Surgical, Interventional, and Medical Palliation of Portal Hypertension

Seriously ill surgical patients require complex and integrated surgical, interventional, and medical management to balance the risks and benefits that complicate decision-making. Palliative care principles can aid surgeons in these cases. To illustrate this, we describe a scenario of a patient with unresectable hepatocellular carcinoma with portal vein tumor thrombus causing portal hypertension. We discuss options for managing the sequelae of portal hypertension, including varices and ascites. We explore the interventional and surgical options for mitigating or palliating the underlying portal hypertension. Advances in interventional radiological techniques can facilitate the creation of transjugular intrahepatic portosystemic shunts (TIPSs), even with extensive portal vein thrombus. If interventional approaches are not possible, surgical shunts can be considered but carry significant risks that must be weighed against the benefits. To communicate effectively, we outline key steps to breaking bad news. To make shared decisions in challenging cases, we describe how to elicit a patient’s hopes, expectations, concerns, and preferences; how to synthesize goals of care from these stated values; and how to use those goals to guide decision-making.

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Prevention of portal hypertension and portosystemic shunts by early chronic administration of clonidine in conscious portal vein-stenosed rats

Hepatology ◽

10.1002/hep.1840140220 ◽

1991 ◽

Vol 14 (2) ◽

pp. 325-330

Author(s):

Han-Chieh Lin ◽

Olivier Soubrane ◽

Didier Lebrec

Keyword(s):

Portal Hypertension ◽

Portal Vein ◽

Chronic Administration ◽

Portosystemic Shunts

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An Unusual Case of Portal Hypertension Secondary to Primary Hypoplasia of the Portal Vein

Journal of the American Animal Hospital Association ◽

10.5326/jaaha-ms-6428 ◽

2017 ◽

Vol 53 (6) ◽

pp. 331-337

Author(s):

Lauren Harris ◽

Miryam Reems ◽

Sharon Dial

Keyword(s):

Portal Hypertension ◽

Portal Vein ◽

Clinical Manifestations ◽

Normal Liver ◽

Normal Serum ◽

Serum Bile Acid ◽

Liver Histopathology ◽

Portosystemic Shunts ◽

Portosystemic Collateral ◽

Portal Hypoperfusion

ABSTRACT Primary hypoplasia of the portal vein with secondary portal hypertension and acquired portosystemic collateral circulation is infrequently reported in the veterinary literature. Diagnosis of this condition requires documentation of abnormal hepatocellular function, the lack of intrahepatic or extrahepatic macroscopic congenital portosystemic shunts, and liver histopathology demonstrating portal hypoperfusion in the absence of hepatic inflammation or nodular regeneration. Due to a perceived poor prognosis, many patients with this condition are euthanized; however, those that are spared can be medically managed, in some cases for years. This case report describes the diagnosis and management of a patient with primary hypoplasia of the portal vein and secondary portal hypertension that presented with the severe but typical clinical manifestations of ascites and hepatic encephalopathy, normal liver enzyme concentrations, and normal serum bile acid concentrations.

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Informazione e comunicazione in caso di patologia con prognosi grave o infausta: considerazioni etiche e medico-legali

Medicina e Morale ◽

10.4081/mem.2011.173 ◽

2011 ◽

Vol 60 (2) ◽

Author(s):

Paola Delbon ◽

Adelaide Conti ◽

Massimo Gandolfini

Keyword(s):

Decision Making ◽

Family Members ◽

Bad News ◽

Decision Making Process ◽

Breaking Bad News ◽

Sufficient Time ◽

Good Communication ◽

Breaking Bad ◽

The Family

Comunicare “cattive notizie” ai pazienti rappresenta un compito non facile: indubbiamente le modalità ed il contesto in cui tali notizie vengono comunicate hanno importanti implicazioni sia per il medico sia per il destinatario delle informazioni, ovvero assicurare un contesto adeguato (ambiente confortevole e riservato, disponibilità di tempo) per permettere al paziente ed ai familiari di porre domande o esprimere emozioni e paure; la possibilità che un amico o un familiare del paziente sia presente, per assicurare al paziente supporto e la sensazione di non essere solo nella gestione di tale situazione; una buona comunicazione medico-paziente-familiari. In particolare, la comunicazione delle cattive notizie dovrebbe avvenire in maniera tale che il paziente e i familiari comprendano la situazione, anche per poter partecipare al processo decisionale, ma in modo tale da non aggravare il malessere derivante dalla natura delle stesse notizie. ---------- Breaking bad news to patients can be a difficult task: certainly how the news are conveyed and the circumstances surrounding the receipt of the news have implications for the giver and the receiver, i.e. to assure an appropriate setting (comfortable and quiet location, sufficient time) to allow for the patient and the family members to ask questions or express emotions and fears; the possibility for a patient’s friend or relative to be present – to provide the patient with a sense of support and a belief that he/ she does not have to deal with the crisis alone -; a good communication between physician and patient/ family. In particular, breaking bad news process must ensure that the patient or family comprehend the news – to understand the situation and participate in decision-making process – but in ways that not exacerbate the discomfort associated with the news itself.

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