Portal hypertension (ABCDE)

Question 1

Definition

Answer 1

Increased blood pressure in the hepatic portal system - or portal venous system

Question 2

Aetiology (Prehepatic, Intrahepatic, Post-hepatic)

Answer 2

Pre-hepatic: due to blockage of portal vein before liver
- portal vein thrombosis
Intra-hepatic: resulting from distortion of liver architecture
- cirrhosis (MC)
- schistosomiasis
Post hepatic: due to venous blockage outside of liver
- RSHF
- Budd Chiari
- Constrictive pericarditis

Question 3

Pathophysiology

Answer 3

Normal pressure = 5-8mmHg in portal vein
- Following liver injury + fibrogenesis (e.g. due to cirrhosis), the contraction of activated myofibroblasts (mediated by endothelin-1, NO + prostaglandins) contributes to increase resistance to blood flow
- Leads to portal hypertension = splanchnic vasodilation = drop in BP = increased CO to compensate for BP = salt + water retention to hyperdynamic circulation (increased portal flow)
- Formation of collaterals between portal + systemic systems e.g. lower oesophagus + gastric cardia

Question 4

Signs and symptoms

Answer 4

Mostly asymptomatic
Present when oesophageal varices rupture
Ascites
Bleeding
- hematemesis
- melena or haematochezia
Caput medusae
Diminished liver function
- jaundice
Enlarged spleen
Hepatic encephalopathy
- asterixis
- lethargy
- seizures
- coma

Question 5

Diagnosis

Answer 5

GOLD STANDARD = hepatic venous pressure gradient measurement (catheter measures pressure gradient from inside IVC then inside portal vein to measure difference between both pressures
USS
CT/MRI
Labs
- liver enzymes
- serology
- FBC
Upper GI endoscopy = Oesophageal varices

Question 6

Treatment

Answer 6

Portal hypertension
- beta blockers (PROPANOLOL)
- nitrates (GTN spray)