1. Pathology and Pathophysiology of Portal Hypertension
Division of Gastroenterology, Kurume University School of Medicine
Masafumi Kumamoto, Yukihiko Morita, Kenji Miyakoda, Keigo Emori, Michio Sata
Division of Pathology, Kurume University School of Medicine, Division of Pathology, Kurume University Hospital
Jun Akiba, Masayoshi Kage
Unit of Gastroenterology, Yasumoto Hospital
Department of Internal Medicine, Yanagawa Hospital
The portal pressure is regulated by portal venous flow and intrahepatic portal vascular resistance against portal inflow. Portal hypertension is a state characterized dy a disturbed of circulating portal venous flow and increased portal flow due to a hyperdynamic state. The development and maintenance of portal hypertension are concerned in the factor “forward” and “backward” flow mechanisms. Portal hypertension is classified into intra-hepatic and extra-hepatic etiologies. Intra-hepatic ones include pre-sinusoidal, sinusoidal, and post sinusoidal, with extra-hepatic ones including pre-hepatic and post-hepatic ones. Liver cirrhosis, idiopathic portal hypertension (IPH), nodular regenerative hyperplasia (NRH), extrahepatic portal obstruction (EHO), and Budd-Chiari syndrome are well known etiologies of portal hypertension. Understanding of the pathophysiology of each portal hypertensive disease is important for diagnosis and treatment and to achieve longer survival.
- Portal hypertension
2. Endoscopic Treatment for Esophageal and Gastric Varices
Department of Endoscopy, Fukushima Medical University Hospital
Esophageal and gastric varices are the main causes of upper gastrointestinal bleeding, which may lead to liver failure resulting in a poor prognosis.
Therefore, diagnosis of variceal bleeding by urgent endoscopy is very important. Then active bleeding from varices needs to be stopped and preventative measures for recurrence should be undertaken by endoscopic procedures.
Nowadays, various treatment methods are available for variceal bleeding. Therefore, we should provide each patient with the optimal treatment, which will require variceal treatment to be safe, effective and able to maintain a patient’s quality of life.
For a good prognosis, it is essential for the patients with esophagogastric varices to receive the optimal treatment according to their general condition and portal hemodynamics.
- Esophageal varices
- Gastric varices
- Endoscopic treatment
3. Imaging and Interventional Treatments of Portal Hypertension :Gastric (Esophageal) Varices
Department of Radiology, Oita University Hospital
Vascular anatomy and treatment options of the esophageal and gastric varices are demonstrated. Esophageal varices are supplied mainly from the left gastric vein and terminate in the azygos vein, which are usually treated by endoscopic procedures. Gastric varices are roughly divided into two types of gastroesophageal varices and isolated gastric varices. The gastroesophageal varices are formed in a part of esophageal varices and can be treated by endoscopic procedures or TIPS. Isolated gastric varices are formed as a part of a large portosystemic shunt between the gastric veins and the left inferior phrenic veins. The left inferior phrenic vein terminates to the IVC, left hepatic vein, or the renal veins, and has various communications with the peridiaphragmic veins such as pericardiophrenic vein, intercostal vein, or paravertebral veins. Types of the drainage routes from isolated gastric varices depend on the types of termination and anastomoses of the left inferior phrenic vein.
The majority of isolated gastric varices can be treated by balloon-occluded transvenous obliteration technique. However, there are some difficulties based on the anatomical features of gastric varices in complicated varices. These complicated features of the afferent and drainage veins and recent development of B-RTO techniques to overcome are also discussed in this paper.
- Gastric varices
- Gastric vein
- Inferior phrenic vein
4. Interventional Radiology for Portal Hypertension : Portal Vein Thrombosis, Portal Vein Occlusion, Budd-Chiari Syndrome
Department of Radiology, Wakayama Medical University
Hirohiko Tanihata, Morio Sato
The role of Interventional Radiology as the treatment of portal hypertension is roughly divided into its decompression and embolization for gastroesophageal varices achieved with low invasiveness compared with surgery. Diseases in with portal pressure can be decompressed by IVR include portal vein thrombosis, portal vein obstruction, and Budd-Chiari syndrome.
The treatment of symptomatic portal vein thrombosis by Interventional Radiology is fibrinolytic therapy, mechanical disruption and aspiration of thrombus, stent placement in portal vein and transjugular intrahepatic portosystemic shunt (TIPS). Fibrinolytic therapy has two routes of medication administration, intra-arterial infusion and direct injection of urokinase into portal vein.
The three ways of approach into portal vein are percutaneous transhepatic access, a route via TIPS and a route via an ilial vein under minilaparotectomy. Once it can reach portal vein, the medical treatment by a combination with other procedure, for example, mechanical disruption and aspiration of thrombus and stent placement, will also be attained. IVR for Budd-Chiari syndrome is angioplasty by a balloon catheter and/or stent placement and TIPS. Especially percutaneous transluminal angioplasty (PTA) for membrane obstruction according to IVR is established.
- Portal vein thrombosis
- Budd-Chiari syndrome