Portal hypertensia – the syndrome developing owing to violation of a blood-groove and increase in blood pressure in the pool of a vorotny vein. Portal hypertensia is characterized by the dyspepsia phenomena, a varicosity of a gullet and stomach, a splenomegaliya, ascites, gastrointestinal bleedings. In diagnosis of portal hypertensia the leading place is taken by x-ray methods (a X-ray analysis of a gullet and stomach, a kavografiya, a portografiya, a mezenterikografiya, a splenoportografiya, a tseliakografiya), a chreskozhny splenomanometriya, EGDS, ultrasonography, etc. Radical treatment of portal hypertensia – quick (imposing of a portokavalny anastomoz, selective splenorenalny anastomoz, mezenteriko-kavalny anastomoz).
Portal hypertensia (portal hypertension) is understood as the pathological simptomokompleks caused by increase in hydrostatic pressure in line with a vorotny vein and connected with violation of a venous blood-groove of various etiology and localization (at the level of capillaries or large veins of the portal pool, hepatic veins, the lower hollow vein). Portal hypertensia can complicate the course of many diseases in gastroenterology, vascular surgery, cardiology, hematology.
Reasons of portal hypertensia
The Etiologichesky factors leading to development of portal hypertensia are diverse. As the leading reason massive damage of a hepatic parenchyma owing to liver diseases acts: acute and chronic hepatitises, cirrhosis, tumors of a liver, parasitic infections (shistosomatoz). Portal hypertensia can develop at the pathology caused out of - or an intra hepatic holestaz, secondary biliarny cirrhosis, primary biliarny cirrhosis, tumors of a holedokh and hepatic bilious channel, cholelithiasis, pancreas head cancer, intraoperative damage or bandaging of bilious channels. A part is played by toxic damage of a liver at poisonings with hepatotrophic poisons (drugs, mushrooms, etc.).
Thrombosis, congenital atresia, tumoral sdavleniye or stenosis of a portal vein can lead to development of portal hypertensia; thrombosis of hepatic veins at Badda-Kiari's syndrome; increase in pressure in the right departments of heart at a restrictive cardiomyopathy, a konstriktivny perikardit. In certain cases development of portal hypertensia can be connected with critical conditions at operations, injuries, extensive burns, the DVS-syndrome, sepsis.
The direct allowing factors giving an impetus to development of a clinical picture of portal hypertensia infections, gastrointestinal bleedings, massive therapy as tranquilizers, diuretics, abuse of alcohol, excess of animal protein in food, operation quite often act.
Classification of portal hypertensia
Depending on prevalence of a zone of the increased blood pressure in the portal course distinguish total (the covering all vascular network of portal system) and segmentary portal hypertensia (limited by violation of a blood-groove on a splenic vein with preservation of a normal blood-groove and pressure in vorotny and bryzheechny veins).
On localization of the venous block allocate the prehepatic, intra hepatic, post-hepatic and mixed portal hypertensia. The causes have various forms of portal hypertensia. So, development of prehepatic portal hypertensia (3-4%) is connected with violation of a blood-groove in portal and splenic veins owing to their thrombosis, a stenosis, a sdavleniye etc.
The structure of intra hepatic portal hypertensia (85-90%) distinguish the presinusoidalny, sinusoidal and post-sinusoidal block. In the first case the obstacle in a way of an intra hepatic blood-groove arises before capillaries sinusoids (meets at a sarkoidoza, a shistosomoza, an alveokokkoza, cirrhosis, a polikistoza, tumors, nodular transformation of a liver); in the second – in hepatic sinusoids (the reasons - tumors, hepatitises, cirrhosis); in the third – outside hepatic sinusoid (develops at an alcoholic liver disease, fibrosis, cirrhosis, a venookklyuzionny disease of a liver).
Post-hepatic portal hypertensia (10-12%) is caused by Badda-Kiari's syndrome, a konstriktivny perikardit, thrombosis and a sdavleniye of the lower hollow vein, etc. the reasons. At the mixed form of portal hypertensia violation of a blood-groove, both in extra hepatic veins, and in the liver takes place, for example, at cirrhosis and thrombosis of a vorotny vein.
As the main pathogenetic mechanisms of portal hypertensia existence of an obstacle for outflow of portal blood, increase in volume of a portal blood-groove, the increased resistance of branches vorotny and hepatic veins, outflow of portal blood through system kollateraly (potrtokavalny anastomoz) in the central veins act.
In the clinical course of portal hypertensia 4 stages can be allocated:
- initial (functional)
- moderate (compensated) – a moderate splenomegaliya, insignificant expansion of veins of a gullet, ascites is absent
- expressed (dekompensirovanny) – expressed hemorrhagic, edematous syndromes, a splenomegaliya
- the portal hypertensia complicated by bleeding from varicose and expanded veins of a gullet, a stomach, a rectum, spontaneous peritonitis, a liver failure.
