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

11/26/2018 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 ook F orwa rd to E ve ryda y? 1

11/26/2018 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 Ca pilla rie s Arte ry Ve nule s Arte riole s Ve in Ca pilla rie s Ve na Ca va Rig ht Ve ntric le Syste mic VS Po rta l Circ ula tio n I nflo w vs Ouflo w L ive r Porta l Circ ula tion 2

11/26/2018 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. R e fe rre d to a s he pa tic porta l c irc ula tion 3

11/26/2018 PORT AL HYPE RT E NSI ON Gre a te r tha n 5mmHg He pa to Va sc ula r Re sista nc e (c o ng e stio n) N G A S I I N C R E 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 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 I ntra He pa tic Pre He pa tic Po stHe pa tic L ive r Dise a se s Ve sse l Oc c lusio n Outflo w Ob struc tio n Sple nic Ve in o r Me se nte ric Infe c tio ns Budd-Chia ri Ve in T hro mb o sis Auto immune Dz E xtra he pa tic Po rta l Ve in T o xins 90% 4

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11/26/2018 HE PAT OVASCUL AR RE SI ST ANCE Inc re a se in He pa tic Struc tura l Va sc ula r T one Arc hite c ture • No dule F o rma tio n • Sinuso ida l E ndo the lia l Dysfunc tio n • Re mo de ling o f Sinuso ids • 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 F ib ro sis • • Oxida tive Stre ss Ang io g e ne sis • L o ss o f No rma l Phe no type o f live r sinuso ida l • Va sc ula r Oc c lusio n 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 6

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11/26/2018 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 86/ 52 He pa tic Hypo te nsio n Va ric e a l Ble e ding E nc e pha lo pa thy T re a t o nly if Pre ve ntio n E le va te d Ammo nia Sympto ma tic GI Co nsult fo r E GD fo r L a c tulo se Mido drine b a nding Rifa ximin ? ? F luids a lb umin PRBC, Pla te le ts, F F P PORT ALHYPE RT E NSI ON He pa to re na l He pa to pulmo na ry Asc ite s Syndro me Syndro me Diure tic s Alb umin Cha lle ng e 25% Alb umin 25% Oxyg e n Mido drine T I D Pa ra c e nte sis Oc tre o tide SQ T I D T I PS Ga rlic 8

11/26/2018 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: T e mp 37.8 37.4 37.6 Ammo nia 80 H/ H 7.8/ 22.5 Plt 48 I NR 2.2 Na 128 Cr 2.2 HR 90 110 88 BP 82/ 48 86/ 52 84/ 56 RR 20 20 18 Sa ts 90% 90% 88% _fig2_224038128 RE F E RE NCE S Garbuzenko, D.V. (2016) Restructuring of the vascular bed in response to hemodynamic disturbances in portal hypertension. World Journal of Hepatology. 8(36), 1602-1609. Gracia‐Sancho, J. (2015) Pathophysiology and Rational Basis for Therapy. Digestive Diseases. 35, 508‐514. Iwakini, Y. (2014) Pathophysiology of Portal Hypertension. Clinical Liver Diseases 18(2), 281‐291. Pillai, A.K. et al. (2015) Portal Hypertension: a review of portosystemic collateral pathways and endovascular interventions. Clinical Radiology. 70, 1047‐1059. https://www.google.com/search?q=systemic+circulation+capillary+beds&rlz=1C1MKDC_enUS774US774&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiI_ dLjs5rcAhXNnuAKHdkfA6QQ_AUICigB&biw=1284&bih=636#imgdii=bmhe9LoKIr6pKM:&imgrc=3krq‐aRLewfq_M: https://www.google.com/search?q=portal+circulation+capillary+beds&rlz=1C1MKDC_enUS774US774&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiz‐ qqjtJrcAhXyguAKHeRjDewQ_AUICigB&biw=1284&bih=636#imgrc=G_iNYYiEZrx5oM https://www.google.com/search?q=cirrhosis+collateral+to+ivc&rlz=1C1MKDC_enUS774US774&source=lnms&tbm=isch&sa=X&ved=0ahUKEwil4onE9bjcAh WL0FMKHVAaDy0Q_AUICigB&biw=768&bih=379#imgrc=Hb7DsBSbizRAoM https://www.elveflow.com/wp‐content/uploads/2017/09/liver‐on‐chip‐liver‐lobule‐microfluidics.jpg https://www.researchgate.net/figure/Intrahepatic‐vascular‐resistance‐modulation‐Hyperactive‐hepatic‐stellate‐cells T ha nk You 9