Hemodynamic Evaluation of the Patient with Portal Hypertension

Negi

Journal of Clinical and Experimental Hepatology

et al. 2014

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of noncirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes. ( J CLIN EXP HEPATOL 2014;4:163-171) P regnancy associated with liver diseases is an infrequent situation, but when seen together, presents a complicated clinical situation. Portal hypertension develops as a result of number of etiologies. In the west, cirrhosis is the commonest cause of portal hypertension. In the setting of cirrhotic portal hypertension, pregnancy is very rare due to hepatocellular damage leading to amenorrhea and infertility, the incidence of cirrhosis in pregnancy has been reported as 1 in 5950 pregnancies. 1 Cirrhosis may get exacerbated during pregnancy and has significant adverse effects on the mother and the baby. [2][3][4] In the developing countries, other causes like extrahepatic portal vein obstruction contribute significantly to noncirrhotic portal hypertension (NCPH). Mostly liver function is much better preserved in women with NCPH and pregnancy is spontaneous in these women. Portal hypertension associated with pregnancy is a high risk situation as both pregnancy and portal hypertension share some of the hemodynamic changes. The physiological changes, in adaptation to the pregnancy and fetal needs, worsen the portal hypertension resulting in potentially life-threatening variceal bleed and other complications. Pregnancy is a potential hazard for occurrence of recurrent variceal bleed due to its hyperdynamic state causing increase in flow to the collaterals. 5-7 Therefore management in pregnancy requires knowledge of both the effects of changes during pregnancy on portal hemodynamics and the effects of portal hypertension and its cause on both mother and fetus, hepatotoxic...

Section: Pathophysiology Of Portal Hypertensionmentioning

confidence: 99%

Pregnancy with Portal Hypertension

Negi

Journal of Clinical and Experimental Hepatology

et al. 2014

“…These problems were not present in our study, since in alcoholic cirrhosis HVPG clearly reflects portal pressure (Boyer et al, 1977;PomierLayrargues et al, 1985;Bosch et al, 1986 (Freeman et al, 1983). Difference in dose and timing might also explain, at least in part, different results.…”

Section: Resultsmentioning

confidence: 50%

The calcium‐channel blocker, verapamil, does not improve portal pressure in patients with alcoholic cirrhosis.

Merkel

Gatta

Bolognesi

et al. 1988

Brit J Clinical Pharma

1. Recently the calcium‐channel blocker, verapamil, has been reported to decrease portal pressure in rats with experimental cirrhosis and in patients with liver cirrhosis. 2. In eight patients with alcoholic cirrhosis the effect of verapamil (5 mg i.v.) on systemic and splanchnic haemodynamics was investigated. 3. Mean arterial pressure, wedged hepatic venous pressure, hepatic venous pressure gradient, and verapamil plasma concentrations were measured before and at 10, 20, 30 min following 5 mg i.v. administration of verapamil. At 30‐40 min cardiac output, systemic vascular resistance and hepatic blood flow were also measured. 4. Verapamil plasma concentrations averaged 47.9 +/− 52.0, 36.5 +/− 36.3, 31.3 +/− 33.9 ng ml‐1 at 10, 20, 30 min respectively: mean arterial pressure and systemic vascular resistance decreased significantly (‐9% and −14% respectively), and cardiac index increased significantly (+8%). Wedged hepatic venous pressure and hepatic venous pressure gradient remained unchanged, variations never exceeding 0.2 kPa. Hepatic blood flow increased significantly by 12%. 5. These results show that i.v. administration of 5 mg verapamil does not decrease portal pressure in alcoholic cirrhosis. This lack of effect is probably the consequence of a balance between decrease in porto‐hepatic vascular resistance and increase in splanchnic blood inflow.

