Portal hypertension - is a complex syndrome, which is characterized by a marked increase in the pressure in the portal vein blood flow hindered the investigation.Normally, the pressure in the vein does not exceed 7 mm Hg.If the blood pressure in the portal vein rises to 12 - 20 mm Hg, it begins to expand.Varicose Vienna exposed ruptures, which in turn leads to the development of bleeding.It is a pathological condition has a large number of preconditions for development, which will be discussed below.
portal hypertension syndrome
Portal hypertension - a disease that is not an independent nosology.This syndrome is accompanied by a large number of somatic diseases.The basis of all the changes taking place in the human body is increased pressure in the portal vein.Forms and severity of portal hypertension is directly dependent on the degree of obstruction to blood flow of the veins system.There are forms of portal hypertension syndrome as predpechenochnaya or dopechenochn
Predpechenochnaya form of portal hypertension develops due to congenital abnormal structure of the portal vein, as well as due to the formation of blood clots in it.The birth defects veins include: hypo- and aplasia, narrowing of the veins on any part or total restriction.Reason imperforate portal vein is associated with the spread occurring in arantsievom duct and umbilical vein of normal obliteration.Thrombus formation and as a consequence, vein occlusion occurs during septic various processes in the body (suppuration abdominal umbilical septicemia pyosepticemia) at its infiltration or compression of the cyst.
cause of intrahepatic portal hypertension form the majority of reported cases are cirrhotic changes in the liver.Sometimes the reason for the development of portal hypertension can serve as local centers of sclerosis in the liver tissue.According to the statistics of the five patients with portal hypertension is four affected intrahepatic block.
When suprarenal portal hypertension significantly affected the outflow of blood from the veins of the liver.The reason for the problems with the normal flow of blood is often endoflebit with partial or total obstruction of the vessel.This condition is called Chiari syndrome.Separately, called Budd-Chiari disease.In this case, the suprarenal portal hypertension is directly related to thrombotic occlusion of the vena cava masses at the location of the hepatic veins.Among the reasons is not the last place is the anomaly and bookmark the inferior vena cava.Squeezes pericarditis, tumor and cystic neoplasms and tricuspid valve can obstruct the flow of blood through the vessels and become the cause of the suprarenal portal hypertension.
combined forms of portal hypertension occurs in the case of blockage of the portal vein blood clots in people with cirrhosis of the liver.
With a sharp increase in pressure in the portal vein to 450 mm Hg (normal - 200) in people suffering from portal hypertension, the blood flow through portocaval anastomoses.These anastomoses are three groups.Normal anastomoses are present in the lower third of the esophagus and gastric cardia.From the system of portal vein blood flows through the venous plexus of the above bodies in the azygos vein, which in turn empties into the inferior vena cava.Thus, if the patient portal hypertension, varices are found in the esophagus, which may lead to massive bleeding from the body.Contribute to the development of bleeding may reflux esophagitis or ulceration of the esophagus.Also, there are anastomoses between the rectal veins (upper, middle and lower).In this case, blood flowing from the upper rectal veins, which are relevant to the portal system, the system continues to move anastomoses, internal iliac vein passes and flows directly into the inferior vena cava.
If a person suffering from portal hypertension, there is a steady expansion of the venous plexus of the rectum, it may result in heavy bleeding from the anus.There is also an anastomosis between the umbilical and umbilical vein (in the event that an umbilical Vienna has not undergone involution).This resets the anastomosis of blood from the portal vein in the umbilical.Then it enters the vein of the outer abdominal wall, in the upper and lower vena cava.When portal hypertension suffered this group of anastomoses on the abdomen of the patient will be seen the so-called pattern of enlarged veins of the abdominal wall.This pattern is called "Head of Medusa."
Causes of portal hypertension
etiological factors that can lead to the development of portal hypertension, a large number.The most important reason is the serious damage to the liver parenchyma.Parenchyma may suffer because of hepatitis (chronic and acute, viral and medicines), cirrhotic changes malignancies body, parasitic infestations, such as schistosomes.
