Post on 30-Dec-2021
Hospital Universitario San Vicente Fundación HUSVF Medellín – Colombia www.elhospital.org.co
Gastroenterólogo – Hepatólogo .
Hospital Universitario San Vicente Fundaciòn . Medellin
Clinica SOMER . Rionegro
Jefe servicio Gastroenterología Hospital Universitario San Vicente Fundacion .
Coordinador posgrado Gastroenterología Universidad CES
Luis Gonzalo Guevara Casallaslggc@sanvicentefundacion.com
gonzogastro@gmail.com
HEMODINAMIA HEPATICA COMO HERRAMIENTA USUAL
PRESION PORTAL
PRESION PORTAL
SISTEMA SUPRAHEPATICO
A.H V.P
PRESION PORTAL
P = Q x RR= 8nl/π r
REGULACION ARTERIOLAR
SISTEMA DE BAJA RESISTENCIA
PRESION PORTAL
• Resistencia Intrahepatica
Componente Reversible
Activacion de Celula Estelada
CONTRACTILIDAD
( NO E 1)
FIBROGENESIS
PRESION PORTAL
PRESION PORTAL
Efecto vasoconstrictor/vasodilatador HIPERTENSION PORTAL
EndotelinaAngiotensinaNorepinefrinaVasopresinaLeucotrienos
otros
Oxido NitrícoCO
otros
HIPERTENSION PORTAL
• Sx Clínico definidopor un aumentopatológico de la presión dentro del sistema venosoportal, definido en terminos de gradiente de presión
entre la vena porta y la vena cava.
• > 5 mmHg
GENERALIDADES
• Presion Portal 5-7 mmHg• Gradiente (GPVH) 1-5mmHg• Ascitis >8mmHg• Varices >10mmHg• Sangrado
>12mmHg
Garcia-Tsao G , Groszman RJ . Hepatology 1985, 5: 419
Valor Pronostico de Medición Temprana de Presion Portal en Sangrado Agudo Variceal
23%
50%
64%
0%
12%
20%
0%
10%
20%
30%
40%
50%
60%
70%
Falla del
Control HVASangradoTemprano
Mortalidad
1 año
HVPG > 20 mmHg
HVPG < 20 mmHgP <0.004
P< 0.003
P< 0.004
Moitinho et al. Gastroenterology, 1999; 117: 626
Valor Pronostico de Medición Temprana de Presión Portal en Sangrado Agudo Variceal
0
2
46
810
121416
1820
Transfusion Dias enUCI Dias enHospital
HVPG > 20 mmHg
HVPG < 20 mmHg
Moitinho et al. Gastroenterology, 1999; 117: 626
P< 0.007
P< 0.03
P< 0.02
CSPH : Hipertension portal clinicamente significativa
cACLD : Enfermedad hepatica cronica avanzada compensada
“Cirrosis compensada”
BAVENO VI
ESTRATEGIAS
• CATETERISMO DE VENAS SUPRA HEPATICAS
• BIOPSIA HEPATICA TRANS YUGULAR
• PORTA CO2
• TIPS
• TIPS TEMPRANO
7. SummaryThe modern paradigm considers cirrhosis as a dynamic and potentiallyreversible disease. It consists of two different entities, compensated and decompensated cirrhosis, each with a distinct prognosis and differ- entpredictors of survival. The development of portal hypertension is a hallmark in the history of cirrhosis, and its progression parallels that of the disease. In consequence, portal pressure measurement by means of HVPG allowsstratifying cirrhosis in stages with defined outcomes, prognosis, and management strategies.
TIPS
TIPS
Ruddler M, Early TIPS in patients with acute variceal bledding: an external
validation. Groupe Hospitalier Pitie Salpetriere, AP-HP, Paris, France
Abstract AASLD 2012 n = 22 Control sangrado 96% similares resultados
Rudler M, Aliment Pharmacol Ther 2014; 40 (9): 1074-1080
N = 31
Z Gastroenterol 2016; 54 - P82DOI: 10.1055/s-0036-1584060Effectiveness of early TIPS for the treatment of acute variceal bleeding – the VienneseexperienceN Göschl , T Bucsics .1Div. of University of Vienna, Vienna, Austria
Results: Forty-nine patients. Six-week re-bleeding occurred in only four (8%) patients. Six-week bleeding-related mortality was 20.4%
Conclusions: Early TIPS placement is effectiveto control acute variceal bleeding in a real-life cohort of patients with cirrhosis. PTFE-TIPS was superior in preventing variceal rebleeding andresults in longer survival.
HEMODINAMIA HEPATICA COMO
HERRAMIENTA USUAL ?
GRACIAS