Research methods patients to identify portal hypertension

In addition to the normal, usual, physical methods of research of patients to identify portal hypertension use special methods. The most common is x-ray examination of the esophagus and cardia to identify varicose modified veins. When x-rays of the esophagus instead of reaching a longitudinal folds of mucous membrane is detected enlightenment round shape, located in a chain or branching strips. Often simultaneously with esophageal varices are observed in the cardiac Department of the stomach. To improve x-ray diagnostics it is recommended to use a contrasting blend with barium sodium methyl cellulose and conduct research at the horizontal position of the patient.
Diagnostic possibilities of ezofagoskopia much wider. If ezofagoskopia varicose veins of the esophagus is revealed in 69%, while the x-ray inspection - only 16 - 18% of cases. The percentage of positive findings increases, if ezofagoskopia patient to give the Trendelenburg position. However, due to the swelling of the veins become prominent as if even camouflaged varicose submucosal nodes.
To identify varicose veins during the development of collaterals for mesenteric-hemorrhoidal path is used sigmoidoscopy. The study is conducted according to the standard technique with caution. Under the mucous of rectum and sigmoid colon clearly visible varicose veins, the diameter of which reaches sometimes 4-6 mm
To determine the magnitude of portal pressure was originally supposed to measure it by puncture of esophageal veins under the control of esophagoscopy (Palmer). But the large spread this method has not received due to the complexity of implementation and the risk of subsequent hemorrhage.
In 1950 Davidson proposed to measure the pressure in the varicose veins of the anterior abdominal wall, as these veins well communicated with the system of the inferior Vena cava. However, the pressure in the system of portal vein is much higher than in the veins of the anterior abdominal wall, and a clear interdependence between them there. Such a measure is justified only in the presence of the syndrome Cruveillier - Baumgarten, when the umbilical vein is not obliterans and there is a really wide communication between the veins of the abdominal wall and the portal vein.
For more accurate results measurement of pressure in the portal vein or its branches (mesenteric, the stuffing, the greater curvature of the stomach)produced during the operation. These methods are used in patients with a remote spleen. Much less widely measurement intrahepatic pressure (portogalo-manometry), conducted by puncture of the liver in the ninth - tenth intercostal space to the right. Figures pressure are obtained on 10-20 mm waters. cent. higher than in the determination vnutrikletochnogo pressure. In cases of extra-hepatic forms of portal hypertension intrahepatic pressure is considerably lower than vnutrikletochnogo.
To identify features of portal pressure determine the so-called occlusion pressure by hepatic veins catheterization. Through the cubital vein under the control of the x-ray screen spend a catheter into the right atrium and through it into the inferior Vena cava to the hepatic vein. Bill catheter causes a blockage (occlusion") one of the hepatic veins in which to measure portal pressure. It has been experimentally proved that the "occlusion" and portal pressure reflects the value of pressure in the portal vein.
The most common method of determining the value of portal pressure is splenomegalia. Patient is placed back on rohoska with the thrown back his head with his left hand. Puncture spleen is in the ninth - tenth intercostal space in the middle or rear axillary lines. After anesthesia in this place is long needle diameter 1,5 mm It passes through the pleural sinus and aperture. After feeling puncture of the diaphragm offer the patient to breathe deeply, her hand through a needle feels sliding capsules spleen), then hold your breath, then vigorous movement promoting needle for another 3-4 cm deep. The free end of the needle must immediately be released from his hands, and only after that you can allow the person to breathe. Otherwise, inevitably, there is a gap capsules spleen and dangerous bleeding. When the correct position of the needle from it begins dropwise to enter the blood. Needle connected to a manometer with rubber tubes. Sterile gauge and sterile tube should be filled with a sterile saline solution. Zero mark gauge and immersed in the spleen the end of the needle must be at the same level. OK vnutricletocny pressure is 120-180 mm waters. Art.
Pressure rise above 200 mm of water. senior indicates the existence of a breach of the portal circulation. In patients with intrahepatic unit and total portal hypertension level vnutrikletochnogo pressure is a reliable indicator of the pressure in the portal vein.
