Portal Hypertension

Related Subjects: |Chronic liver disease |Cirrhosis |Alkaline phosphatase (ALP) |Liver Function Tests |Ascites Assessment and Management |Budd-Chiari syndrome |Autoimmune Hepatitis |Primary Biliary Cirrhosis |Primary Sclerosing Cholangitis |Wilson disease |Hereditary Haemochromatosis |Alpha-1 Antitrypsin (AAT) deficiency |Non alcoholic steatohepatitis (NASH) |Spontaneous Bacterial Peritonitis |Alcoholism and Alcoholic Liver Disease |Liver Transplantation

ℹ️ About Portal Hypertension

• Defined as elevated portal venous pressure (indirectly via HVPG).
• Normal HVPG: ≤5 mmHg.
• Portal hypertension: HVPG ≥6 mmHg.
• Clinically significant portal hypertension (CSPH): HVPG ≥10 mmHg → risk of varices, ascites, decompensation.
• High-risk for bleeding/decompensation: HVPG ≥12 mmHg.

🫀 Anatomy of the Portal System

• IMV joins splenic vein → splenic + SMV form portal vein.
• Collaterals: oesophageal/gastric varices, rectal varices, paraumbilical vein.

📊 Classification & Causes of Portal Hypertension

Note: Cirrhosis dominates Western practice; schistosomiasis leads globally in endemic regions (often no cirrhosis/failure).

⚙️ Pathophysiology

• Pressure = flow × resistance.
• ↑ intrahepatic resistance (fibrosis, nodules, endothelial dysfunction) + splanchnic vasodilation (NO excess) → ↑ inflow.
• Angiogenesis → collaterals/varices.
• Complications: varices ± bleed, ascites, splenomegaly/hypersplenism, encephalopathy (shunting).

🩺 Clinical Features

• 🔹 Splenomegaly: Nearly always present; hypersplenism → thrombocytopenia (50–100 ×10⁹/L), leukopenia, anaemia.
• 🔹 Ascites: Common decompensation marker (CSPH).
• 🔹 Varices: Oesophageal/gastric (bleed risk), rectal (mimic haemorrhoids).
• 🔹 Other: Cruveilhier-Baumgarten (rare: patent paraumbilical vein → venous hum at umbilicus; minimal ascites).
• 🔹 Decompensation: bleed, ascites, encephalopathy, jaundice.

🔎 Investigations

• Bloods: CBC (hypersplenism), LFTs, coagulation (↑ INR advanced), viral serology, AFP (HCC).
• Ultrasound + Doppler: First-line (liver nodularity, splenomegaly, portal vein >13 mm, flow reversal, ascites).
• Transient elastography (FibroScan): LSM ≤15 kPa + platelets ≥150 rules out CSPH; LSM ≥25 kPa rules in (Baveno VII).
• CT/MRI: Detailed (thrombosis, tumours, collaterals).
• EGD: Gold standard for varices detection/grading/surveillance.
• HVPG: Invasive gold standard; CSPH ≥10 mmHg, bleed risk ≥12 mmHg; prognostic (NSBB response: ↓ ≥20% or <12 mmHg).

💊 Management

• 🔹 Primary prophylaxis (prevent first bleed): Carvedilol (preferred NSBB) in CSPH/varices; EVL if large/high-risk or NSBB intolerant (Baveno VII).
• 🔹 Acute variceal bleed: Resuscitate, vasoactives (terlipressin/octreotide), prophylactic antibiotics, urgent EGD (banding), preemptive TIPS (high-risk Child B/C + active bleed).
• 🔹 Secondary prophylaxis: NSBB + EVL best; TIPS if rebleed.
• 🔹 Ascites: Salt restriction, spironolactone ± furosemide; LVP + albumin for tense/refractory; TIPS consider.
• 🔹 Refractory: TIPS (bleed/ascites); liver transplant (decompensated).
• 🔹 Supportive: Abstain alcohol, treat cause (e.g., antivirals HCV), nutrition, variceal surveillance.

Cases - Portal Hypertension Examples

• Case 1 – Variceal bleeding 🩸: 55M alcoholic cirrhosis → haematemesis/hypotension. Spider naevi, splenomegaly. EGD: bleeding varices. Rx: fluids, terlipressin, antibiotics, banding.
• Case 2 – Ascites 💧: 60F HCV cirrhosis → distension/oedema. Shifting dullness, splenomegaly, US ascites/portal dilatation. Rx: Na restriction, diuretics, paracentesis.
• Case 3 – Hypersplenism 🦠: 48M NAFLD cirrhosis → pancytopenia. Splenomegaly, platelets 60 ×10⁹/L. Rx: optimise cirrhosis, screen varices; transplant eval.
• Case 4 – Encephalopathy 🧠: 62M decompensated post-bleed → confusion/asterixis. ↑ ammonia. Rx: lactulose/rifaximin, treat trigger.

Teaching Point 🩺: Portal hypertension complicates cirrhosis → varices/bleed, ascites, encephalopathy, hypersplenism. Key causes: Cirrhosis (Western), schistosomiasis (endemic). Diagnosis: Non-invasive (elastography/platelets) for CSPH; HVPG gold standard. Management: Carvedilol prophylaxis, acute bleed (vasoactives + banding + TIPS), treat underlying; transplant end-stage.

📚 References (Feb 2026)

• Baveno VII Consensus (J Hepatol 2022; 2025 meta-analyses/refinements).
• AASLD Guidance: Risk Stratification & Management Portal Hypertension (2024/2025).
• StatPearls: Portal Hypertension (updated 2025).
• Baveno VIII Workshop (March 2026; consensus pending).