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