15肝胆外科-门脉高压症（教学）

门脉高压症ThePortalHypertension贺志军教授中南大学湘雅二医院普外器官移植科贺志军教授简介1982–1987衡阳医学院医疗系，获学士学位1987–1991耒阳市人民医院外科，住院医生1991–1996湘雅医院普外科硕博连读研究生，获博士学位1996–1998芬兰Tampere大学医院普外科博士后，临床外科访问学者1998–2000青岛大学医学院附属烟台毓璜顶医院肝胆外科主任，副教授，硕士生导师2000–2003美国西北大学腹部器官移植中心、德州大学医学院、匹兹堡大学器官移植中心访问学者2003–现在湘雅二医院器官移植中心教授，外科副主任授课主要内容什么是门脉高压？Whatistheportalhypertension?门脉高压如何产生？Howdoseithappen?门脉高压的危害？Whatisitsresults?如何诊断门脉高压？Diagnosis如何治疗门脉高压？Treatment解剖Anatomy什么是门脉高压症？ThedefinitionofportalhypertensionPortalhypertensionisdefinedasaportalveinpressureabovethenormalrangeof5to8mmHg.Portalhypertensionmayalsobedefinedbythehepaticvein-portalveinpressuregradient,whichisgreaterthan5mmHginportalhypertensivestates.病因Etiology宏观肝前性、肝性、肝后性prehepatic,hepaticandposthepaticconditions.微观窦前性、窦性、窦后性presinusoidal,sinusoidal,orpostsinusoidalconditions.病理生理pathophysiology增加门脉压力的因素thefactorsofportalhypertensionincreasedresistance:cirrhosis,portalveinthrombosis,orhepaticvenousobstruction.increaseinsplanchnicflow:splanchnicvasodilationbyvariouscytokinesandhormonesArteriovenousshunts：nitricoxide,prostacyclins,endotoxins,andglucagon第一章肝硬化门静脉高压症Theportalhypertensionwithcirrhosis病因Etiology肝炎hepatitis血吸虫schistosomiasis病理生理pathophysiologyWhenhisportalveinpressureincreasedmorethan25-50cmH2O.静脉曲张varices脾大、脾亢hypersplenotrophy腹水ascites肝性脑病hepaticencephalopathy腹水形成的机制腹水肝内血管阻力低蛋白血症胶体渗透压淋巴液组织静水压毛细血管通透性门静脉压全身水负荷临床表现clinicalmanifestation脾大、脾亢Hypersplenotrophy,Hypersplenia呕血、GastroenterologicalBleeding腹水Ascites诊断和鉴别诊断Diagnosisanddifferentialdiagnosis病史及临床表现实验室检查Lab.Test影像学检查ImagesX光照片X-rayB超B-UltrasonographyCT,MRIandportalangiography临床评估目标ClinicalEvaluation(1)todeterminethecauseofportalhypertension.(2)toestimatehepaticfunctionalreserve.(3)todefinetheportalvenousanatomyandassesshemodynamicstatus.(4)toidentifythesiteofGIhemorrhage(ifpresent).CHILD-TURCOTTECRITERIAFORHEPATICFUNCTIONALRESERVE门脉高压症的治疗食道静脉破裂出血脾亢、脾大腹水原发病-肝硬化1.食道静脉曲张破裂出血的治疗TreatmentofVaricealbleeding非手术治疗expectanttreatment输血bleedtransfusion生长抑素Sandostatin三腔二囊管压迫内镜套扎endoscopicesophagealvaricealligation硬化剂注射endoscopicesophagealvaricealsclerotherapy食道静脉曲张破裂出血的手术治疗Surgicaltreatment分流术shuntoperation断流术devascularizationoperation经颈静脉肝内门腔支架分流术Transjugularintrahepaticportosystemicstentshunt,TIPS门腔分流术portocavalshuntoperation部分门腔分流术partialportacavalshuntoperation肠腔分流术mesocavaloperation选择性远端脾肾静脉分流术Warrenoperation断流术devascularizationoperation内镜及药物处理失败后的食道静脉曲张破裂出血的手术处理方案2.脾亢的外科治疗脾切除术或脾切除+断流术3.腹水的外科治疗腹腔静脉转流术TIPS肝移植4.终末期肝病的根治性处理方案--livertransplantation手术步骤器官修整病肝切除供肝植入切除的病肝良好的肝移植效果肝癌和胆汁淤积性肝硬化患者原发性胆汁淤积症患者肝移植术后其它各类疾病患者肝移植术后状态再次肝移植我中心开展的腹部联合器官移植肝肾联合移植肝胰联合移植（省内首例，国内第二例）胰肾联合移植（省内首位成功病例）（省内首例）第二节肝前型门脉高压症Prehepaticportalhypertension病因etiology先天畸形congenitalmalformation脐静脉炎omphalophlebitis门静脉海绵样变cavernoustransformationofportalvein动静脉瘘A-Vfistula肝前型门脉高压症Prehepaticportalhypertension临床表现clinicalmanifestation处理treatment第三节肝后型门脉高压症Budd-ChiariSyndromeTheBudd-Chiarisyndromeiscausedbyhepaticvenousobstruction.Theobstructionmayoccurattheleveloftheinferiorvenacava,thehepaticveins,orthecentralveinswithintheliveritself.病因Etiologycongenitalwebs(mostcommoninAfricaandAsia),acute/chronicthrombosis(mostcommonintheWest):hypercoagulablestatesassociatedwithpolycythemiavera,myeloproliferativedisorders,paroxysmalnocturnalhemoglobinuria,anddefectsinthecoagulationcascade,asinconditionsassociatedwithhighestrogenlevels(e.g.,pregnancyandadministrationofbirthcontrolpills).malignancy.obliterativeendophlebitisoftheintrahepaticveins分型TypingI型：57%下腔静脉隔膜II型：38%下腔静脉弥漫性狭窄或阻塞III型：5%肝静脉阻塞症状SymptomsAcutesymptomsincludehepatomegaly,rightupperquadrantabdominalpain,nausea,vomiting,andascites.Chronicsymptomsincludevaricealbleeding,ascites,spontaneousbacterialperitonitis,fatigue,andencephalopathy.诊断DiagnosisUltrasonographicevaluationhasasensitivityof85%to95%.CTAngiographyisthe“goldstandard”forthediagnosis,whichprovidesdetailedinformationonthelocationanddegreeofobstruction.治疗TreatmentinterventionportosystemicshuntmesoatrialshuntTIPSlivertransplantationNow,weknowtheanswers!什么是门脉高压？Whatistheportalhypertension?门脉高压如何产生？Howdoseithappen?门脉高压的危害？Whatisitsresults?如何诊断门脉高压？Diagnosis如何治疗门脉高压？TreatmentThanks!Dr.ZhijunHe