Portal Hipertansiyon
Özet
Portal hipertansiyon, en sık karaciğer sirozuyla ilişkilendirilen, artmış hepatik direnç ve splanknik kan akışı nedeniyle portal sistemdeki anormal basınç yükselmesini ifade eden hemodinamik bir anomalidir. Hepatik venöz basınç gradyentinin (HVPG) 5 mmHg'yi aşmasıyla tanımlanan bu durum, 12 mmHg'nin üzerine çıktığında gastroözofageal varis kanamaları, assit, hepatorenal sendrom ve hepatik ensefalopati gibi ölümcül dekompanse komplikasyonlara yol açar. Patofizyolojisinde sinüsoidal endotelyal disfonksiyon, nitrik oksit azalması, tromboksan A2 artışı ve anjiyojenez yer alırken; etiyolojik olarak prehepatik, hepatik ve posthepatik gruplara ayrılır. Tanıda invaziv altın standart HVPG ölçümü ve endoskopi iken, son yıllarda karaciğer/dalak sertliği ölçümü ile multiparametrik MR gibi noninvaziv yöntemler öne çıkmaktadır. Tedavide portal basıncı düşürmek amacıyla karvedilol gibi nonselektif beta-blokerler ve simvastatin gibi farmakolojik ajanlar kullanılır. İlaç tedavisinin yetersiz kaldığı refrakter olgularda ise portal ve hepatik venler arasında yapay bir kanal oluşturan Transjugüler İntrahepatik Portosistemik Şant (TIPS) prosedürü klinik yöntemi önemli ölçüde değiştiren ve sağkalımı artıran etkili bir girişimsel yaklaşımdır.
Portal hypertension is a hemodynamic abnormality primarily associated with liver cirrhosis, characterized by an abnormal pressure increase in the portal system due to elevated hepatic resistance and splanchnic blood flow. Defined by a hepatic venous pressure gradient (HVPG) exceeding 5 mmHg, this condition leads to fatal decompensated complications such as gastroesophageal variceal bleeding, ascites, hepatorenal syndrome, and hepatic encephalopathy when it rises above 12 mmHg. Its pathophysiology involves sinusoidal endothelial dysfunction, decreased nitric oxide, increased thromboxane A2, and angiogenesis, while etiologically it is classified into prehepatic, hepatic, and posthepatic groups. Diagnosis relies on invasive gold standards like HVPG and endoscopy, alongside emerging non-invasive methods such as liver/spleen stiffness measurement and multiparametric MRI. Management involves pharmacological agents like carvedilol, a non-selective beta-blocker, and simvastatin to lower portal pressure. In refractory cases where medical therapy is limited, the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure, which creates an intrahepatic shunt between the portal and hepatic veins, serves as an effective interventional approach that significantly alters clinical management and improves transplant-free survival rates.
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