FN: Portal Hypertension

Question 1

Hepatic Causes

Answer 1

Hepatic: cirrhosis (80% in UK), schisto (commonest

worldwide), sarcoidosis.

Question 2

Pre-hepatic causes

Answer 2

portal vein thrombosis (e.g. pancreatitis)

Question 3

Post-hepatic causes

Answer 3

Post-hepatic: Budd-Chiari, RHF, constrictive

pericarditis, TR

Question 4

Portosystemic anastomoses effect

Answer 4

Oesophageal varices
Caput medusae
Haemorrhoids (worsened)

Question 5

Oesophageal varices portal source and systemic

Answer 5

• Left and short gastric veins

- Inf. oesophageal veins

Question 6

Caput medusae portal and systemic

Answer 6

• Peri-umbilical veins

- Sup-rectal veins

Question 7

Haemorrhoids portal and systemic source

Answer 7

• Sup-rectal veins

- Inf. and mid, rectal veins

Question 8

Prominent abdominal veins

Answer 8

􏰀 A lot more common than caput medusa
􏰀 Blood flow down below the umbilicus: portal HTN
􏰀 Blood flow up below the umbilicus: IVC obstruction

Question 9

Encephalopathy pathophysiology

Answer 9

􏰀 ↓ hepatic metabolic function
􏰀 Diversion of toxins from liver directly into systemic
system.
􏰀 Ammonia accumulates and pass to brain where
astrocytes clear it causing glutamate → glutamine
􏰀 ↑ glutamine → osmotic imbalance → cerebral oedema.

Question 10

Classification of encephalopathy

Answer 10

􏰀 1: Confused – irritable, mild confusion, sleep inversion
􏰀 2: Drowsy – ↑ disorientated, slurred speech, asterixis
􏰀 3: Stupor – rousable, incoherence
􏰀 4: Coma – unrousable, ± extensor plantars

Question 11

Presentation of encephalopthy

Answer 11

􏰀 Asterixis, ataxia
􏰀 Confusion
􏰀 Dysarthria
􏰀 Constructional apraxia
􏰀 Seizures

Question 12

Precipitants - HEPATICS

Answer 12

􏰀 Haemorrhage: e.g. varices
􏰀 Electrolytes: ↓K, ↓Na
􏰀 Poisons: diuretics, sedatives, anaesthetics
􏰀 Alcohol
􏰀 Tumour: HCC
􏰀 Infection: SBP , pneumonia, UTI, HDV
􏰀 Constipation (commonest cause)
􏰀 Sugar (glucose) ↓: e.g. low calorie diet

Question 13

Ix in encephalopathy

Answer 13

raised plasma NH4

Question 14

Treatment of encephalopathy

Answer 14

􏰀 - Nurse 20 degrees heads up
- Correct any precipitants
􏰀 - Avoid sedatives
􏰀 - Lactulose ± PO4 enemas to ↓ nitrogen-forming bowel
bacteria → 2-4 soft stools/d
􏰀- Consider rifaximin PO to kill intestinal microflora ©

Question 15

Sequelae of portal Hypertension

Answer 15

􏰀 Splenomegaly 􏰀 Ascites
􏰀 Varices
􏰀 Encephalopathy

Question 16

Ascites pathophysiology

Answer 16

􏰀 Back-pressure → fluid exudation
􏰀 ↓ effective circulating volume → RAS activation
􏰀 (In cirrhosis: ↓ albumin → ↓ plasma oncotic pressure
and aldosterone metabolism impaired)

Question 17

symptoms of ascites

Answer 17

􏰀 Distension → abdominal discomfort and anorexia 􏰀 Dyspnoea

􏰀 ↓ venous return

Question 18

Differential of ascites

Answer 18

Serum Ascites Albumin Gradient (SAGG)

Question 19

SAAG >􏰊1.1g/dL =

Answer 19

Portal HTN (97% accuracy)
􏰁 Pre-, hepatic and post
􏰁 Cirrhosis in 80%

Question 20

SAAG < 1.1g/dL

Answer 20

Other Causes
􏰁 Neoplasia: peritoneal or visceral (e.g. ovarian) 􏰁 Inflammation: e.g. pancreatitis
􏰁 Nephrotic Syndrome
􏰁 Infection: TB peritonitis

Question 21

Investigations

Answer 21

􏰀1. Bloods: FBC, U+E, LFTs, INR, chronic hepatitis screen
􏰀 2. US: confirm ascites, liver echogenicity, PV duplex
􏰀 3. Ascitic tap
- 􏰁 MCS and AFB
- 􏰁 Cytology
􏰁- Chemistry: albumin, LDH, glucose, protein 􏰁 - SAAG = serum albumin – ascites albumin
􏰀4. Liver biopsy

Question 22

Treatment

Answer 22

􏰀 Daily wt. aiming for 􏰄0.5kg/d reduction
􏰀 Fluid restrict <1.5L/d and low Na diet
􏰀 Spironolactone + frusemide (if response poor)
􏰀 Therapeutic paracentesis ̄c albumin infusion (100ml
20% albumin /L drained)
􏰁 Respiratory compromise 􏰁 Pain / discomfort
􏰁 Renal impairment
􏰀 Refractory: TIPSS

Question 23

SBP

Answer 23

􏰀 Pt. ̄c ascites and peritonitic abdomen
􏰀 E. coli, Klebsiella, Streps
􏰀 Complicated by hepatorenal syn. in 30%
􏰀 Ix: ascitic PMN > 250mm3 + MC+S
􏰀 Rx: Tazocin or cefotaxime until sensitivities known
􏰀 Prophylaxis: high recurrence 􏰅 cipro long-term

Question 24

Splenomegaly

Answer 24

􏰀 􏰀

Splenic congestion Hypersplenism: ↓ WCC, ↓ plats