Portal hypertension: Diagnosis & Management

• Portal hypertension


  Condition where there is increased pressure in the portal vein
• General approach to portal hypertension


  1. Confirm diagnosis of portal hypertension

  2. Determine cause of portal hypertension

  3. Treat the complications

  4. Follow-up plans
• Diagnosis: Non-invasive


  • Direct clinical signs (at endoscopy)
  • Gastro-esophageal varices
  • Portal hypertensive gastropathy
  • Indirect clinical signs:
  • Splenomegaly
  • Thrombocytopenia
  • Ascites
• Radiology


  • Non-invasive: Portal vein doppler; abdominal CT scan; MRI
  • Invasive: Hepatic venous pressure gradient (the difference between portal vein pressure & intra-abdominal IVC pressure)
• HVPG measurement


  Hepatic venous pressure gradient measurement
• Ascites


  Fluid accumulation in the abdomen, used to diagnose portal hypertension
• Emergency treatment


  1. Resuscitate: ABC's

  2. D's: somatostatin analogue, antibiotic, proton pump inhibitor
• Drugs


  • Somatostatin 250mg ivi bolus followed by 250mg/hr for 5/7
  • Octreotide 50microgram ivi bolus followed by 50microgram/hr infusion for 5/7
  • Terlipressin 2mg/4hrly ivi for 2/7 then 1mg/4hrly ivi for 5/7
  • Pantoloc 40mg 12hrly ivi for 7/7
  • Ceftriaxone 1g 6hrly ivi for 7/7
• Endoscopic management


  1. Gastroscopy

  2. Endoscopic band ligation

  3. Injection sclerotherapy
• Endoscopic band ligation


  • YouTube video demonstrating endoscopic band ligation (2min 40s)
• Sengstaken-Blakemore Tube


  • YouTube video demonstrating placement of Blakemore tube
• Long term treatment


  • Banding programme
  • Non-selective beta blockers
• Surgical options


  • Indications:
  • Refractory bleeding
  • Recurrent bleeds
  • Intractable ascites
  • Massive hypersplenism
  • Shunts: Selective versus non-selective shunts (Radiological versus surgical)
  • Devascularization procedures
  • Liver transplants
• Surgical options: Shunts


  • TIPS
  • MESOCAVAL SHUNT
  • SPLENORENAL SHUNT
• Follow-up


  1. Small varices on no treatment: esophagogastroscopy annually

  2. Small varices on beta blocker: no further endoscopy

  3. If treated with band ligation repeat EGD every 2-4 weeks until all varices eradicated, then repeat after 3months, then after 6 months and then annually
• The treatment of portal hypertension: A meta‐analytic review. Gennaro D'amico Luigi Pagliaro Jaime Bosch. Hepatology 1995: 'https://doi.org/10.1002/hep.1840220145'
• UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Tripathi et al. Gut. 2015: 'http://dx.doi.org/10.1136/gutjnl-2015-309262'
• HVPG measurement

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  C)

  D)

  E)

  
• Investigating ascites to dx portal hypertension

  A)

  B)

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  D)

  E)

  F)

  G)

  H)

  
• MESOCAVAL SHUNT

  
• TIPS (Transjugular intrahepatic portosystemic shunt )

  
• SPLENORENAL SHUNT