Portal Hypertension
......................................................................................................................................................................................................................................................................................................................................................................................................
Portal hypertension is the condition in which portal pressure is increases (more than 12 mmHg) within the portal vein characterized by gastrointestinal bleeding, ascites and encephalopathy due to mechanical obstruction of the portal venous system. Normal portal pressure is normally between 5 and 10 mmHg.
What causes the Portal Hypertension?
Causes of portal hypertension are divided into prehepatic, intrahepatic and posthepatic.
A. Prehepatic causes include:Portal venous thrombosis
- Congenital compression
- Splenic vein thrombosis
- Arteriovenous malformation
- Ascariasis
B. Intrahepatic causes include:
- Liver cirrhosis
- Acute or chronic hepatitis
- Schistosomiasis
- Congenital hepatic fibrosis
- Idiopathic portal hypertension
- Polycystic disease
- Primary biliary cirrhosis
- Vitamin A toxicity
- Sarcoidosis
- Tuberculosis
- Venoocclusive disease
- Wilson disease
- Hemochromatosis
3. Posthepatic causes include:
- Inferior vena cava obstruction
- Heart failure
- Budd-Chiari syndrome
- Constrictive pericarditis
What are the signs and symptoms of Portal Hypertension?
- Gastrointestinal bleeding (Vomiting of blood or black, tarry stools)
- Ascites
- Abdominal pain
- Hepatic encephalopathy
- Decreased levels of platelets or decrease WBC.
- Palmar erythema*
- Jaundice*
- Caput medusa (tortuous dilated veins around the umbilicus)
- Dilated vein in the abdominal wall
- Spider angiomas*
- Gynecomastia*
- Muscle wasting*
- Testicular atrophy*
- Splenomegaly
- Bounding pulses
* Signs due to liver failure
How is Portal hypertension diagnosed?
Diagnosis relies on patient’s history, physical examination, Laboratory tests, radiological imaging and histological findings.
1. Laboratory tests include:
- Liver function tests
- Serum albumin
- Prothrombin time
- Platelet count
- Serum ceruloplasmin
- Serum iron
2. Radiological imaging includes:
- Ultrasound
- MRI angiography
- CT scan
- MRI
- Endoscopy ( for esophageal and gastric varices , varices confirm the diagnosis or portal hypertension)
How is portal hypertension managed?
The aim of treatment includes
- Stop variceal hemorrhage
- Prevent of complications (Hepatic encephalopathy, renal failure, respiratory failure, spontaneous bacterial peritonitis)
- Prevent recurrent bleeding
- Management of ascites
Management of variceal bleeding:
- Pharmacological therapy like octreotide (synthetic analogue of somatostatin), vasopressin, and terlipression is used to prevent acute variceal bleeding.
- Balloon tamponade
- Endoscopy sclerotherapy
- Endoscopic variceal ligation
- Transjugular intrahepatic portosystemic shunt
- Selective portosystemic shunt
Management of hepatic encephalopathy
- High carbohydrate diet
- Low protein diet
- Lactulose
- Low salt diet
- Antibiotic like neomycin
- Vitamin K supplements
- Liver transplantation
Management of Ascites:
- Low salt diet
- Diuretics
- Therapeutic paracentesis
Prophylaxis for bleeding:
Propranolol and nadolol is used to prevent recurrent variceal bleeding
What is the prognosis of portal hypertension?
Prognosis depends upon the present of ascites, underlying disorder, degree of reversibility and the response to treatment.
References:
- Sabiston textbook of surgery 18th edition
- The Washington manual of surgery, 5th edition.
- emedicine.medscape.com
- http://www.medicinenet.com
- http://en.wikipedia.org
- http://www.uptodate.com
- http://www.ncbi.nlm.nih.gov
- Harrison’s Principles of Internal Medicine, 17th edition.
- Davidson’s Principles and Practice of Medicine, 20th Edition
Filed Under: Gastroenterology
Loading ...