Portal hypertension can begin in chronic pathological changes caused by intra- and extrahepatic bile stasis, with biliary cirrhosis (primary and secondary) tumors of the bile duct and common bile duct itself.This may be because calculous cholecystitis, cancer of the pancreatic head, medical error during the ligation of the bile duct during surgery.An important role in the pathogenesis of portal hypertension plays and the impact of various toxins to the liver parenchyma tropic (some types of mushrooms, drugs).
portal hypertension may also result in abnormal congenital atresia, thrombosis, stenosis or portal vein tumor thrombosis, venous disease Budd-Chiari syndrome, restrictive cardiomyopathy, namely, increased pressure in the right atrium and ventricle, as well as compressing pericarditis.In certain cases, the syndrome of portal hypertension has a relationship with the crises during surgery, with massive burns with a large percentage of soft tissue, DIC, sepsis, trauma.
Direct predisposing factors that can give a boost to the development of the expanded clinical portal hypertension with all its consequences are various infections, bleeding of the stomach and intestines, the alcoholism, the prevalence of food animal fats of vegetable, long-term treatment with tranquilizers, diuretics, heavy operationsa long period of recovery.
Symptoms of portal hypertension
Clinic of any form of portal hypertension is directly related to the disease that caused the persistent increase in the pressure in the portal vein.It is important to remember and use during patient survey and analysis of the clinical picture, especially in the case when there are serious complications of portal hypertension (vein thrombosis, massive bleeding from esophageal varices or rectum).
portal hypertension can be characterized by the following symptoms: sudden enlargement of the spleen, the presence of varicose veins in the esophagus or stomach, bleeding from these vessels, increased belly size because of fluid accumulation (ascites), the symptoms of dyspepsia (pain in the epigastric region, the absence of the chairfor several days, nausea, lack of appetite until absolute refusal to eat).People with portal hypertension are characteristic of spider veins on the skin, in the blood - decrease in the number of platelets, white blood cells, significantly less anemia, marked changes in the coagulation system (there is a tendency to anticoagulation).
Predpechenochnaya form of portal hypertension usually manifests in childhood, during favorable.On gross examination, some patients may notice that the portal vein replaced the small veins.This formation is called "cavernoma."Most often, the disease manifests itself esophageal bleeding, which are the first sign of the disease in childhood, there is an increase in size of the spleen, hypersplenism, blood clots in the veins.
intrahepatic shape also has its own characteristics, such as developing portal hypertension in liver cirrhosis.The nature and speed of the development of symptoms depends on the type of cirrhotic changes (Postnecrotic cirrhosis, alcohol, etc..), The level of compensation for impaired function.Portal hypertension in these patients manifested hemorrhage, the appearance of "the head of Medusa", an enlarged spleen, stomach.
serious complication that threatens human life is bleeding from veins of the esophagus and stomach.It usually occurs suddenly, it is not preceded by any pain in the epigastric and even discomfort.The patient has this form of portal hypertension occurs sudden vomiting blood without impurities.Vomiting blood changes may occur if the blood from the stomach into the esophagus stiff.Vomiting This will be the color of coffee grounds, in addition, the patient will be a chair with blood.In this state very rapidly growing phenomenon of post-hemorrhagic anemia.Fatal bleedings have first portal hypertension is equal to thirty percent.If history were bleeding, visible yellowness and increased stomach, in this case we have advanced stage of cirrhosis, which is virtually impossible effectiveness of medical or surgical treatment.
suprarenal form of portal hypertension - impact of Chiari disease or Budd-Chiari syndrome.If the disease is acute, the patient rapidly emerge intense epigastric pain under the ribs on the right, is rapidly increasing in size of the liver, there is persistent febrile, appears ascites.The main causes of death in this form of portal hypertension - massive blood loss during bleeding from the esophagus, acute renal hepatic insufficiency.
In the case of chronic disease and hepato-splenomegaly progressing slowly on the anterior abdominal wall evolves from small collateral veins, growing symptoms of ascites, there are disturbances in protein metabolism of the body, the man looks exhausted.
signs of portal hypertension
diagnosis of portal hypertension is based on the study of the history of life and disease on the clinical presentation and severity, as well as the mass of instrumental studies that can detect and point out the signs of this syndrome.
