Hipertension portal
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“Se define como el aumento de la
presión de los sinusoides hepáticos a
mas 6 mm de hg, causando
alteraciones, clínicas, bioquímicas y
hemodinámicas, independientemente
de la etiología”
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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•Anatomía normal
•Fisiología normal
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Feldman:
Sleisenger
and Fordtran's
Gastrointestin
al and Liver
Disease, 9th
ed. PortalHypertension
and
Gastrointestin
al Bleeding
Vijay H. Shah
and Patrick S.
Kamath
![Page 5: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/5.jpg)
Sistema porta:› Mesentérica superior
Venas pancreatoduodenales
Vena gastroomental derecha
› Vena Esplénica
Venas gástricas cortas
Vena gastroomental izquierda
Mesentérica inferior
› Vena gástrica izquierda
› Vena gástrica derecha
› Vena paraumbilical
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Mesentérica inferior
› Hemorroidal superior
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Sistema ácigos: Vena ácigos
Vena Hemiazigos
Vena Hemiázigos accesoria
Vena ácigos: es una vía colateral entre lavena cava superior e inferior. Nace de lacara posterior de la VCI o de la vena renal.› Venas interconstales posteriores
› Venas mediastinicas
› Venas esofagicas inferiores
› Venas bronquiales
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Vena Hemiazigos: nace a la izquierda
en la unión entre la vena subcostal
izquierda y lumbar ascendente.
› Tres ultimas interconstales posteriores
› Venas esofagicas inferiores
› Venas mediastinicas de pequeño tamaño
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Vena hemiazigos accesoria: comienza
en el extremo medial del 4 a 5to
espacios intercostales, recibe afluentes
de:
› Venas bronquiales izquierdas
Se une con la vena azigos
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Sistema de alta “compliance” y baja resistencia.
“El hígado recibe doble suministro de sangre
(arteria hepática, y vena porta) que es casi el 30%
del gasto cardiaco”
El 75% de la sangre que llega al hígado procede
de la circulación mesentérica, el resto viene de la
arteria hepática.
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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Respuesta amortiguadora arterial
hepática:
› Respuesta autorreguladora para mantener
un flujo sanguíneo hepático constante.
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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El endotelio vascular hepático es
altamente especializado. Sinusoides
(fenestras), alta permeabilidad a las
macromoleculas.
Célula estelar hepática : en condiciones
normales acumula vitamina A. En HTP o
cirrosis se convierten en pericitos
sinusoidales con capacidad contráctil.
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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Células de Kupffer: contribuyen a la
homeostasis hemodinámica liberando
citoquinas como, el facto de necrosis
tumoral.
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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Vasodilatación hepática:
› Oxido nítrico sintetasa (eNOS)
› Endotelina-1 (ET-A, ET-B )
› Monoxido de carbono
› Norepinefrina
› Angiotensina
› Prostaglandinas, tromboxanos, leucotrienos
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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•Ley de Ohm
•Resistencias intrahepaticas
aumentadas• Cambios mecánicos
• Cambios hemodinámicas
•Circulación hiperdinamica
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AP = F x R
AP; gradiente de presión en la
circulación portal
F; flujo portal
R; Resistencia al flujo
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
![Page 22: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/22.jpg)
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Nódulos regenerativos
Bandas fibroticas
Capilarizacion de los sinusoides
Inflamación celular (celulas de kupffer y
hepatocitos)
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
![Page 24: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/24.jpg)
Disminución del la producción de NO
(oxido nítrico)
› Por defectos en la activación de la eNOS
(sintetasa de oxido nítrico)
› Aumentos de la caveolina-1, inhibidora de
la eNOS
› Disminución de la fosfoliracion de la eNOS
por AKT-B (protein kinasa B)
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
![Page 25: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/25.jpg)
Aumento en la producción de la
endotelina-1
Por lo tanto activación de las células
estelares hepáticas
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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Kumar:
Robbins and
Cotran
Pathologic
Basis of
Disease,
Professional
Edition, 8th
ed.Copyright ©
2009
Saunders, An
Imprint of
Elsevier
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Aumento del “inflow” portal
Vasodilatación esplacnica
Vasodilatación periférica
Reducción de la tensión arterial media
Aumento del gasto cardiaco
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
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Circulación esplacnica:
› Arterias celiacas
› Mesentérica superior
› Mesentérica inferior
El hígado recibe 1000ml/min de la vena
porta y 500 ml/min de la arteria hepática
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Vasodilatación esplacnica:
› Aumento en la producción de oxido nítrico
› Aumento de la eNOS (por estrés de la
pared)
› Aumento en los niveles de ET-1?
Retroalimentación negativa?
› Aumento del factor de necrosis tumoral alfa
› Aumento del (VEGF) factor de crecimiento
vascular endotelial
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
![Page 31: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/31.jpg)
Feldman:
Sleisenger
and
Fordtran's
Gastrointestin
al and Liver
Disease, 9th
ed. Portal Hypertension
and
Gastrointestin
al Bleeding
Vijay H. Shah
and Patrick S.
Kamath
![Page 32: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/32.jpg)
•Gradiente de presión de la vena hepática
•Presión de la pulpa esplénica
•Presión de la vena porta
•Presión varicealendoscópica
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Gradiente de presión de la vena
hepática:
› (WHVP) – (FHVP)
› WHVP; presión en cuña de la arteria hepática
› FHVP; presión de la vena hepática libre
› Se realiza con catéter, guía radiológica,
acceso transyugular o femoral.
› Refleja la presión en los sinusoides.
Feldman:
Sleisenger
and
Fordtran's
Gastrointestin
al and Liver
Disease, 9th
ed. Portal Hypertension
and
Gastrointestin
al Bleeding
Vijay H. Shah
and Patrick S.
Kamath
![Page 34: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/34.jpg)
Presión de la pulpa esplénica:
› Para detectar hipertensión portal
presinusoidal
› Anecdótica, no se usa por sangrados frecuentes
Feldman: Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 9th ed. Portal Hypertension and Gastrointestinal Bleeding Vijay H. Shah and Patrick S. Kamath
![Page 35: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/35.jpg)
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•Prehepatica
•Intrahepatica
• Presinusoidal
• Sinusoidal
• Postsinusoidal
•Posthepatica
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Feldman:
Sleisenger
and
Fordtran's
Gastrointesti
nal and Liver
Disease, 9th
ed. Portal Hypertension
and
Gastrointesti
nal Bleeding
Vijay H. Shah
and Patrick
S. Kamath
![Page 38: Hipertension portal](https://reader034.fdocuments.net/reader034/viewer/2022052602/559b16f01a28ab7c308b474c/html5/thumbnails/38.jpg)
Cirrosis:
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•Formación de circulación colateral (varices esofágicas)
•Ascitis
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Feldman:
Sleisenger
and Fordtran's
Gastrointestin
al and Liver
Disease, 9th
ed. Chapter
91 – Ascites
and
Spontaneous
Bacterial
Peritonitis
Copyright ©
2010
Saunders, An
Imprint of
Elsevier