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 are divided into pre-hepatic, intra-hepatic and post-hepatic.
Pre-hepatic causes
- Extra-hepatic portal vein obstruction
  - Idiopathic.
  - 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.

Variceal bleeding
- Esophago-gastric varices (micro venous bleeding) develop in about 50-60% of cirrhotic PHT.
- 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 failure
- This 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.
Other features
- Dilated 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.

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- 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- to differentiate early cirrhosis from NCPF.
Portovenography- percutaneous splenoportography (SPG) is commonly done for visualization of portal vein and its main tributaries.

Non-surgical

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

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.

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