Robert W. Hobson, III, M.D.
I. Anatomy and Pathophysiology
1. Describe the anatomy of the liver and its portal and arterial circulations.
2. Understand the relationships of extra- and intrahepatic pathological abnormalities resulting in portal hypertension and a tendency to variceal bleeding secondary to the elevations in portal pressure.
3. Define the limits of portal pressure and its influence on variceal bleeding.
4. Understand the physiology of increased splanchnic blood flow observed in the later stages of intrahepatic and extrahepatic disease. The importance of splanchnic vasodilation and its contribution to portal hypertension should be appreciated.
5. Understand the hemodynamics associated with the portal hypertension syndrome to include decreases in mean arterial pressure and peripheral resistance, while increases in cardiac index and output are observed. As a result of an associated peripheral vasodilation , describe the neurohumoral pathways which are activated leading to sodium retention, expansion of plasma volume, and increased arterial pressure and cardiac output.
1. Describe intrahepatic and extrahepatic (pre- and posthepatic ) causes of obstruction to the portal circulation.
2. Understand the causes of portal hypertension which are extrahepatic , intrahepatic , sinusoidal and hepatic venous in etiology. Categorize portal vein thrombosis, schistosomiasis , cirrhosis, and Budd- Chiari syndrome in this classification.
3. Understand and define the determinants of variceal bleeding.
III. Diagnostic Evaluation
1. Define the Child's classification
2. Understand the clinical evaluation of the portal hypertensive patient and describe the stigmata of liver disease detailed during a history and physical examination.
3. Describe the importance of liver function studies in the Child's classification.
4. Understand angiographic imaging of the portal vein by selective splanchnic angiography. Alternative techniques including computed tomography and magnetic resonance imaging may also contribute and should be understood in the evaluation of these patients.
5. Describe the role for hemodynamic measurements including wedge hepatic venous pressure as well as duplex imaging of the portal vein.
1. Control of acute variceal bleeding.
a. Understand the circumstances of variceal bleeding, its mortality in relationship to the Child's classification, and the natural history of bleeding.
b. Understand the role of fluid management, pharmacological treatment with splanchnic vasoconstrictors (vasopressin), vasodilators (nitroglycerin) and other pharmacologic agents.
c. Understand the role of the Sengstaken -Blakemore and Linton tubes in the control of acute variceal bleeding.
d. Describe the value of endoscopic sclerotherapy in the management of acute variceal bleeding. Understand the efficacy and timing as well as the technique used for endoscopic injection.
e. Describe endoscopic variceal band ligation and percutaneous transhepatic embolization in the control of variceal bleeding.
2. Surgical Management of Portal Hypertension
a. Understand the historical development of the Eck fistula and its impact on the surgical management of portal hypertension.
b. Understand the difference between total portal-systemic shunts and selective (distal splenorenal ) shunts.
c. Describe the non-shunt surgical management of varices including the Womack and Sugiura procedures.
d. Describe the development and use of intrahepatic shunts ( transjugular intrahepatic portosystemic shunts-TIPS).
e. Describe the advantages of the TIPS procedure for acute variceal bleeding and the anticipated mortality when compared with portal-systemic shunts.
f. Understand the role of liver transplantation in patients with portal hypertension and variceal bleeding.
V. Describe a current clinical algorithm for the management of variceal hemorrhage.
a. Understand the role of early endoscopic diagnosis in the control of variceal bleeding.
b. Understand that endoscopic sclerotherapy will control the majority of patients with acute variceal bleeding, while balloon tamponade or TIPS may be required in the remainder of patients.
c. Understand options for non-alcoholic and alcoholic patients with controlled or recurrent bleeding: selective variceal decompression with distal splenorenal shunt, sclerotherapy with or without pharmacological agents, and liver transplantation.
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Posted June 2010