Valuable advantage of splenomegaly is the ability followed her to produce x-ray study of the portal blood flow - splenoportography. X-ray examination of the vessels of the portal vein, it was suggested Abeatici and Campi in 1951, the Authors of the experiment showed the safety of the method and its great value, as splenoportography allows to clearly judge the state splenoportography bed. To do this, after measuring vnutrikletochnogo pressure manometer is cut off from the needles. Patient offer take a deep breath, then exhale and hold your breath. At this point in the spleen through a needle within 3-4 seconds impose 20-40 ml of the radiopaque solution (eurotrast, cardiotest, tsiotras, diodon).
If the x-ray machine has a console to serial production of images, they do through 1, 3, 5, 7, 9 and 11 seconds after injection of contrast. In the absence of such things is 1 shot with the exposition in 8-10 seconds, and high voltage include 2 seconds after the start of injection of contrast so that the second half of the contrast medium was introduced during the snapshot. On completion of the film exhibition, immediately remove the needle from the spleen and only then allow the person to breathe. It is necessary to monitor the General condition of the patient and hemodynamics. If the patient weakness, nausea, symptoms of peritoneal irritation, a hint of dulling the sound in shallow parts of the abdomen, lower blood pressure, you should immediately do a laparotomy, because, apparently, there is a rupture of the spleen.

If after contrast administration appear burning pain in the abdomen, this means that the contrast is entered instead of the spleen in the peritoneal cavity. The peritoneal irritation usually gradually passes. Sometimes after splenoportography can receive the phenomenon yodizma. Special measures of struggle with it is usually not necessary.
Using splenoportography can be stated cross splenoportography bed, branching of blood vessels of the system of portal vein to the liver, caliber vessels, the presence or absence of reflux in contrast mesenteric vein or veins of the stomach, the presence or absence of the anastomosis between the veins of the spleen and aperture. The last circumstance is very important because, if splenomegalia anastomoses very developed, then the decision about removal of the spleen should be taken with great caution, for it may cause deterioration portal outflow and an even greater increase of portal hypertension. So after splenectomy operation need to complete the creation or splenorenal anastomosis, or stuffing-organ outflow from the system portal system Vena cava (if not imposed splenomegaly anastomosis).
When intrahepatic block on splenoportography see only the main trunks branch of the portal vein. When extrahepatic splenoportography you can check the location of the unit and to decide on the suitability of the splenic vein to overlay spleno-renal anastomosis.
If, on the proposal of E. I. Halperin, to use as contrast agents with splenoportography bilignost or biligrafin simultaneously with contrast venous branches in the picture become prominent gallbladder and extrahepatic bile ducts. This splenoportography is even more diagnostic value.
In some cases, especially when the spleen is already deleted, produce umbilic-pantogematogen by injection of contrast in razbazarivanii umbilical vein laid down in the thickness of the abdominal wall, I.e. Ostroverkhov, A. D. Nikolskiy, 1963).
Others, and the most obvious way of rentgencontrastnoe veins portal system is mesenteric-ortografia. She, however, requires a small laparotomy, which is not always beneficial to the patient, or occurs at the beginning of main operations, planning and taking over of portal hypertension.
Finally, one of the special methods of research of ways of collateral outflow from the system of portal vein is wanasegara. Under local anesthesia thick needle is used to puncture IX rib on the left and in the bone marrow injected 1-2 ml of contrast. If the needle is correctly installed and on the radiograph kontroliruya VI-VII intercostal Vienna, then enter the remaining 18 ml of contrast and immediately produce a picture. In the presence of portal hypertension become visible natural Porto ashokamala anastomoses.
In portal hypertension always in varying degrees, suffer from liver function. Therefore, prior to surgical treatment of the depth of the lesion should be defined. To do this, we seem to be the most valuable bromsulfaleinovy test, determination of the level of bilirubin in blood prothrombin test with vikasolom load, determination of protein sediment samples, study of the serum protein fractions of blood, determination of serum enzymes activity (aminotransferases), the calculation golato-cholesterol ratio, determination of residual nitrogen and urea blood. Of special investigation methods we attach great importance to the scanning liver, rheography her and examined it through the laparoscope.
The most reliable method of determining the degree of liver needle biopsy is under the control of the laparoscope or without it. During laparoscopy, in addition to the degree of expansion and voltage veins packing and stomach, visible morphological changes in the liver. Visual liver biopsy allows to take for a research piece of tissue from the most noteworthy of the site and sufficient for the study of magnitude.