PORTAL HYPERTENSION An Introduction to the Culprit of Many Liver Failure Complications

Transcription

1 PORTAL HYPERTENSION An Introduction to the Culprit of Many Liver Failure Complications Edy G. Trujillo, RN, MSN, ACNP-BC Liver Transplant RRUCLA Medical Center July 31, 2018 What Do We All Look Forward to Everyday? 1

2 OBJECTIVES 1. Identify one key difference between the Systemic Circulation and Portal Circulation Systems. 2. Define Portal Hypertension. 3. Identify the main complication caused by Portal Hypertension on Systemic Circulation 4. Identify two main changes that occur in the portal system that lead to Portal Hypertension 5. Identify two or more complications of Portal Hypertension in Liver Disease SYSTEMIC CIRCULATION Left Ventricle Aorta Artery Arterioles Capillaries Capillaries Venules Vein Vena Cava Right Ventricle Systemic VS Portal Circulation Inflow vs Ouflow Portal Circulation Liver 2

3 SYSTEMIC VS PORTAL CIRCULATION Systemic Circulation Portal Circulation PORTAL SYSTEM Circulation of blood to the liver from small intestine, part of the colon, and spleen through the portal vein. Referred to as hepatic portal circulation 3

4 Greater than 5mmHg HepatoVascular Resistance (congestion) I N C R E A S I N G Clinically Significant when it reaches 10mmHg This Photo by Unknown Author is licensed under CC BY- SA The Culprit of Many Liver Failure Complications GI Bleeding: Esophageal and Gastric Varices Hypotension Ascites Hepatic Encephalopathy Hepatorenal Syndrome Hepatic Hydrothorax Hepatopulmonary Syndrome DISRUPTION IN PORTAL SYSTEM PreHepatic Vessel Occlusion IntraHepatic Liver Diseases PostHepatic Outflow Obstruction Splenic Vein or Mesenteric Vein Thrombosis Extrahepatic Portal Vein Infections Autoimmune Dz Toxins Budd-Chiari 90% 4

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6 HEPATOVASCULAR RESISTANCE Increase in Hepatic Vascular Tone Sinusoidal Endothelial Dysfunction Defective production of vasodilators Defective Production of Vasoconstrictors Oxidative Stress Loss of Normal Phenotype of liver sinusoidal endothelial cells Prothrombotic Proinflammatory Increase Deposition of Collagen Fibrogenesis Increase HVR Structural Architecture Nodule Formation Remodeling of Sinusoids Fibrosis Angiogenesis Vascular Occlusion 6

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8 Splanchnic Vasodilation Systemic Hypotension Ascites Hepatic Encephalopathy GI Bleeding: Esophageal and Gastric Varices Hepatorenal Syndrome Hepatic Hydrothorax / Hepatopulmonary Syndrome Hepatic Encephalopathy Elevated Ammonia Lactulose Rifaximin Hypotension Treat only if Symptomatic Midodrine??Fluids albumin 86/52 Variceal Bleeding Prevention GI Consult for EGD for banding PRBC, Platelets, FFP Ascites Diuretics Albumin 25% Paracentesis TIPS Hepatorenal Syndrome Albumin Challenge 25% Midodrine TID Octreotide SQ TID Hepatopulmonary Syndrome Oxygen Garlic 8

9 CASE FOR THOUGHT 58 F PMHx ESLD secondary to AutoImmune Hepatitis admitted to hospital with MS changes other significant PMHx Hepatopulmonary Syndrome uses oxygen at home VS: T: 38.1 HR 86 BP 90/58 RR 16 O2 Sats: 88% on RA 96% on 2L O2 via NC PE: A and O x 1 (person only), BS clear, neg orthostatic BP, + BS, + Ascites, large nontender abdomen, no obvious bleeding, Labs: Ammonia 80 H/H 7.8/22.5 Plt 48 INR 2.2 Na 128 Cr 2.2 Temp HR BP 82/48 86/52 84/56 RR Sats 90% 90% 88% _fig2_ Garbuzenko, D.V. (2016) Restructuring of the vascular bed in response to hemodynamic disturbances in portal hypertension. World Journal of Hepatology. 8(36), REFERENCES Gracia Sancho, J. (2015) Pathophysiology and Rational Basis for Therapy. Digestive Diseases. 35, Iwakini, Y. (2014) Pathophysiology of Portal Hypertension. Clinical Liver Diseases 18(2), Pillai, A.K. et al. (2015) Portal Hypertension: a review of portosystemic collateral pathways and endovascular interventions. Clinical Radiology. 70, dljs5rcahxnnuakhdkfa6qq_auicigb&biw=1284&bih=636#imgdii=bmhe9lokir6pkm:&imgrc=3krq arlewfq_m: WL0FMKHVAaDy0Q_AUICigB&biw=768&bih=379#imgrc=Hb7DsBSbizRAoM content/uploads/2017/09/liver on chip liver lobule microfluidics.jpg vascular resistance modulation Hyperactive hepatic stellate cells Thank You 9