Portal Hypertension and Oesophageal varices

Question 1

Portal hypertension is a complication of…

Answer 1

cirrhosis

Question 2

Portal hypertension is increased pressure in the…

Answer 2

portal vein

Question 3

What are pre-hepatic causes of portal hypertension?

Answer 3

Portal vein thrombosis

Question 4

What are intra-hepatic causes of portal hypertension?

Answer 4

Cirrhosis (most common in UK)
Schistosomiasis (worms from freshwater causing inflammation)

Question 5

What are post-hepatic causes of portal hypertension?

Answer 5

Budd-Chiari (hepatic vein obstruction)
RHS heart failure
Constrictive pericarditis

Question 6

How does constrictive pericarditis cause portal hypertension?

Answer 6

Fibrosis/calcification/thickening of pericardium means the pericardium loses its elasticity and impairs filling ability of heart. Leads to elevated pressures in central veins which is transmitted back to portal vein. Can lead to hepatic congestion

Question 7

What is the normal pressure within the portal vein?

Answer 7

5-8 mmHg

Question 8

Cirrhosis of the liver means there is increased resistance to flow therefore s______ d______ and compensatory increased c_____ o_____

Answer 8

splanchnic dilation (arteries to abdominal GI organs)

cardiac output

Question 9

The splanchnic dilation and compensatory increased cardiac output (due to cirrhosis) result in…

Answer 9

fluid overload in portal vein (pressure 10+ is bad, 12+ is very bad)

Question 10

What is the response to fluid overload of the portal vein?

Answer 10

Collateral blood shunting to gastroesophageal veins

Question 11

What complication can be caused by collateral blood shunting in hepatic hypertension?

Answer 11

Oesophageal varices at cardia and lower oesophagus

Question 12

What are symptoms of portal hypertension?

Answer 12

Mostly asymptomatic
Possible oesophageal varices rupture

Question 13

What is the presenting symptom oesophageal varices haemorrhage?

Answer 13

Haematemesis

Question 14

What are 2 conditions causing blood in the oesophagus with haematemesis on presentation?

Answer 14

Oesophageal varices and Mallory Weiss tear

Question 15

How are oesophageal varices diagnosed?

Answer 15

(OGD) Oesophagogastroduodenoscopy

Question 16

What is acute treatment for oesophageal varices?

Answer 16

Resus until haemodynamically stable (blood volume, pressure and perfusion eg IV fluids, blood transfusions and meds for anaemia)

Consider blood transfusion if Hb under 70g/L or 80g/l with cardiac comorbidity

Question 17

What treatment is performed to stop the bleed of a ruptured oesophageal varices?

Answer 17

IV Terlipressin

Variceal band ligation (bands off varices)

TiPPS (Transjugular intrahepatic portosystemic shunt to decrease portal pressure by diverting to other larger veins)

Question 18

What is a complication of TiPPS procedure?

Answer 18

Hepatic encephalopathy as blood is not filtered properly

Question 19

What treatment is given to prevent oesophageal haemorrhage?

Answer 19

Non-selective Beta-blocker like propranolol

Nitrates

Repeat variceal banding

Last resort = liver transplant (for decompensated cirrhosis)

Question 20

How does propranolol (non-selective beta-blocker) help to prevent oesophageal haemorrhage?

Answer 20

Lowers portal pressure by decreasing splanchnic blood flow
Decreases CO by decreasing contractility via adrenergic receptors