Symptoms of portal hypertensia
As the earliest clinical displays of portal hypertensia serve dispepsichesky symptoms: a meteorizm, an unstable chair, feeling of overflow of a stomach, nausea, deterioration in appetite, pain in an epigastriya, the right podreberye, podvzdoshny areas. Emergence of weakness and bystry fatigue, weight loss, development of jaundice is noted.
Sometimes the splenomegaliya which expressiveness depends on the level of obstruction and size of pressure in portal system becomes the first symptom of portal hypertensia. At the same time the sizes of a spleen become less after gastrointestinal bleedings and pressure decrease in the pool of a portal vein. Splenomegaliya can be combined with a gipersplenizm – the syndrome which is characterized by anemia, thrombocytopenia, a leykopeniya and developing as a result of the increased destruction and partial deposition in a spleen of uniform elements of blood.
Ascites at portal hypertensia differs in a persistent current and resistance to the carried-out therapy. At the same time increase in volumes of a stomach, hypostases of anklebones is noted, at survey of a stomach the network of expanded veins is visible to a forward belly wall in the form of "the head of a jellyfish".
Characteristic and dangerous displays of portal hypertensia are bleedings from varikozno the changed veins of a gullet, a stomach, a rectum. Gastrointestinal bleedings develop suddenly, have plentiful character, are inclined to a recurrence, quickly lead to development of post-hemorrhagic anemia. At bleeding from a gullet and a stomach bloody vomiting, a melena develops; at gemorroidalny bleeding – release of scarlet blood from a rectum. Bleedings at portal hypertensia can be provoked by wounds mucous, increase in intra belly pressure, decrease in coagulability of blood etc.
Diagnosis of portal hypertensia
Careful studying of the anamnesis and clinical picture, and also carrying out set of tool researches allows to reveal portal hypertensia. At survey of the patient pay attention to existence of signs of collateral blood circulation: expansions of veins of a belly wall, existence of wavy vessels about a navel, ascites, hemorrhoids, okolopupochny hernia, etc.
The volume of laboratory diagnostics at portal hypertensia includes a research of clinical blood test and urine, a koagulogramma, biochemical indicators, AT to viruses of hepatitis, serumal immunoglobulins (IgA, IgM, IgG).
In a complex of x-ray diagnostics the kavografiya, a portografiya, an angiography of mezenterialny vessels, a splenoportografiya, a tseliakografiya is used. These researches allow to reveal the level of blocking of a portal blood-groove, to estimate possibilities of imposing of vascular anastomoz. The condition of a hepatic blood-groove can be estimated during a static stsintigrafiya of a liver.
Ultrasonography of an abdominal cavity is necessary for identification of a splenomegaliya, a gepatomegaliya, ascites. By means of a dopplerometriya of vessels of a liver assessment of the sizes vorotny, splenic and top bryzheechny veins which expansion allows to judge existence of portal hypertensia is made. For the purpose of registration of pressure in portal system resort to carrying out a chreskozhny splenomanometriya. At portal hypertensia pressure in a splenic vein can reach 500 mm w.g., whereas normal it makes no more than 120 mm w.g.
Inspection of patients with portal hypertensia provides obligatory carrying out an ezofagoskopiya, FGDS, rektoromanoskopiya allowing to find a GIT varicosity. Sometimes instead of endoscopy the X-ray analysis of a gullet and stomach is carried out. Obtaining the morphological results confirming the disease which led to portal hypertensia resorts to a biopsy of a liver and a diagnostic laparoscopy in case of need.
Treatment of portal hypertensia
Therapeutic methods of treatment of portal hypertensia can be applicable only at a stage of functional changes of intra hepatic haemo dynamics. In therapy of portal hypertensia nitrates (nitroglycerine, isosorbide), β-adrenoblokator (, propranolol), APF inhibitors (enalaprit, fozinoprit), glikozaminoglikana (), etc. are used. At sharply developed bleedings from varicose and expanded veins of a gullet or a stomach resort to their endoscopic alloying or a sklerozirovaniye. At inefficiency of conservative interventions it is shown proshivany varicose the changed veins through a mucous membrane.
As the main indications to surgical treatment of portal hypertensia serve gastrointestinal bleedings, ascites, a gipersplenizm. Operation consists in imposing of the vascular portokavalny anastomoz allowing to create roundabout to a soustya between a vorotny vein or its inflows (the top bryzheechny, splenic veins) and the lower hollow vein or a renal vein. Depending on a form of portal hypertensia operations of direct portokavalny shunting, mezenterikokavalny shunting, selective splenorenalny shunting, transjyugulyarny intra hepatic portosistemny shunting, a reduction of a splenic arterial blood-groove, a splenektomiya can be executed.
Palliative measures at the dekompensirovanny or complicated portal hypertensia, can be drainage of an abdominal cavity, .
The forecast at portal hypertensia
The forecast at portal hypertensia, is caused by character and the course of the main disease. At an intra hepatic form of portal hypertensia an outcome, in most cases, adverse: death of patients occurs from massive gastrointestinal bleeding and a liver failure. Extra hepatic portal hypertensia has more good-quality current. Imposing of vascular portokavalny anastomoz can sometimes prolong life for 10 — 15 years.