Portal Hypertension

Question 1

Define Portal Hypertension

Answer 1

High blood pressure in the hepatic portal system, which are the portal vein and its branches that drain most of the intestines to the liver (>5-10mmHg)

Question 2

Aetiology of Portal Hypertension

Answer 2

Pre-hepatic: portal/splenic vein thrombosis
Hepatic: cirrhosis, granulomata (sarcoidosis), schistosomiasis
Post-hepatic: Budd-Chiari syndrome, congestive cardiac failure, constrictive pericarditis

Alcoholic and viral cirrhosis are the leading causes in Western countries

Question 3

What is Budd-Chiari syndrome

Answer 3

(Hepatic vein thrombosis)
Usually seen in the context of underlying haematological disease or another procoagulant condition.

Causes:
Polycythaemia rubra vera
Thrombophilia: activated protein C resistance, antithrombin III deficiency,protein C + S deficiencies
Pregnancy
Combined oral contraceptive pill

Triad:

1. Sudden abdominal pain
2. Ascites
3. Tender hepatomegaly

Question 4

Symptoms of Portal Hypertension

Answer 4

Abdominal distension/bloating
Visible veins
Oesophageal varices (haematemesis, melaena, haematochezi a)
Haemorrhoids

Often Hx of cirrhosis of CLD

Question 5

Signs of Portal Hypertension on examination

Answer 5

Triad:

1. Ascites
2. Visible veins (Caput medusae, varicose veins)
3. Splenomegaly

Haemorrhoids
Anorectal varies

Question 6

Investigations for Portal Hypertension

Answer 6

Hepatic venous pressure gradient: difference between portal vein and IVC

FBC: may show macrocytic anaemia
LFTs: Raised GGT and bilirubin, reduced albumin, raised urea

Liver USS: may show cirrhosis (nodular)
CT or MRI: ascites, cirrhosis, splenomegaly
Endoscopy: oesophageal varices

Question 7

Management for Portal Hypertension

Answer 7

Transjugular intrahepatic portosystemic shunt (TIPS) - creates a vascular tract in the liver from hepatic to portal veins to allow decompression of HTN (risk of hepatic encephalopathy)

Question 8

Management for portal hypertension if there are Varices, ascites or encephalopathy

Answer 8

Varice:

1. ABCDE
2. Fluids and regular monitoring
3. Terlipressin (Vasopressin analogue) to reduce HTN
4. Endoscopy + band ligation

Ascites:

1. Salt restriction
2. Diuretic
3. Paracentesis
4. TIPS

Encephalopathy:
Lactulose, phosphate enemas, antibiotics

Question 9

Complications of Portal Hypertension

Answer 9

Reduced liver function
Oesophageal varices -> haemorrhage
Rectal varices