“…PC flow mapping permits the generally small vessels, draining blood from the intercostal veins to the superior vena cava. 1,28 Until recently, hemody-quantitative assessment of hemodynamic changes induced by therapeutic interventions. In all 18 patients with patent namic evaluation of azygos flow parameters has been limited to invasive, continuous thermodilution techniques.…”

Section: Portal Hypertension Is Initially Caused By An Increase Ofmentioning

confidence: 99%

“…PC flow mapping permits the generally small vessels, draining blood from the intercostal veins to the superior vena cava. 1,28 have been demonstrated to significantly reduce azygos blood flow. 38 Similar to the TIPS-induced changes in azygos flow volume, they too were characterized by considerable variability.…”

Section: Portal Hypertension Is Initially Caused By An Increase Ofmentioning

confidence: 99%

“…Similar elevation of azygos flow in patients with portal hypertension has been tal venous flow measurements based on Cine-PC have been shown to be accurate. 24,25 Reflecting the complexity of splanchnic hemodynamics in portal hypertension, 1,3,35,36 there was considerable intersubject variability among portal vedramatic decreases in azygos venous flow volume, and 3) the lack of portal and azygos flow change suggests TIPS malfunc-nous flow measurements obtained in the 20 evaluated patients. Mean flow amounted to 1,061 mL/min or 14.1 mL/ tion.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Azygos blood flow: Phase contrast quantitation in volunteers and patients with portal hypertension pre- and postintrahepatic shunt placement

Debatin¹

1996

Hepatology

collaterals are formed. Numerous such collateral pathways Flow volume in the azygos venous system was quantioccur; clinically, the most relevant are gastroesophageal varitated with Cine-phase contrast (PC) velocity mapping ces. Hemorrhage from gastroesophageal varices is the main in volunteers and compared with patients with known complication and leading cause of death in patients with porportal hypertension, who were referred for transjugular tal hypertension. 4 Although a multitude of clinical, laboraintrahepatic portosystemic shunt (TIPS) placement.tory, and endoscopic parameters have been evaluated for risk Subsequently, the TIPS-induced hemodynamic effects stratification with regard to variceal hemorrhage, their clinion portal and azygos flow were analyzed. To assess intracal usefulness has been limited. 1,5-12 and intersubject variability, flow in the azygos veins wasBecause gastroesophageal collaterals drain into the azymeasured in each of 10 normal subjects at three different gous system, measurement of the flow therein reflects the times. Subsequently, portal and azygos flow was quantidegree of gastroesophageal collateralization. 13 Several autated in 20 patients with portal hypertension, before and thors have demonstrated an increased azygous flow in paafter TIPS placement. All imaging was performed on a tients with portal hypertension [14][15][16][17] and revealed an associa-1.5-tesla magnetic resonance imaging (MRI) system. tion between the risk of variceal hemorrhage and highly Azygos flow was measured transaxially at the midthoelevated azygous flow. 17 The clinical significance of these racic level. Cine-PC flow measurements of the main porfindings was limited, however, by the invasive nature of the tal vein followed morphological evaluation of the portal employed continuous thermodilution flow measurement techvenous system with axial and coronal breath-held magnique. net resonance angiogram. Azygos flow in normal subPhase contrast (PC) velocity mapping allows for the direct jects was characterized by high inter-and low intrasubquantitative evaluation of flow dynamics. The phase of proton ject variability. Azygos flow in patients with portal spins is modulated by altering the first moment of the maghypertension was significantly higher (P õ .001). Follownetic field in any direction. The gradient modulation causes ing successful TIPS placement in 18 patients, Cine-PC spins moving in the encoded direction to acquire a phase revealed a mean decrease in azygos flow of 46.3% (P õ shift, which is proportional to velocity. Cine-PC flow mea-.001) and a 134% (P õ .001) increase of portal flow. Resurements have been validated in vitro 18 as well as in vivo, 19-23 flecting the complexity of portal hemodynamics, there including the portal vein. 5,24,25 Combined with Cine-imaging, was no correlation between the changes in the portal this technique provides a two-dimensional velocity map in a and azygos systems. In 2 patients with early occlusion cross-section with good temporal resolution. 27 of TIPS, docume...