aspects hémodynamiques et hypertension portale
TRANSCRIPT
![Page 1: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/1.jpg)
Aspects Hémodynamiques et Hypertension Portale
DU Réanimation Hépatique 23 novembre 2012 Dr Dominique THABUT UPMC, AP-HP, Hôpital Pitié-Salpêtrière Paris, France
!
![Page 2: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/2.jpg)
![Page 3: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/3.jpg)
Histoire Naturelle de l’HTP Augmentation Pression Porte (GPH > 10 mmHg)
Formation de Varices Rétention hydrosodée
Dilatation des varices Ascite
Rupture de varices (GPH > 12 mmHg)
Mortalité à un an: 1%
Mortalité à un an: 3%
Mortalité à un an: 20%
Mortalité à un an: 50%
Pas de Traitement
![Page 4: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/4.jpg)
Mechanisms of Portal Hypertension
Ø Pressure (P) results from the interaction of resistance (R) and flow (F):
P = R x F
Ø Portal hypertension can result from: Ø increase in resistance to portal flow and/or Ø increase in portal venous inflow
MECHANISMS OF PORTAL HYPERTENSION
![Page 5: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/5.jpg)
SINUSOIDAL PORTAL HYPERTENSION
Cirrhotic liver
Portal vein
Sinusoidal Portal Hypertension Portal systemic collaterals
Splenomegaly
1. Increased hepatic vascular resistance
3. Increased splanchnic blood flow
2. Formation of portosystemic collaterals
éR éP éF
P = R x F
![Page 6: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/6.jpg)
SINUSOIDAL PORTAL HYPERTENSION
Cirrhotic liver
Portal vein
Sinusoidal Portal Hypertension Portal systemic collaterals
Splenomegaly
1. Increased hepatic vascular resistance
3. Increased splanchnic blood flow
2. Formation of portosystemic collaterals
éR éP éF
P = R x F
![Page 7: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/7.jpg)
Augmentation de la résistance vasculaire intrahépatique
2 composantes
1.Composante mécanique Remaniements architecturaux Fibrose Oblitération vaisseaux
2.Composante dynamique Dysfonction endothéliale Augmentation du tonus vasculaire
![Page 8: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/8.jpg)
L’augmentation de la résistance vasculaire intrahépatique: une cible thérapeutique ?
Vasodilatateurs NO
Monoxyde de carbone Prostaglantines
Vasoconstricteurs Endothéline Angiotensine
Norépinéphrine Leucotriènes Thromboxane
…
![Page 9: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/9.jpg)
IN THE NORMAL LIVER, NITRIC OXIDE PLAYS AN IMPORTANT ROLE IN THE REGULATION OF INTRAHEPATIC RESISTANCE
Normally Nitric Oxide (NO) Plays A Major Role in Regulating Intrahepatic Resistance
![Page 10: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/10.jpg)
IN CIRRHOSIS, NITRIC OXIDE ACTIVITY IS REDUCED AND THE ACTIVITY OF VASOCONSTRICTORS IS INCREASED In Cirrhosis, Nitric Oxide (NO) Activity is Reduced and Vasoconstrictors (VC) are Increased
![Page 11: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/11.jpg)
SINUSOIDAL PORTAL HYPERTENSION
Cirrhotic liver
Portal vein
Sinusoidal Portal Hypertension Portal systemic collaterals
Splenomegaly
1. Increased hepatic vascular resistance
3. Increased splanchnic blood flow
2. Formation of portosystemic collaterals
éR éP éF
P = R x F
![Page 12: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/12.jpg)
Formation des collatérales Reperméabilisation vaisseaux pré-existants
![Page 13: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/13.jpg)
Formation des collatérales Reperméabilisation vaisseaux pré-existants
Formation nouveaux vaisseaux (angiogenèse)
![Page 14: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/14.jpg)
Portal hypertension
Porto-systemic shunts
Venous return
NO
eNOS activity
Shear stress
Vasodilatation
Cardiac output
Hyperdynamic Circulation in Cirrhosis: Role of Nitric Oxide (eNOS)
Lebrec and Moreau 2000.
![Page 15: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/15.jpg)
Augmentation du débit sanguin splanchnique
Vasodilatation splanchnique
Syndrome hyperkinétique: Augmentation IC Diminution résistances périphériques Hypovolémie effective Activation du SRA, rétention hydrosodée
![Page 16: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/16.jpg)
SINUSOIDAL PORTAL HYPERTENSION
Cirrhotic liver
Portal vein
Sinusoidal Portal Hypertension Portal systemic collaterals
Splenomegaly
1. Increased hepatic vascular resistance
3. Increased splanchnic blood flow
2. Formation of portosystemic collaterals
éR éP éF
P = R x F
![Page 17: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/17.jpg)
Vasodilation and Hyperdynamic Circulation in Cirrhosis - Multiple Organ Involvement
Splanchnic vasodilation
Peripheral vasodilation
Pulmonary vasodilation
Cerebral vasodilation
![Page 18: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/18.jpg)
Vasodilation and Hyperdynamic Circulation in Cirrhosis - Multiple Organ Involvement
Peripheral vasodilation Decrease effective blood volume
Renal vasoconstriction Hepatorenal syndrome
Na / H2O retention
Ascites
![Page 19: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/19.jpg)
Portal venous inflow Variceal growth
Splanchnic vasodilation
Varices and Variceal Hemorrhage
![Page 20: Aspects Hémodynamiques et Hypertension Portale](https://reader031.vdocument.in/reader031/viewer/2022022621/621936bb8224204752452639/html5/thumbnails/20.jpg)
SINUSOIDAL PORTAL HYPERTENSION
Cirrhotic liver
Portal vein
Sinusoidal Portal Hypertension Portal systemic collaterals
Splenomegaly
1. Increased hepatic vascular resistance
3. Increased portal blood flow
2. Formation of portosystemic collaterals
éR éP éF
P = R x F
Donneurs NO Activateurs NOSe Inhibiteurs endothéline
Somatostatine Terlipressine B-Bloquants Anti-angiogéniques
Somatostatine Terlipressine B-Bloquants Anti-angiogéniques