Management and Complications
of PORTAL
HYPERTENSION
SHIV SANTHOSH.G
INVESTGATONS
Blood tests: Anemia may be present
due to hyper-splenism and bleeding
varices. Liver function tests are
usually normal in patients with non-
cirrhotic portal hypertension but may
be altered in cirrhosis.
Endoscopy: Upper GI endoscopy
shows gastro-esophageal varices
Ultrasonography: Ultrasonography
(USG) of the liver and portal venous
system helps to establish the
diagnosis of portal HTN. It shows
dilated collaterals around the
gastroesophageal junction and
splenic hilum, splenomegaly, and
dilated portal vein and splenic vein. It
can also help in diagnosing the cause
of portal HTN such as cirrhosis, portal
vein throm-bosis, etc. Doppler USG
can assess the direction and velocity
of blood flow in the portal vein
Liver biopsy: It is indicated in
selected cases to diagnose the cause
of portal HTN.
Portal venography: Demonstrates
the site and often the cause of portal
venous obstruction and is performed
prior to surgical intervention.
Complications of Portal
Hypertension
Variceal bleeding
Congestive gastropathy
Hypersplenism
Ascites
Renal failure
Hepatic encephalopathy
Treatment
Reduction of Portal Pressure
Nonselective beta-blockers such as
propranolol or nadolol reduce portal
pressure through splanchnic
vasoconstriction and reduced cardiac
output. Drugs should be titrated to a
target pulse rate of 60/min or reduction of
resting pulse by 25%. Nitrates (isosorbide
mononitrate and dinitrate can be used if
beta-blockers are contraindicated
DIETARY MODIFICATION The goal
of treatment for the patient with
ascites is a negative sodium balance
to reduce fluid retention.
DIURETICS Use of diuretics along
with sodium restriction is successful
in 90% of patients with ascites.
PARACENTESIS Paracentesis is the
removal of fluid (ascites) from the
peritoneal cavity through a small
surgical incision or puncture made
through the abdominal wall under
sterile conditions.
BALLOON TAMPONADE To control
hemorrhage in certain patients,
balloon tamponade may be used. In
this procedure, pressure is exerted on
the cardia (upper orifice of the
stomach) and against the bleeding
varices by a balloon tamponade. The
tube has four openings, each with a
specific purpose: gastric aspiration,
esophageal aspiration, inflation of the
gastric balloon, and inflation of the
esophageal balloon
ENDOSCOPIC SCLEROTHERAPYIn
endoscopic sclerotherapy (also
referred to as injection
sclerotherapy), a sclerosing agent is
injected through a fiber optic
endoscope into the bleeding
esophageal varices to promote
thrombosis and eventual sclerosis.
ESOPHAGEAL BANDING THERAPY
(VARICEAL BAND LIGATION)In
variceal banding, a modified endoscope
loaded with an elastic rubber band is
passed through an over-tube directly
onto the varix (or varices) to be
banded. After suctioning the bleeding
varix into the tip of the endoscope, the
rubber band is slipped over the tissue,
causing necrosis, ulceration, and
eventual sloughing of the varix.
TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNTING
Transjugular intrahepatic portosystemic
shunting (TIPS) is a method of treating
esophageal varices in which a cannula
is threaded into the portal vein by the
transjugular route. An expandable
stent is inserted and serves as an
intrahepatic shunt between the portal
circulation and the hepatic vein,
reducing portal hypertension.
Portosystemic shunt surgeries such as
protocavar shunt, splenorenal shunt,
etc. are done less commonly now with
the availability of TIPS.
TIPS (transjugular intrahepatic
portosystemic shunt): Here, a portal-
systemic shunt is placed through
internal jugular vein percutaneously. It
decompresses the portal circulation.
Wherever possible, underlying cause
of portal HTN should be treated.
Liver transplantation is helpful in
selected patients.
Treatment of Complications
Complications such as variceal
bleed, encephalopathy, ascites, etc.
should be treated as per standard
guidelines.
