Portal hypertension

Question 1

What is portal hypertension?

Answer 1

Portal hypertension = abnormally increased pressure of blood in the hepatic portal vein
• Clinically defined as a hepatic venous pressure gradient >/= 6mmHg (Significant when over 10-12)

Question 2

What is the aetiology of portal hypertension?

Answer 2

Can have pre-hepatic, hepatic and post-hepatic causes

Pre-hepatic
Portal/splenic vein thrombosis
Other: congenital atresia, tumour compression

Hepatic
Cirrhosis = most common cause
Granulomata – sarcoid
Schistosomiasis
Myeloproliferative diseases

Post-hepatic
Budd-Chiari syndrome = thrombosis of a hepatic vein
Congestive HF
Constrictive pericarditis

Can also be caused by increased splenic blood flow and hepatoportal AV fistula

Question 3

What is the epidemiology of portal hypertension?

Answer 3

Most commonly due to cirrhosis

Present at diagnosis in 30% of compensated and 60% of decompensated

90% develop varicies

Responsible for 10% of upper GI bleeding

Question 4

What are the symptoms of portal hypertension?

Answer 4

Symptoms of liver disease - Jaundice

Complications of portal hypertension - 
Varices - Haematemesis +/- melaena
Encephalopathy
Lethargy, irritable, change in sleep
Ascites - Weight gain
Splenomegaly - LHS upper quadrant discomfort
SBP - Fever, abdominal pain

Question 5

What are the signs of portal hypertension?

Answer 5

Cardinal signs
o	Varices - Gastro-oesophageal junction = oesophageal varices
Umbilical  = caput medusae
Anorectal junction = rectal varices
o      Ascites
o	Splenomegaly

Signs of liver failure
o	Hands
o	General body
Jaundice
Gynaecomastia
Testicular atrophy
o	Encephalopathy = disorder of brain
Fetor hepaticus
Confusion
Liver flap
o	Hyperdynamic circulation
Bounding pulse
Low BP
o	Enlarged/small liver

Question 6

What are the investigations for portal hypertension?

Answer 6

OGD - Oesophageal varices

US
Abdominal - Liver/spleen size, ascites, thrombosis of portal/splenic veins
Doppler - Direction of blood flow in portal vessels

Bloods
o FBC: normocytic anaemia
o Clotting: thrombocytopenia, prolonger PT
o LFTs: elevated ALT/AST/AlkPhos/bilirubin and low albumin
o Serology: hep B/C

Liver biopsy
o Confirm cause

Question 7

What is the management of portal hypertension?

Answer 7

IF acute variceal bleeding
o Emergency OGD

Treat underling cause (e.g. cirrhosis)

Prophylaxis
o Primary = prevent first bleed Non-selective beta-blocker (e.g. propranolol) to lower portal pressure
o Secondary = prevent second bleed Non-selective beta-blocker, Variceal band ligation

Transjugular intrahepatic portosystemic shunt

Management of complications
o Ascites - Salt restriction, Diuretics
o Encephalopathy - Lactulose, Enemas, ABs

Question 8

What are the possible complications of portal hypertension?

Answer 8

• Varices - GI bleeding
• Splenomegaly
• Ascites - SBP, hepatorenal syndrome, hepatic hydrothorax
• Encephalopathy
• Liver failure
• Hepatopulmonary syndrome - Dilation of pulmonary vessels lead to VQ mismatch

Question 9

What is the prognosis of portal hypertension?

Answer 9

30-40% of patients with cirrhosis will get variceal bleeding
o RF: variceal size, Child-Purgh score

Cirrhosis is the 12th leading cause of death

Severe/persistent upper GI haemorrhage carries high morbidity and mortality
o Risk of death maximal in first few days