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Portal Hypertension
Walter M. Kim, MD, PhD
Jyoti Ramakrishna, MD
image BASICS
  • Increased portal venous pressure >5 mm Hg that occurs in association with splanchnic vasodilatation, portosystemic collateral formation, and hyperdynamic circulation
  • Most commonly secondary to elevated hepatic venous pressure gradient (HVPG; the gradient between portal and central venous pressures)
  • Course is generally progressive, with risk of complications including acute variceal bleeding, ascites, encephalopathy, and hepatorenal syndrome.
  • Prevalence: <200,000 persons in the United States
  • Predominant age: adult
  • Predominant sex: male > female
  • Causes generally classified as follows:
    • Prehepatic (portal vein thrombosis or obstruction)
    • Intrahepatic (most commonly cirrhosis)
    • Posthepatic (hepatic vein thrombosis, Budd-Chiari syndrome, right-sided heart failure)
  • Cirrhosis accounts for 90% of intrahepatic cases; may be due to the following:
    • Virus (hepatitis B, hepatitis C, hepatitis D)
    • Alcoholism
    • Schistosomiasis
    • Wilson disease
    • Hemochromatosis
    • Primary biliary cirrhosis (PBC)
    • Sarcoidosis
  • Increased HVPG results in venous collateral formation in the distal esophagus, proximal stomach, rectum, and umbilicus.
  • Gastroesophageal variceal formation is found in 40% of patients with portal hypertension.
  • Progression of portal hypertension results in splanchnic vasodilation and angiogenesis.
No known genetic patterns except those associated with specific hepatic diseases that cause portal hypertension
See “Etiology.”
Pediatric Considerations
In children, portal vein thrombosis is the most common extrahepatic cause; intrahepatic causes are more likely to be biliary atresia, viral hepatitis, and metabolic liver disease.
  • Exam findings may be general or related to specific complications.
  • General
    • Pallor
    • Icterus
    • Digital clubbing
    • Palmar erythema
    • Splenomegaly
    • Caput medusa
    • Spider angiomata
    • Umbilical bruit
    • Hemorrhoids
    • Gynecomastia
    • Testicular atrophy
  • Gastroesophageal varices
    • Hypotension
    • Tachycardia
  • Ascites
    • Distended abdomen
    • Fluid wave
    • Shifting dullness with percussion
  • Hepatic encephalopathy
    • Confusion/coma
    • Asterixis
    • Hyperreflexia
Usually related to specific presentations
  • Gastroesophageal varices with hemorrhage
    • Portal hypertensive gastropathy
    • Hemorrhagic gastritis
    • Peptic ulcer disease
    • Mallory-Weiss tear
  • Ascites
    • Spontaneous bacterial peritonitis (SBP)
    • Pancreatic ascites
    • Peritoneal carcinomatosis
    • Tuberculous peritonitis
    • Nephrotic syndrome
    • Fluid overload from heart failure
    • Hepatic malignancy
  • Hepatic encephalopathy
    • Delirium tremens
    • Intracranial hemorrhage
    • Sedative abuse
    • Uremia
  • Hepatorenal syndrome
    • Drug nephrotoxicity
    • Renal tubular necrosis
Initial Tests (lab, imaging)
Direct calculation of HVPG (approximation of the gradient in pressure between portal vein and IVC):
  • HVPG = wedged hepatic venous pressure (WHVP)
    • free hepatic venous pressure (FHVP)
  • HVPG >10, esophageal varices generally develop.
  • WHVP is estimated by occlusion of the hepatic vein by a balloon catheter and measurement of the proximal static column of blood.
  • FHVP is estimated by direct measurement of the patent hepatic vein, intra-abdominal inferior vena cava, or right atrium.
  • Nonspecific changes associated with underlying disease:
    • Hypersplenism: anemia (also may be due to malnutrition or bleeding), leukopenia, thrombocytopenia
    • Hepatic dysfunction
      • Hypoalbuminemia
      • Hyperbilirubinemia
      • Elevated alkaline phosphatase
      • Elevated liver enzymes (AST, ALT)
      • Abnormal clotting (prothrombin time, international normalized ratio, partial thromboplastin time)
    • GI bleeding
      • Iron deficiency anemia
      • Elevated serum ammonia
      • Fecal occult blood
      • Thrombocytopenia
    • Hepatorenal syndrome
      • Elevated serum creatinine (Cr), blood urea nitrogen (BUN)
      • Urine Na <5 mEq/L (<20 mmol/L)
    • US and CT scan/MRI may detect cirrhosis, splenomegaly, ascites, and varices.
    • US/duplex Doppler
      • Can determine presence and direction of flow in portal and hepatic veins
      • Useful in diagnosing portal vein thrombosis, shunt thrombosis, or the presence of ascites
    • CT scan/MRI: angiographic measurement of hepatic venous wedge pressure via jugular or femoral vein
      • Correlates with portal pressure
      • Risk of variceal bleeding is increased if hepatic venous pressure gradient >12 mm Hg.
    • Upper GI series may outline varices in esophagus and stomach.
    • Transient elastography is an emerging method to determine hepatic fibrosis and to predict portal hypertension (1).
Diagnostic Procedures/Other
Endoscopy can diagnose esophageal and gastric varices and portal hypertensive gastropathy.
Test Interpretation
Specific for underlying disease
  • Avoid sedatives that may precipitate encephalopathy.
  • Limit sodium intake because cirrhotic patients avidly retain sodium.
Therapy for encephalopathy: See “Hepatic Encephalopathy.”
First Line
  • Prophylaxis against variceal bleeding (2,3)[A]:
    • Nonselective &bgr;-blockade
      • Propranolol: start with 10 to 20 mg/day PO BID to TID
      • Nadolol: 40 to 80 mg/day PO once-daily dosing
    • