Hypertension is a common disease we all are aware of. Portal hypertension is slightly different from systemic hypertension. For ensuring blood supply to the major organs, our body forms collateral circulation, in a simple way, the connection between veins and capillaries is known as portal circulation.
In the human body, portal circulation is seen in the liver and kidney. The normal portal vein pressure is 5-10 mmHg. When portal pressure exceeds the normal range, more precisely >10 mmHg is known as the portal hypertensive state.
20% of upper gastrointestinal hemorrhage is due to portal hypertensive bleeding. Let’s explore this phenomenon.
Reasons behind portal hypertension
Any obstruction in the portal collateral system can lead to portal hypertension.
Even though these many causes can lead to portal hypertension, the main cause behind sinusoidal portal hypertension is found to be cirrhosis, and the main cause of intrahepatic presinusoidal portal hypertension is Schistosomiasis.
As a consequence of these causes, increased portal vascular resistance and increased portal flow occurs, it will result in portal hypertension.
The Patient
How do we recognize the patient?
Portal hypertension per se doesn’t show any typical symptoms. Usually, the patient is identified by any chance when it is associated with decompensated chronic liver disease and encephalopathy, ascites, or variceal bleeding. Many patients show three primary complications. They are esophageal varices, Splenomegaly, and Ascites. It is known as the triad of portal hypertension. Other symptoms can vary based on the underlying causes.
On examination, we can find audible venous hum in caput medusa, known as Cruvielhier-Baumgarten murmur. The Patient may complain about bleeding episodes in the upper GI, usually in the first 1-2 years after the identification of varices.
Consequences Of The Disease
The primary complications of portal hypertension are gastroesophageal varices with hemorrhage, ascites, hypersplenism, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatocellular carcinoma.
Confirming Your Suspicion
For confirming the diagnosis is portal hypertension, the investigation choice is color Doppler studies.
For treatment the purpose we must know about the underlying cause. In order to identify the cause, we do blood investigation, Liver function tests, renal function tests, liver biopsy, the ascitic tap, and esophago-gastroscopy.
Ultrasound abdomen, contrast CT and MRI, MR venogram, etc., help to detect the portal vein status in portal hypertension. Hepatic venous pressure gradient (HVPG) - is considered the gold standard to diagnose portal hypertension.
Treatment
Usually, the patient will come to OPD with hematemesis (bleeding in GI); it’s a complication of portal hypertension. In such cases, our primary goal is to stop the bleeding. It can be done by, Blood transfusion, Correct coagulopathy, esophageal balloon tamponade (Sengstaken–Blakemore tube), Drug therapy (terlipressin), Endoscopic sclerotherapy or banding, Assess portal vein patency (Doppler ultrasound or CT), Transjugular intrahepatic portosystemic stent shunts (TIPSS)
The second aim is to prevent further bleeding. For that, we must eliminate the causative factor which leads to portal hypertension. For this purpose, we can go for splenectomy and gastro-oesophageal de-vascularisation.
Management Of Variceal Bleeding
Drugs used in portal hypertension
Points To Remember
Left-sided portal hypertension or sinistral hypertension occurs due to isolated splenic vein thrombosis. In this case, portal vein pressure is normal. The main cause of splenic vein thrombosis is pancreatitis. Splenectomy is the treatment of choice for this condition.
In portal hypertension, variceal formation occurs when portal pressure is >10mmHg, and variceal bleeding occurs when portal pressure is >12mmHg.
Porto pulmonary hypertension denotes pulmonary artery hypertension (pressure gradient >25 mmHg) in portal hypertension. It predisposes to intra-operative cardiac arrhythmias and arrest.
The main complication of Balloon tamponade is aspiration pneumonia.
References
- Bailey& Loves short practice of surgery 27th edition; Page no: 1163-1166
- SRB Manual of surgery 5th edition; Page no: 614-617
- Surgery essence Pritesh Singh 3rd edition; Page no: 140-145
- Harrison’s Principles of Internal Medicine 20th edition; Page no: 2410-2411
Author’s Footnotes
Feel free to click on the references for a more in-depth reading if you so desire.
If you feel any information can be added or that there are any inadvertent errors, feel free to let us know in the comments below or bring it to our notice via support@medicalwizardry.com.
Ever otherwise, feel free to use the comments section for discussion.
We would love to hear from you. Reach out to us via admin@medicalwizardry.com to share any random gibberish/ideas that you would like implemented.