Portal Hypertension

Question 1

Define portal hypertension. When will it cause varices and bleeding?

Answer 1

Pressure >6 mm hg
Varices if >8
May bleed if >12
( normal 3-5)

Question 2

Name 8 causes and classification portal hypertension

Answer 2

Pre-hepatic (pre-sinusoidal)
• schistosomiasis mansoni or japonicum (most common pre hepatic cause adult ) → fibrosis along tracts portal vein, sparing hepatocytes
• portal vein thrombosis (most common prehepatic cause child )

Hepatic (sinusoidal) = Any cause liver cirrhosis → affect hepatocytes
• hepatitis B and c
• alcoholic
• non-alcoholic steatohepatitis ( these are all common)
• Wilson’s disease, autoimmune = rare

Post hepatic /sinusoidal
• Budd-chiari syndrome (veno-occlusive disease, spectrum from venous malformation at immediate post-sinusoidal level up to major hepatic vein obliteration or webs in IVC)
• Hepato pulmonary syndrome
• ivc/ hepatic v thrombosis

Question 3

Presentation portal hypertension? (2)

Answer 3

Bleeding, depending on which varices are bleeding
• gastro-oesoph variceal bleeds = most common: haematemesis
• rectal varices:pr bleed.

Complications = Ascites, kaput medusae, encephalopathy..

Question 4

Management portal hypertension variceal bleed? (12)

Answer 4

•Atls
• always give somatostatin analogue: ocreotide preferred, somatostatin, terlipressin - to decrease splanchnic blood flow
• PPI to increase gastric ph and allow for blood clot stabilisation
• prophylactic antibiotic (co-amoxiclav or cephalosporin) for occult infection that may have precipitated bleed and prophylaxis to prevent spontaneous bacterial peritonitis
• endoscopy to confirm diagnosis and stop bleed preferably with rubber band ligation otherwise injection sclerotherapy.
• if fail, use self expanding metal stent (SEMs), otherwise sengstaken Blakemore tube
• if fail, emergency transjugular intrahepatic portosystemic shunt (tipss)
• open surgical shunt last resort, very high mortality.

• once stabilized and stopped bleeding for a few days, start lifelong non-selective beta blocker to decrease incidence rebleed.
• enter into banding programme where they come back for gastroscope and banding of varices every 3-4 weeks until eradicated.
• treat underlying cause liver cirrhosis if possible.

Question 5

Name 4 indications for surgery in patients with varices caused by portal hypertension

Answer 5

• Ongoing variceal bleeding after failed endoscopy and failed / unavailable TIPSS
•Recurrent variceal bleed despite best medical treatment and a banding programme
• contra-indication to non-selective beta blockers
• relative: where patient lives. Consider shunt in patient without easy access to hospital which can manage acute variceal bleed

Question 6

Surgical options in patients with varices (without current bleeding) due to portal hypertension? (3)

Answer 6

• Portosystemic shunt - nonselective bypass whole portal system (no longer in favour due to complications: encephalopathy, Ascites ) vs selective bypass portion eg distal splenorenal shunt
• devascularization procedures (ligation gastro-oesoph varices, transection with re-anastomosis of oesophagus and in some cases splenectomy) - high incidence recurrence and recurrent bleeds.
• liver transplant: only cure- cure underlying cirrhosis and completely decompress portal system.