Portal Hypertension
Signs and symptoms
* Jaundice
* History of blood transfusion
* Intravenous drug abuse
* History of alcohol consumption
* Pruritus
* Hematemesis
* Melena
* Lethargy
* Increased irritability
* Altered sleep patterns
* Increased abdominal girth due to ascites
* Hematochezia
* Abdominal pain
* Fever
Signs of port systemic collateral formation
* Dilated veins in the anterior abdominal wall
* Venous pattern on the flanks
* Caput medusa
* Rectal hemorrhoids
* Ascites
* Paraumblical hernia
Signs of liver disease
* Ascites
* Jaundice
* Spider nevi
* Gynecomastia
* Dupuytren’s contracture
* Muscle wasting
* Palmar erythema
* Asterixis
* Testicular atrophy
* Splenomegaly
Causes
Prehepatic
* Portal vein thrombosis
* Splenic vein thrombosis
* Extrinsic compression by tumor
* Arteriovenous fistula
Intrahepatic presinusoidal and/ or postsinusoidal
* Hepatic cirrhosis
* Acute alcoholic hepatitis
* Primary biliary cirrhosis
* Congenital hepatic fibrosis
* Vitamin A toxicity
* Budd chiari syndrome
* Pelisosis hepatitis
Intrahepatic, predominantly presinusoidal
* Shistosomiasis
* Primary biliary cirrhosis
* Nodular regenerative hyperplasia
* Polycystic disease
* Hepatic metastasis
* Granulomatous disease (sarcoidosis and tuberculosis)
Treatment
Emergency treatment
* Each episode of variceal bleeding is associated with 30% mortality fever.
* Initial resuscitation with replacement of blood volume loss by packed or whole red blood cells or plasma expanders.
* Avoid intravascular volume and variceal overexpansion to prevent re bleeding.
* Prophylactic antibiotic use to decrease the rate of bacterial infections.
Pharmacotherapy
* Somatostatin- is an endogenous hormone that decreases the portal blood flow by vasoconstriction.
* Octreotide- it’s an analogue of somatostatin, also effective in reducing the complications of variceal bleeding after emergency sclerotherapy or variceal ligation
* Vasopressin- Most potent vasoconstrictor has more side effects.
* Terlipressin- has fewer adverse effects than vasopressin.
Endoscopic therapy
* Endoscopic therapy has the advantage of allowing specific therapy at the time of diagnosis.
* >80% of hemostasis can be achieved.
* Endoscopic injection sclerotherapy involves injecting sclerosant solution like sodium morrhuate, sodium tetradecyl sulfate, and ethanolamine oleate into the bleeding veins.
Endoscopic variceal ligation
Other interventions
* Balloon tube tamponade
* Minnesota tube
Primary prophylaxis
* Beta blockers- Propranolol and Nadolol
* Vasodilators- Isosorbide mononitrate
* Combination therapy- Propranolol and Isosorbide mononitrate
* Prophylactic sclerotherapy
* Prophylactic endoscopic variceal ligation
Surgical care
Decompressive shunts
* Total portal systemic shunts
* Partial portal systemic shunts
* Selective shunts
Devascularization procedures
* Splenectomy
* Liver transplantation
