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Mechanism and Pathophysiology of Portal Hypertension

  • Atsushi ToyonagaEmail author
Chapter

Abstract

This chapter discusses the developmental and pathophysiological mechanisms of portal hypertension and the consequent formation of esophagogastric varices. Anatomical and pathophysiological findings regarding the diagnosis and treatment of varices can provide useful information for clinical practice. In addition, hemodynamic changes caused by treatment are also described. Endoscopic treatment is well indicated for esophagogastric varices, irrespective of urgent, elective, or prophylactic purposes. As an endoscopic treatment-resistant condition, a pipeline stem varix of the esophagus is presented.

Among gastric varices, acutely bleeding large isolated gastric fundal varices (IGFVs) that do not communicate with esophageal varices are resistant to endoscopic treatment and require the use of n-butyl-2-cyanoacrylate (tissue adhesive glue) injection for hemostasis. Patients with large IGFVs often have portosystemic shunts, mainly splenorenal (S-R) shunts, and are prone to recurrent hepatic encephalopathy.

Balloon-occluded retrograde transvenous obliteration (B-RTO), a procedure developed in Japan, can totally eradicate large IGFVs with S-R shunts. With major shunt obliteration achieved, B-RTO is also markedly effective against shunt encephalopathy. Portosystemic shunt syndrome (portosystemic shuntopathy), which has been defined based on accumulated B-RTO case data, is also described herein.

Keywords

Esophagogastric varices Balloon-occluded retrograde transvenous obliteration (B-RTO) Portosystemic shunt syndrome (portosystemic shuntopathy) Pipeline stem varix Point of no return 

