Portal Hypertension | Causes Symptoms, Diagnosis And Treatment

Portal Hypertension | Causes Symptoms, Diagnosis And Treatment .

What is Portal hypertension?

Portal hypertension (PHT) is defined as sustained rise in hydrostatic pressure within portal venous system over 10mm Hg or 15cm of saline.

Causes of PHTPre-hepatic causes:/>

• Extra-hepatic portal vein obstructionI diopathic.
• Neonatal umbilical vein sepsis.
• Umbilical vein catheterization for exchange transfusion.
• Congenital stenosis of portal vein.
• Isolated splenic vein thrombosis-Chronic pancreatitis.
• Cancer pancreas.

Intra-hepatic causes:

• Cirrhosis post hepatic, alcoholic.
• Congenital hepatic fibrosis.
• Non cirrhotic portal fibrosis (NCPF).
• Veno occlusive disease.
• Hepatic venous outflow tract obstruction (HVOO).

Post hepatic causes:

• Inferior vena cava obstruction.
• Constrictive pericarditis.
• Tricuspid incompetence.
• Right sided heart failure.

Symptoms of Portal Hypertension

• Variceal bleeding Esophago-gastric varices (micro venous bleeding) develop in about 50-60% of cirrhotic PHT.
  
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• Variceal bleeding is characterized by spontaneous, profuse, painless haematemesis (vomiting of blood) associated with melena (blood in stools).
• In young children, it is precipitated by upper respiratory tract infection.
• Varices patient develops venous and capillary portal hypertensive gastropathy.
• Splenomegaly (enlargement of spleen)
• It is usually mild in cirrhosis and large in patients with EHPVO and NCPF.
• Ascites and liver cell failureThis is seen mainly in cirrhotic patients and is indicative of severe hepatic decompensation.
• Transient ascites may occur in patients with NCPF and EHPVO following massive gastrointestinal bleeding.
• Features of liver failure in form of acute or chronic encephalopathy, testicular atrophy and erythematous eruption are seen in patients with cirrhosis of liver.
  
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• Other featuresDilated veins with blood flowing away from umbilicus (caput medusa) are seen in intra-hepatic PHT and rarely a venous murmur at the umbilicus (Cruveilhier-Baumgartan venous hum).
• Patients with HVOO have dilated veins over flank and at back, massive hepatomegaly (enlargement of liver), ascites and edema of feet.

Diagnosis of Portal Hypertension

• Liver function test (LFT): Raised LFT indicates active liver damage. Low albumin level indicates established cirrhosis. Elevated prothrombin time indicates end stage liver disease with poor prognosis.
• Endoscopy: It helps document esophago-gastric varices.
• USG of liver and portal venous system helps diagnosis of PHT by demonstration of dilated collaterals around gastro-esophageal junction and dilated portal vein.
• Liver biopsy: It helps differentiate early cirrhosis from NCPF.
• Portovenography: Percutaneous splenoportography (SPG) is commonly done for visualization of portal vein and its main tributaries.

Treatment for Portal HypertensionNon-surgical

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Drug therapy: Vasoconstrictor drugs like vasopressin, vasodilators like nitroglycerin, beta-blockers and hormones like somatostatin.

Balloon tamponade for temporary arresting heavy bleeding in an unstable patient or when facilities for urgent endoscopic therapy are not available.

Endoscopic therapy: Endoscopic variceal injection sclerotherapy (EVS) is safe and effective for control of variceal bleeding.

Surgical

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Portal decompression procedure (porto-systemic shunts) – these aim to decrease portal venous pressure by anastomosing portal vein and its branches.

Non-decompression procedure- includes variceal ligation.

Liver transplantation.