needle placement 10-12
  hrs after LMWH dose
• Acute coronary syndrome / thrombo -embolism
  therapy - 24 hrs after last LMWH dose
• Post operative LMWH
• Twice daily dosing
• 1st dose LMWH 24 hrs postoperatively
• Epidural catheter to be removed prior to LMWH
  initiation
• LMWH dose 2 hours after catheter removal

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• Single daily dosing
• Initiation of LMWH - 6-8 hrs postoperatively,
  then 24 hrs later
• Indwelling catheters can be kept
• Catheter removal 10-12 hrs after last LMWH dose
• Subsequent LMWH dose 2 hours after catheter
  removal
• If blood on needle/catheter placement - delay
  initiation of LMWH 24 hours postoperatively

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• Patients on chronic warfarin
• Stop warfarin 4-5 days prior
• Ensure PT/INR within normal limits
• Patients given initial dose gt24 hrs prior to
  surgery or second dose administered
• Check PT/INR prior to block
• Low dose warfarin during epidural analgesia
• PT/ INR checked daily before catheter removal
• Catheter removal when INR lt1.5
• Neurological testing for gt 24 hrs following
  catheter removal
• INR gt 3 with epidural catheter in situ- with
  hold warfarin

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• Antiplatelets
• Stop clopidrogel 7 days
• Ticlopidine 14 days
• eptifibatide, tirofiban 8hours
• Abciximab 24- 48 hours
• Avoid starting these with catheter in place
• Start atleast 2 hrs of removal

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THANK YOU
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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