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Portal Hypertension

  • Frequently complicates cirrhosis
  • Normal hepatic venous pressure gradient – 5-6mmHg
  • PHTN is >10mmHg – causes increased risk of variceal bleeding

Etiology – see diagram

    • Childhood PHTN – extrahepatic portal vein obstruction MCC
    • Adult PHTN – cirrhosis MCC

Pathophysiology

  • Increased portal vascular resistance leads to ↓portal blood flow to liver
  • Leads to development of collateral vessels
    • allows blood to bypass the liver and enter systemic circ directly
  • Portosystemic shunting occurs – esp in GIT (oesophagus, stomach, rectum); anterior abdominal wall; renal, lumbar, ovarian & testicular vasculature
  • As collaterals form, >50% of portal blood flow may be shunted directly to systemic circulation

Clinical features

  • Result from portal venous congestion and collateral vessel formation
  • Splenomegaly – cardinal finding
  • Collateral vessels on anterior abdominal wall
    • caput medusae – engorgement of paraumbilical veins
  • Collateral formation occurs in oesophagus, stomach, rectum – varices
    • Source of severe bleeding
    • Can be aggravated by use of NSAIDs
  • Fetor hepaticus – thiols pass directly to the lungs as a result of portosystemic shunting
    • Results in musty breath

Investigations (dx can be made clinically)

  • Portal venous pressure measurement – to differentiate between pre-sinusoidal and sinusoidal forms
    • Balloon catheter inserted via the IVC into the hepatic vein and then the hepatic venule to measue WHVP (wedged hepatic venous pressure)
  • Thrombocytopenia – due to hypersplenism
  • Endoscopy – to detect oesophageal varices
  • CT/MRI angiography – identify extent of portal vein clot

Management (prevention/control of variceal bleeding)

  • Primary prevention – non bleeding varices identified at endoscopy, reduce PVP by – propranolol (80-160mg/d)
  • Managing acute variceal bleeding (see table)
    • Aim – restore circ with blood and plasma, because shock reduces liver BF and deteriorates liver function
    • Terlipressin [2mg IV qid] – vasopressin analogue, splanchnic vasoconstrictor
      • reduces portal BF and hence reduces portal pressure
      • If hemodynamically stable w/ FFP, Vit K, platelets
    • Band ligation/sclerotherapy – most widely used treatment
    • Balloon tamponade – Sengstaken-Blakemore tube with 2 balloons that exert pressure in the fundus of the stomach and in the lower oesophagus (to control life threatening variceal bleeding)
    • TIPSS – transjugular intrahepatic portosystemic stent shunting
      • Stent placed between portal and hepatic vein via internal jugular v
    • Oesophageal resection – last resort, high mortality

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