Portal Hypertension Flashcards
def
high blood pressure in the hepatic portal system
hepatic venous pressure gradient >6mmHg
what is the hepatic venous pressure gradient
pressure difference between portal vein and SVC
what is the most common cause of portal HTN in the UK
cirrhosis
what are the causes of cirrhosis
1 pre-hepatic -thrombosis in portal/splenic vein 2 hepatic -cirrhosis -schistosomiasis 3 post-hepatic -thrombosis in hepatic vein -RHF (e.g. by constrictive pericarditis) -IVC obstruction
what is the most common cause of portal HTN in the world
schistosomiasis
pre-hepatic causes of portal HTN
thrombosis in portal/splenic vein
splenomegaly
hepatic causes of portal HTN
cirrhosis schistosomiasis PBC/PSC chronic pancreatitis drugs
what drugs can cause portal HTN
azathioprine
methotrexate
amiodarone
post-hepatic causes of portal HTN
thrombosis in hepatic vein
RHF (e.g. by constrictive pericarditis)
IVC obstruction
budd-chiari syndrome
epi
very common with cirrhosis
males>females
history
SYMPTOMS OF CAUSE 1 history of liver disease, blood transfusions + IV drug use (for hep B/C), alcohol abuse 2 CLD -malaise + fatigue -N+V -RUQ pain SYMPTOMS OF COMPLICATIONS 1 haematemesis/meleana due to oesphageal varices
examination
SIGNS OF CLD
1 ascites
-abdominal tenderness (if bacteria infect ascites - SBP)
2 jaundice
3 palmar erythema, spider naevi, gynaecomastia
SIGNS OF PORTAL HTN + OESOPHAGEAL VARICES
1 pallor (suggestive of active bleeding)
2 haematemsis/meleana
3 caput medusae
what symptom is common to cirrhosis
muscle cramps
what are caput medusae
distended and engorged superficial veins which radiate from the umbilibus
the paraumbilical veins re-open due to portal HTN
investigations
1 bloods -FBC -LFTs + PT -albumin (commonly hypoalbuminaemia) 2 imaging 3 procedures -liver biopsy (for cirrhosis) -measure hepatic venous pressure gradient
management
1 emergency treatment
-ABC evaluation
-IV fluids or bloods
-portal pressure reduction
-control + prevent bleeding from oesophageal varices (vasoconstrictors e.g. octreotide, endoscopic therapy e.g. EVL)
2 primary prophylaxis
-beta-blockers
-nitrates
3 secondary prophylaxis
-beta-blockers
-endoscopic therapy e.g. EVL/endoscopic banding
4 surgical
-portosystemic shunts
-shunt non-intestinal flow to systemic venous drainage leaving intestinal venous drainage to pass through portal vein to liver
-transjugular intrahepatic portosystemic shunting (artificial channel between in the liver between inflow portal vein and outflow hepatic vein
how does terlipressin reduce bleeding
lowers BP
reduces oesophageal varices
what is EVL
endoscopic variceal ligation
when do complications of portal hypertension arise
> 12mmHg portal pressure
complications
oesophageal varices
ascites
prognosis
90% of patients with cirrhosis causing portal HTN develop varices
30% of varices bleed
significant risk of death with variceal haemorrhage
