Portal Hypertension Flashcards
What is portal hypertension? When is this defined as clinically significant?
Abnormally high pressure within the hepatic portal vein.
Hepatic venous pressure gradient > 10 mm Hg
(NORMAL: < 5mmHg)
What is the most common cause of portal hypertension? Describe the mechanism of this
CIRRHOSIS
Collagen deposition + fibrosis.
+
Sodium retention + vasoactive substances e.g. NO (due to accumulation of toxic metabolites) increase plasma volume + splanchnic vasodilation, maintaining portal HTN.
How can other causes of portal hypertension be classified?
Pre-Hepatic: blockage of the portal vein before the liver
Hepatic
Post-Hepatic: blockage of hepatic veins or venules
Describe the epidemiology of portal hypertension
Common consequence of cirrhosis
List symptoms of portal hypertension
Features of Liver Disease (likely to coexist with portal HTN)
Jaundice
List 3 signs of portal hypertension
Caput medusae
Splenomegaly
Ascites
What rhyme can be used to remember signs of portal hypertension?
Butt: Rectal varices
Gut: Splenomegaly + Oesophageal varices
Caput: Caput medusa
List 9 signs of liver failure that may be seen in portal hypertension
Asterixis Confusion Palmar erythema Enlarged or small liver Fetor hepaticus Gynaecomastia Jaundice Spider naevi Testicular atrophy
List 3 common features in the history of patients with portal hypertension
Hx of alcohol abuse
RF for viral hepatitis (e.g. tattoos, unprotected sex, IV drug use, travel abroad + blood transfusion)
FH (e.g. haemochromatosis)
List 5 hepatic causes of portal hypertension
CIRRHOSIS Chronic hepatitis Schistosomiasis Granulomata Myeloproliferative disease
List 4 pre-hepatic causes of portal hypertension
Congenital stenosis
Portal vein thrombosis
Splenic vein thrombosis
Extrinsic compression
List 3 post-hepatic causes of portal hypertension
Budd-Chiari syndrome
Constrictive pericarditis
Right heart failure
What is Budd-Chiari syndrome?
Sudden-onset ascites with tender hepatomegaly in the absence of jaundice (hepatic vein obstruction)
Triad: Abdo pain, ascites + hepatomegaly
What bloods are taken in portal hypertension?
LFTs U+Es Blood glucose FBC Clotting screen (prolongation of PT = early sign of liver failure)
What specific tests are requested in portal hypertension to determine cause?
Ferritin: haemochromatosis Hepatitis serology Autoantibodies (e.g. ASMA in AI hepatitis) Alpha1-antitrypsin levels Caeruloplasmin: Wilson's disease
What imaging is performed in portal hypertension?
Abdominal US: check liver + spleen size + assess portal blood flow
Doppler US: assess direction of blood flow in vessels
CT/MRI: if other imaging methods are inconclusive
What invasive tests may be performed in portal hypertension?
Endoscopy: identify oesophageal varices + measure hepatic venous pressure gradient (HVPG)
Liver Biopsy
What is the immediate treatment for oesophageal varices in portal hypertension?
Terlipressin: ADH agonist, causes splanchnic vasoconstriction reducing portal pressure
+ prophylactic abx
Endoscopy within 12h to diagnose + treat using band ligation or injection sclerotherapy
What conservative management approaches can be taken in portal hypertension?
Diuretics
Reduce salt intake
Describe surgical management in portal hypertension
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) - surgical shunt placed between hepatic portal vein + hepatic vein to ease congestion in the portal vein
List 6 complications of portal hypertension
Bleeding from oesophageal varices: Haematemesis Ascites + complications of ascites Pulmonary complications Liver failure Hepatic encephalopathy Cirrhotic cardiomyopathy
What is Spontaneous bacterial peritonitis?
infection of ascitic fluid that can’t be attributed to any intra-abdominal, ongoing inflammatory, or surgically correctable condition
What is hepatorenal syndrome?
Rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure
Life threatening
What is hepatic hydrothorax?
Transudative pleural effusion in pts with portal HTN without any underlying primary cardiopulmonary cause
What is hepatopulmonary syndrome?
Triad of:
Hepatic dysfunction
Hypoxaemia
Extreme vasodilation (intrapulmonary vascular dilatation)
List 3 complications of ascites developing in portal hypertension
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatic hydrothorax
List 2 pulmonary complications that may develop in portal hypertension
Portopulmonary HTN
Hepatopulmonary syndrome
What is the prognosis in portal HTN?
Depends on the underlying CAUSE
Variceal haemorrhages have a 1-year mortality of 40%
Why are non selective B blockers a first line drug used in management of portal HTN? Give an example
e.g. carvedilol
Reduce portal pressure (inhibit B2 receptors in GIT, cause splanchnic vasoconstriction, reduce portal blood flow)
Reduce rates of bleeding + re-bleeding in patients with oesophageal varices.
May protect against SBP (increase intestinal transit).
Give 3 indications for a TIPSS procedure
Persistent, recurrent or tx resistant oesophageal varices
Gastric varices
Refractory ascites
