Podcast (Video Recorded Lecture Series): Portal HTN and Derivatives for the USMLE Step One Exam. Ultrasound (w/ doppler) Reversal of flow Portal Vein
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1 Podcast (Video Recorded Lecture Series): Portal HTN and Derivatives for the USMLE Step One Exam Hepatic Vein (Budd Chiari) Ultrasound (w/ doppler) Reversal of flow Portal Vein Howard J. Sachs, MD
2 Lobule w/ Portal Triad and Central Vein Portal Vein: Splenic Vein Superior Mesenteric Celiac Artery: Left Gastric Common Hepatic Splenic Bile Duct (Bile): Bile Salts Cholesterol Bilirubin
3 Lobule w/ Portal Triad and Central Vein Portal Vein: Splenic Vein Superior Mesenteric Central vein hepatic vein IVC RA
4 Zone 1: HCV likes oxygen Zone 3: APAP (toxins) feeds on hypoxia (and p 450) 1 3 O2-Rich Not so much
5 Diseases of Portal Circulation? S/s Portal HTN: 3 rd space fluid accumulation: Edema/ascites [Other: no JVD, (+) renal hypoperfusion RAA hypona+] Splenic congestion: cytopenias (all cell lines) Varices (porto-caval circulation)
6 Portal vein thrombosis is fun Hepatic vein thrombosis (Budd-Chiari) is thrilling Cirrhosis is common S/s Portal HTN: 3 rd space fluid accumulation: Edema/ascites [Other: no JVD, (+) renal hypoperfusion RAA hypona+] Splenic congestion: cytopenias (all cell lines) Varices (porto-caval circulation)
7 Portal Circulation: WYNTKFTB Circulation Manifestations of Portal HTN Recognizing the common conditions Portacaval anastamoses WYNTKFTB: What You Need To Know For The Boards
8 the Circulation þ þ Key Points: 1. Dual circulation 2. Portal VV thrombosis 3. Portal HTN/cirrhosis 4. Congestive hepatopathy Portal HTN: Ascites, Hypersplenism, Varices Portal HTN is only one of the manifestations of cirrhosis (and has other causes)
9 the Circulation Liver is not involved PVT: Pre-hepatic Key Points: 1. Dual circulation 2. Portal VV thrombosis 3. Portal HTN/cirrhosis 4. Congestive hepatopathy Portal HTN: Ascites, Hypersplenism, Varices Portal HTN is only one of the manifestations of cirrhosis (and has other causes)
10 the Circulation Cirrhosis: Most common Key Points: 1. Dual circulation 2. Portal VV thrombosis 3. Portal HTN/cirrhosis 4. Congestive hepatopathy Central Vein Congestion (CHF) Obstruction: HVT (Budd-Chiari) Portal HTN: Ascites, Hypersplenism, Varices Portal HTN is only one of the manifestations of cirrhosis (and has other causes)
11 the Circulation Hypoperfusion Shock liver Transaminase
12 Pre-Hepatic Portal V thrombosis Splenic V thrombosis Manifestions: Ascites/Edema; Hypersplenism Pre-hepatic means before the liver so the liver is spared. They will describe s/s with a predisposing (thrombophilic) cause BUT normal liver chems/exam
![Pericarditis [TB, radiation; (+) JVD] Budd-Chiari](/docs-images/96/128970852/images/13-1.jpg "(hepatic vein thrombosis) Budd-Chiari: Ascites, Large,")
13 Hepatic manifestation of heart disease Post-Hepatic (congestive hepatopathy) Right CHF Constrictive Pericarditis [TB, radiation; (+) JVD] Budd-Chiari (hepatic vein thrombosis) Budd-Chiari: Ascites, Large, Tender Liver Thrombophilic state (including): Ø Myeloproliferative Disorder (P Vera) Ø OCP (also a/w hepatic adenoma) Dx: U/S reversal of flow
14 Hepatic Vein (Budd Chiari) Ultrasound (w/ doppler) Reversal of flow Portal Vein How would portal vv thrombosis (prehepatic) differ from hepatic vv thrombosis (posthepatic)?
15
16 The Language of Cirrhosis Hepatic Failure ( prognostic factors ) Synthesis Albumin (edema, ascites - oncotic) Vit K Factors, 1972 (coagulopathy, bleeding; PT >> aptt) Metabolism/Excretion Bilirubin (jaundice; excretion is rate-limiting step ) Ammonia (encephalopathy; failure to metabolize gut NH3; glutamine urea) Hyperestrogenism (increased estradiol:testosterone ratio) Palmar erythema, spider angiomata, gynecomastia Portal HTN Varices (all sources, bleeding) Hypersplenism (affects all cell lines, bleeding) Edema/Ascites hydrostatic
17 Portacaval Anastamoses Esophagus Varices SMV-LGV-EV-AV
18 Portacaval Anastamoses Rectum Hemorrhoids SV-IMV-SRV-M/IRV
19 Portacaval Anastamoses Umbilical Caput SMV-PUV-S/IEV
20 Portacaval Anastamoses Rarely ask the vessel Common mentions: Inform you of cirrhosis derivative Query you on PVT Confuse you c/w Mallory-Weiss tear Paraumbilical LGV Esophageal Superficial/Inferior Epigastric Azygous
21 Portacaval Anastamoses Hypersplenism Classically thrombocytopenia Other cell lines may also be affected
22 Portal Circulation: WYNTKFTB Circulation Portal Vein Hepatic Artery Central Vein Hepatic Vein IVC right heart Manifestations of Portal HTN Fluid (edema/ascites), Congestive splenomegaly w/ sequestration, Varices Recognizing the common entities Cirrhosis, Thrombosis (portal v, hepatic), Cardiac cirrhosis Portacaval anastamoses SMV LGV EV AV SMV PUV Superficial/Inferior Epigastric V
23 50 y.o. guy presents to ER after vomiting large amt of red blood. PE: O2 sat 92%, irregular pulse, palpable spleen. Labs: HCT 59%; EGD: esophageal varices; Liver bx: normal. Most likely diagnosis to explain his clinical presentation? A. Chronic alcohol consumption B. Chronic hepatitis C infection C. Hepatic vein thrombosis D. Hepatocellular carcinoma E. Gastric ulcer F. Portal vein thrombosis
24 50 y.o. guy presents to ER after vomiting large amt of red blood. PE: O2 sat 92%, irregular pulse, palpable spleen. Labs: HCT 59%; EGD: esophageal varices; Liver bx: normal. Most likely diagnosis to explain his clinical presentation? A. Chronic alcohol consumption B. Chronic hepatitis C infection C. Hepatic vein thrombosis: post-hepatic congestive liver disease D. Hepatocellular carcinoma E. Gastric ulcer F. Portal vein thrombosis Ø Varices with normal liver in thrombophilic state (P vera)
25 Clot in Portal Vein: how would you expect the patient to present? Portal HTN Normal liver Predisposing etiology
Cirrhosis and Portal Hypertension Gastroenterology Teaching Project American Gastroenterological Association
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