References

  1. 1.
    Kelty RH, Baggentoss AH, Butt HR, et al. The relation of the regenerated liver nodule to the vascular bed in cirrhosis. Gastroenterology. 1950;15:285–95.PubMedGoogle Scholar
  2. 2.
    Orrego H, Blendis LM, Crossley IR, et al. Correlation of intrahepatic pressure with collagen in the Disse space and hepatomegaly in humans and in the rats. Gastroenterology. 1981;80:546–56.PubMedGoogle Scholar
  3. 3.
    Marteau P, Ballet F, Chazouilleres O, et al. Effect of vasodilators on hepatic microcirculation in cirrhosis: a study in the isolated perfused rat liver. Hepatology. 1989;9:820–3.CrossRefGoogle Scholar
  4. 4.
    Bathal PS, Grossmann HJ. Reduction of the increased portal vascular resistance of the isolated perfused cirrhotic rat liver by vasodilators. J Hepatol. 1985;1:325–37.CrossRefGoogle Scholar
  5. 5.
    Skikuler E, Kravetz D, Groszmann RJ. Evolution of portal hypertension and mechanisms involved in its maintenance in a rat model. Am J Physiol. 1985;248(6 Pt 1):G618–25.Google Scholar
  6. 6.
    Benoit JN, Womack WN, Hernandez L, et al. “Forward and backward” flow mechanisms of portal hypertension. Relative contribution in the rat model of portal vein stenosis. Gastroenterology. 1985;89:1092–6.CrossRefGoogle Scholar
  7. 7.
    Kiel JW, Oitts V, Benoit JN, et al. Reduced vascular sensitivity to norepinephrine in portal hypertensive rats. Am J Physiol. 1985;248:G192–5.PubMedGoogle Scholar
  8. 8.
    Levy M, Allotery JB. Temporal relationships between urinary salt retension and altered sysytemic hemodynamics in dogs with experimental cirrhosis. J Lab Clin Med. 1987;92:560–99.Google Scholar
  9. 9.
    Inokuchi K, Kobayashi M, Saku M, et al. Characteristics of splanchnic circulation in portal hypertension as analysed by pressure study in clinical cases. Kanzo. 1977;18:891–8. (Jpn with English summary).CrossRefGoogle Scholar
  10. 10.
    Koyanagi N, Inokuchi K, Beppu K, et al. Hyperdynamic circulation in the left gastric venous area in patients with portal hypertension: angiological assessment. Jpn J Surg. 1985;15:134–9.CrossRefGoogle Scholar
  11. 11.
    DeCarvalho CAF. Sur l’angio-architecture verineuse de la zone de transition oesophagogastrique et son interpretation fonctionellw. Acta Anat. 1966;64:125–6.CrossRefGoogle Scholar
  12. 12.
    Arakawa M, Noda T, Kage M, et al. Clinicopathological studies of esophageal varices—the structure of blood vessels in esophageal wall. J Jpn Soc Gastroenterol. 1983;80:2339–46. (Jpn with English summary).Google Scholar
  13. 13.
    Noda T. Angioarchitectural study of the esophageal varices. With special reference to variceal rupture. Virchows Arch A Pathol Anat Histopathol. 1984;404:381–92.CrossRefGoogle Scholar
  14. 14.
    Viannna A, Hayes PC, Moscoso G, et al. Normal venous circulation of the gastroesophageal junction. A rout to understanding varices. Gastroenterology. 1987;93:876–89.CrossRefGoogle Scholar
  15. 15.
    Okubo K. The changes of portal collaterals in upper gastric area by endoscopic injection sclerotherapy (EIS). Acta Hepatologica Japonica. 1988;29:230–40. (Jpn with English summary).CrossRefGoogle Scholar
  16. 16.
    Toyonaga A, Iwao T, Shigemori H, et al. Distinctive portal venographic pattern in patients with sclerotherapy resistant esophageal varices. J Gastroenterol Hepatol. 1996;11:1110–4.CrossRefGoogle Scholar
  17. 17.
    Hamaguchi M, Higuchi K, Arakawa T, et al. Efficacy of combination of endoscopic variceal ligation with sclerotherapy on pipe-line varix: report of a case. Gastroenterol Endosc. 1999;41:65–71.Google Scholar
  18. 18.
    Soehendra N, Nam VC, Grimm H, et al. Endoscopic obliteration of large esophagogastric varices with Bucrylate. Endoscopy. 1986;18:25–6.CrossRefGoogle Scholar
  19. 19.
    Oho K, Iwao T, Sumino M, et al. Ethanolamine oleate versus butyl cyanoacrylate for bleeding gastric varices: a nonrandomized study. Endoscopy. 1995;40:48–51.Google Scholar
  20. 20.
    de Franchis R, on behalf of the Baveno VI faculty. Expanding consensus in portal hypertension report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–52.CrossRefGoogle Scholar
  21. 21.
    Garcia-Tsao E, Groszmann RJ, Fisher RL, et al. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology. 1985;5:419–24.CrossRefGoogle Scholar
  22. 22.
    Iwao T, Toyonaga A, Sumino M, et al. Development of gastroesophageal varices and risk of variceal bleeding in patients with cirrhosis. Dig Endosc. 1991;3:485–90.CrossRefGoogle Scholar
  23. 23.
    Cales P, Zabotto P, Meskens C, et al. Gastroesophageal endoscopic features in cirrhosis. Observation variability, interassociation, and relationship to hepatic dysfunction. Gastroenterology. 1990;98:156–62.CrossRefGoogle Scholar
