8 Sep 2008

PORTOSISTEMSKI SHUNT (”ŠANT”)

To je večinoma prirojena ali občasno dedna napaka, kjer žile med črevesjem in jetri ne potekajo tako kot bi morale. Vzpostavljen je neatomski ali nefiziološki spoj med portalnim in sistemskim venskim obtokom. Ločimo selektivne, delne in neselektivne portosistemske shunte. Razvrstitev je opravljena na podlagi krvi, ki jo obvod spelje mimo jeter.
Kri naj bi iz črevesja prihajala v jetra v portalni sistem preko žil, ki so v jetrih in nato preko velike krvne vene prihajala nazaj do srca. V portosistemskem shuntu pa portalna kri obide jetra in gre direktno v sistemsko cirkulacijo ven.
Pomembna lastnost jeter je, da očistijo kri strupov in škodljivih snovi, katere so proizvedene v črevesju. V shuntu ti strupi ostanejo v krvi in tako krožijo po telesu. To povzroči klinične znake napake, mnogi od teh znakov so nevrološki.

Shunt se pojavi v dveh oblikah, glede na lokacijo kje se nahaja:
- Ekstrahepatični (izven jeter)
- Intrahepatični (v jetrih)
Shunti so ponavadi v večini primerov prirojeni in njihovi znaki se pojavijo v starosti nekje do 6 mesecev starosti. Kjer pa so znaki skoraj neopazni pa lahko napako opazimo šele kasneje. Shunta nastane v plodu ko se razvija. Shunti naj bi se pravilno zaprli v roku treh dneh po rojstvu in mladičkova kri bi se mogla začeti čistiti. Včasih pa se shunti ne zaprejo.
Pasme pri katerih se shunt najpogosteje pojavi:
1.) Ekstrahepatični shunt: majhne pasme, še posebno Yorkshire terrier, miniaturni šnavcer, manj pogosto pa maltežan, Cairn terrier
2.) Intrahepatilni shunt: velike in ogromne pasme, še posebno Irski volčji hrt, manj pogosto pa Avstralski govedar, zlati prinašalec, labradorec.
Približno vsak tretji predstavnik velikih pasem s shuntom ima extrahepatični shunt.
Znaki
Znaki se pokažejo že pri mladičku. Ponavadi se vežejo na centralni živčni, črevesni sistem in sečni trakt. Znaki so nevrološki in se kažejo v obnašanju, kot posledica raztresenosti možganov zaradi strupov v telesu.
Znaki so še:
- izguba apetita
- počasna rast
- bruhanje
- driska
- depresija
- zaspanost
- šibkost
- slaba motorika
- pes nima orientacija
- slepota
- povečano uriniranje
- napihnjen in napet trebuh
- komaZnaki lahko naraščajo in znova upadajo, ponavadi se poslabša po obroku, ki je bogat z beljakovinami. V urinu se lahko pojavi kri, ker posledično pravilno ne delujejo tudi ledvice. Tako se zgradijo minerali soli v telesu, ki se izločajo z urinom.
Diagnoza
Diagnoza se postavi glede na klinične znake psa in laboratorijske preiskave. Prizadeti psi so ponavadi mladi.
Laboratorijske preiskave na katerih se dokaže napako shunta:
1.) Hemogram: ponavadi težko opazimo znake in ne moremo postaviti diagnoze samo preko odvzema krvi. Znaki, ki so skoraj neopazni, toda pomembni za shunt so:
a. šibka slabokrvnost
b. mikrocitoza
c. abnormalne rdeče krvne celice
2.) Biokemija: znaki ki kažejo na shunt:
a. Povišana vsebnost amoniaka v krvi
b. Pomanjkanje krvnih proteinov
c. Pomanjkanje globulina
d. Pomanjkanje albumina
e. Pomanjkanje glicemina
3.) Analiza urina: dokaz za shunt so kristalčki, ki nastanejo v usedlini urina.
4.) Rentgensko slikanje
5.) Ultrazvok
6.) Kontrastna portografija: zelo uspešna tehnika pri določanju shunta. Ta tudi pove ali so shunti intrahepatični ali ekstrahepatični…
Zdravljenje
Zdravljenje, ki začasno odpravi klinične znake zajema:
- Nizko proteinsko dieto (hrana Hills za obolenja z jetri (l/d, Liver), ki zmanjša strupe, ki vplivajo na možgane,
- Antibiotike, ki delujejo kot bakterija, ki čisti kri,
- Sirup Laktulozo, ki nase veže škodljive snovi (kot npr.amoniak). Poleg tega tudi pospešijo prebavo in pes hodi večkrat na potrebo.
Druga možnost pa je operacija. Pri extrahepatičnem shuntu ta operacija ni tako zahtevna in je večinoma zelo uspešna. Medtem ko je operacija intrahepatičnega shunta zelo tvegana. Potrebno je narediti dve operaciji in pes mora nekaj dni počakati na kliniki. Pri slednji mora namreč kirurg operirat v jetrih in najti pravo žilo, ki jo zapre. Ta operacija traja kar nekaj časa in kar je najtežje je potrebno najti pravo veno, jo zapreti, nato mora zašiti psa nazaj, ga pustiti nekaj dni na okrevanju in čez par dni zoper operirati, tokrat da se vena priključi na pravilno.
Zapleti pri operacijah:
Zapleti lahko vključujejo povišan krvni pritisk iz žil, ki gredo v jetra, posledica je nabiranje tekočine v trebuhu. Če je pritisk portne hipertenzije zelo velik so shunti otesnjeni in pes lahko umre.
Približno 15% psov, ki so operirani, razvije majhne shunte, ki načeloma funkcionirajo kot prirojeni shunti in posledično pes rabi terapije celo življenje.
Možen zaplet je tudi infekcija.
Lahko se pojavijo napadi v 3 do 5 dni po operaciji. To je posledica nizkega krvnega sladkorja, ki se hitro pozdravi. Ali pa je posledica neravnovesja snovi v možganih, ko se kri očisti. V tem zadnjem primeru lahko pes umre, če ne reagira na zdravila, ki sledijo.
Nega
Po operaciji je potrebno psa še nekaj časa imeti na dieti z nizko vsebnostjo beljakovin. Ko se kri spet normalizira, lahko postopoma uvajamo na nedietno hrano.
Tudi antibiotiki in laktuloza se daje psu še 10 dni po operaciji.

AVTOR: Maja (Majchy)
VIRI:
- http://www.upei.ca/cidd/Diseases/cardiovascular%20diseases/portosystemic%20shunt.htm
- http://vetsurgerycentral.com/pss.htm

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