portal hypertension
Jump to navigation
Jump to search
Introduction
Elevation of venous pressure in the portal vein.
Etiology
- hepatic cirrhosis (most common)
- liver metastasis
- hepatic failure
- alcoholic hepatitis
- Budd-Chiari syndrome
- right heart failure
- portal vein thrombosis
- myxedema
- fatty liver of pregnancy
- veno-occlusive disease
- schistosomiasis (immigrants & travelers from sub-Saharan Africa)[5]
Pathology
- increased resistance to blood flow through the cirrhotic liver & portosystemic collaterals
- increased blood flow to the mesenteric circulation
- splenomegaly
- esophageal varices
- ascites
- 50% of patients with cirrhosis within 10 years
- portends 50% 2 year survival
- in ascites due to portal hypertension, blood pressure falls resulting in reduced renal blood flow & glomerular filtration[2]
Clinical manifestations
Laboratory
- complete blood count (CBC) may show thrombocytopenia
- serum bilirubin slightly elevated
- serum albumin low
- serum ALT & serum AST may be normal or slightly elevated
- ova & parasites in stool for schistosomiasis[5]
Diagnostic procedures
Complications
Management
- management of ascites takes precedence over prevention of esophageal varices[5]
- non-selective beta-blocker (nadolol, propranolol) to prevent bleeding from esophageal varices
- non-selective beta-blocker not indicated in the absence of esophageal varices[5]
- upper GI bleeding
- endoscopic variceal ligation (see esophageal varices)
- transfuse for GI bleed to blood hemoglogin < 10 g/dL
- transfusion to hemoglobin >=10 g/dL can increase portal pressure increasing risk of bleeding[2]
- see cirrhosis & ascites
- spironolactone with or without furosemide
- discontinue ACE inhibitor & ARBs in the absence of hypertension
- compensatory upregulation of renin-angiotensin system supports blood pressure & renal function[2]
- see schistosomiasis[5]
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 368
- ↑ 2.0 2.1 2.2 2.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021.
- ↑ Talwalker JT & Kamath PS, Influence of recent advances in medical management on clinical outcomes of cirrhosis Mayo Clin Proc 80(11):1501, 2005
- ↑ American Association for the Study of Liver Diseases. Boyer TD, Haskal ZJ The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010 Jan;51(1):306. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19902484
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 NEJM Knowledge+ Gastroenterology
- ↑ 6.0 6.1 Nanchal R et al. Executive Summary: Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU: Neurology, peri-transplant medicine, infectious disease, and gastroenterology considerations. Crit Care Med 2023 May; 51:653. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37052435 https://journals.lww.com/ccmjournal/Fulltext/2023/05000/Executive_Summary__Guidelines_for_the_Management.10.aspx