  24. 24.
    Tajiri H, Yoshida H, Obara K, et al. General rules for recording endoscopic findings of esophagogastric varices (2nd edition). Dig Endosc. 2010;22:1–9.CrossRefGoogle Scholar
  25. 25.
    Toyonaga A, Oho K, Tayama C, et al. Developmental mechanism of esophago -gastric varices. Surgery (Geka). 1992;57:627–33. (Jpn).Google Scholar
  26. 26.
    Hashizume M, Kitano S, Sugimachi K, et al. Endoscopic injection sclerotherapy for 1000 patients with esophageal varices: a 9-year prospective study. Hepatology. 1992;15:69–75.CrossRefGoogle Scholar
  27. 27.
    Stiegmann GV, Cambre T, Sun JH. A new endoscopic elastic band ligation device. Gastrointest Endosc. 1986;32:230–3.CrossRefGoogle Scholar
  28. 28.
    Kanagawa H, Mima S, Kouyama H, et al. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11:51–8.CrossRefGoogle Scholar
  29. 29.
    Toyonaga A, Iwao T, Sumino M, et al. Portal pressure after prophylactic sclerotherapy in patients with high risk varices. J Hepatol. 1994;21:515–20.CrossRefGoogle Scholar
  30. 30.
    Watanabe N, Toyonaga A, Kojima S, et al. Current status of ectopic varices in Japan: results of a survey by the Japan Society for Portal Hypertension. Hepatol Res. 2010;40:763–76.CrossRefGoogle Scholar
  31. 31.
    Sano A, Kuroda Y, Okuda K, et al. Portopulmonary venous anastomosis in portal hypertension demonstrated by percutaneous transhepatic cine-portography. Radiology. 1982;144:479–84.CrossRefGoogle Scholar
  32. 32.
    Murakami K, Kokubu S, Yamagata S, et al. Endoscopic varicealography during injection sclerotherapy of porto-pulmonary venous anastomosis and its complications. Gastroenterol Endosc. 1982;34:2543–51. (Jpn with English summary).Google Scholar
  33. 33.
    Kitano S, Koyanagi N, et al. Prevention of recurrence of esophageal varices after endoscopic injection sclerotherapy with ethanolamine oleate. Hepatology. 1987;7:810–5.CrossRefGoogle Scholar
  34. 34.
    Nakamura S, Mitsunaga A, Murata Y, et al. Endoscopic induction of mucosal fibrosis by argon plasma coagulation (APC) for esophageal varices: a prospective randomized trial of ligation plus APC vs. ligation alone. Endoscopy. 2001;33:210–5.CrossRefGoogle Scholar
  35. 35.
    Kumamoto M, Toyonaga A, Inoue H, et al. Long term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol. 2010;25:1129–35.CrossRefGoogle Scholar
  36. 36.
    Toyonaga A. B-RTO: editorials. Jpn J Port Hypertens. 2001;7:122–8. (Jpn).Google Scholar
  37. 37.
    Shimizu Y, Kusano M. Portosystemic shunt. Kanzo. 2002;43:479–81. (Jpn).CrossRefGoogle Scholar
  38. 38.
    Kato T, Umematsu T, Nishigaki Y, et al. Therapeutic effect of balloon-occluded retrograde transvenous obliteration on portal systemic encephalopathy in patients with liver cirrhosis. Intern Med. 2001;40:688–91.CrossRefGoogle Scholar
  39. 39.
    Fukuda T, Hirota S, Sugimura K. Long term results of balloon-occluded retrograde transvenous obliteration for treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001;12:327–36.CrossRefGoogle Scholar
  40. 40.
    Akahane T, Iwasaki T, Kobayashi N, et al. Changes in liver function parameters after occlusion of gastrorenal shunts with balloon-occluded retrograde transvenous obliteration. Am J Gastroenterol. 1997;92:1026–30.PubMedGoogle Scholar
  41. 41.
    Miyamoto Y, Oho K, Kumamoto M, et al. Balloon-occluded retrograde transvenous obliteration improves liver function in patients with cirrhosis and portal hypertension. J Gastroenterol Hepatol. 2003;18:934–42.CrossRefGoogle Scholar
  42. 42.
    Ninoi T, Nishida N, Yamamoto Y, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long term follow-up in 78 patients. Am J Roentgenol. 2005;184:1340–6.CrossRefGoogle Scholar
  43. 43.
    Poupon RY, Poupon RE, Lebrec D, et al. Mechanisms for reduced hepatic clearance and elevated plasma levels of bile acids in cirrhosis. A study in patients with an end-to-side portacaval shunt. Gastroenterology. 1981;80:1438–44.PubMedGoogle Scholar
  44. 44.
    Hamano K, Shuichi S, Hisatomi K, et al. Metabolic and hormonal alterations observed after TIPS and B-RTO procedures in cirrhotic patients. Jpn Pharmacol Ther. 1998;26:109–14.Google Scholar
  45. 45.
    Tanabe N, Ishii M, Sato Y, et al. Effects of collateral occlusion on oral glucose tolerance test in liver cirrhosis. Dig Dis Sci. 2000;45:581–6.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Kurume University, School of MedicineKurumeJapan
  2. 2.Yasumoto HospitalKurumeJapan

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