The first thing to do if you suspect a patient portal hypertension - a thorough inspection.During the inspection should pay attention to the presence or absence of venous collaterals: veins on the abdomen, near the navel, hemorrhoids, hernia, ascites.It is necessary to carefully examine the color of the skin, sclera, visible mucous, to determine the presence of characteristic vascular.Then you need to palpate the liver and spleen.Normally, a healthy person, the liver does not protrude from the edge of the left costal arch, and the spleen is not palpable.
Laboratory investigation for suspected portal hypertension includes a general analysis of capillary blood and urine tests, coagulation, biochemistry venous blood tests for hepatitis pathogens, detection of antibodies to immunoglobulin A, M, G.
the purpose of proper and accurate diagnosis of disease using x-rayMethods: of port and venacavography, mesenteric angiography of blood vessels, and tseliakografiya splenoportography.The set of data obtained from the above studies will determine the degree of blocking blood flow in the portal vein and to estimate the chances of anastomosis.If you want to determine the quality of liver blood flow, it is necessary to hurt the liver scintigraphy.
Ultrasonography can help to determine precisely enlargement of the spleen, the liver, the presence of free fluid in the abdominal cavity.Hepatic vascular Doppler shows the size of the portal, the superior mesenteric and splenic veins, and the increase in the lumen of the blood vessels - direct signs of portal hypertension.
percutaneous splenomanometriyu do in order to register the pressure in the portal vein.In normal splenic vein pressure does not exceed one hundred and twenty millimeters of mercury, and portal hypertension it reaches five hundred millimeters of mercury.
patients with portal hypertension is mandatory performed esophagoscopy.At esophagoscopy can reveal signs of portal hypertension such as varicose veins in the esophagus.Fibrogastroduodenoscopy also is an informative way to detect signs of portal hypertension in the esophagus and cardia.
Sigmoidoscopy - instrumental method that will detect the changed veins in the rectum of the patient.In some cases, contraindications or patient refusal of instrumental studies, these methods are replaced with X-rays of the esophagus with the stomach.
liver biopsy and diagnostic laparoscopic surgery make only those cases where, for whatever reason, could not confirm the diagnosis of the above methods or if there is a suspicion of malignancy.
Portal hypertension in children
in children is most common form of extrahepatic portal hypertension.This is almost always caused by abnormalities during the laying of the portal vein, which is expressed in the cavernous transformation.Some role among the etiological factors plays an incorrect catheterization in the early neonatal period, leading to the development of the umbilical vein thrombophlebitis.This entails consequences such as thrombosis of the portal vein.
Portal hypertension in a child may start due to various congenital or acquired diseases of the liver.Such diseases include fetal and viral hepatitis, various holangiopatii lead to different levels of bile duct injury (from a small hypoplasia to complete shutdown function).Significantly stimulates the development of symptoms of portal hypertension in children periductular fibrosis (adhesions between the channels) that accompanies all of the above processes.
Recognize extrahepatic portal hypertension in a child may be at a pronounced splenomegaly.Spleen palpation large, almost motionless, does not hurt.There are also manifestations of hypersplenism.Often, when this form of portal hypertension is a rapid expansion of the veins of the esophagus and cardia of the stomach, which leads to a massive spontaneous hemorrhage.
The vast number of patients with extrahepatic portal hypertension hemorrhage - the first manifestation of the disease.From one to the next bleeding the patient feels quite well, the disease is not worried.Increasing the size of the liver in this condition - not a characteristic feature which can develop only as a consequence of thrombosis in the portal vein of the umbilical sepsis.Ascites is also extremely rare.Do not undergo any changes and functional assays.
Decompensated stage of portal hypertension occurs in cirrhosis and observed mainly in adolescents.Bleeding from esophageal varices is also rare.
treatment of portal hypertension
Conservative treatment of diseases such as portal hypertension, is possible only in the event that changes occur only at the level of intrahepatic hemodynamics.For the treatment of portal hypertension using drugs such as beta blockers, nitrates, glycosaminoglycans and angiotensin converting enzyme inhibitors.
dosage and duration of treatment in this drug as Nitrosorbid, selects the physician individually.In most cases, a single dose varies from ten to twenty milligrams, and the number of doses per day ranges from two to five times.