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Portal Hypertension and Related Complications: Diagnosis and Management

Portal hypertension is a major complication of cirrhosis, and its consequences, including ascites, esophageal varices, hepatic encephalopathy, and hepatorenal syndrome, lead to substantial morbidity and mortality. The past several decades have seen major improvements in the clinical management of complications of portal hypertension, resulting in substantial gains in patient outcomes. However, important challenges remain.

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 What is portal hypertension?

In people with liver failure and cirrhosis, the liver is incapable of processing blood from the bowel. As a result, abnormally high pressure develops within the veins that drain blood from the bowels as the body tries to form other channels for the blood to empty into the main (systemic) circulation. These alternate pathways of blood drainage are known as portosystemic collaterals and consist of fragile veins that surround the esophagus, stomach or other areas in the digestive tract. Because of the fragility of these veins, they are prone to rupturing, which can result in massive amounts of bleeding. The abnormally high pressure within the veins draining into the liver (portal hypertension) can also result in the formation of fluid seeping from the surface of the liver and collecting in large quantities in the abdominal cavity. This is known as ascites. Therapies that lower the blood pressure within the veins draining into the liver can lessen the formation of ascites and lower the risk of bleeding from the fragile veins (varices).

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There is a complex imbalance of coagulation factors in the liver patient that is essential to understand for effective management of thrombotic and hemorrhagic events. In general, patients with liver disease are more likely to develop thrombotic disease than they are bleeding diathesis, even if the INR is elevated.

Expanding consensus in portal hypertensio

Portal hypertension is the haemodynamic abnormality associated with the most severe complications of cirrhosis, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Variceal bleeding is a medical emergency associated with a mortality that, in spite of recent progress, is still in the order of 10–20% at 6 weeks. The evaluation of diagnostic tools and the design and conduct of good clinical trials for the treatment of portal hypertension have always been difficult.

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Portal hypertension is a clinical syndrome in which portal venous blood flow obstruction or abnormal increase in blood flow of different etiologies leads to a continuous increase in portal venous system pressure and formation of extensive collateral circulation. In portal hypertension, blood in the portal venous system flows back into the systemic circulation through the collateral vessels of a portosystemic anastomosis, forming multiple collateral circulation pathways away from the liver. Therefore, its clinical manifestations are mainly splenomegaly, hypersplenism, esophagus and gastric fundus, and other collateral varices and ascites

Portal Hypertension

Portal Hypertension = increased resistance to flow through liver -> shunted around the other collateral vascular beds. The most common complication of cirrhotic liver disease.

Portal vein thrombosis

Thrombus formation in the portal vein +/- tributaries (SMV, IMV and splenic vein)

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Consider PVT in patients with hematologic cancers or other pro-thrombotic conditions presenting to the ED with abdominal pain or new ascites.

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Cirrhosis is a common condition in the U.S. and leads to several deadly complications including variceal hemorrhage, ascites, Spontaneous Bacterial Peritonitis (SBP), hepatic encephalopathy, hepatorenal syndrome, and hepatopulmonary syndrome. Key resuscitation techniques and care of the complications of cirrhosis can reduce morbidity and mortality

The Evolution of Portal Hypertension Surgery

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Biliary atresia and extrahepatic portal vein obstruction (EHPVO) are the most common causes of portal hypertension in children. While EHPVO is more common in the developing countries, biliary atresia is a common cause in the developed countries, especially in the USA.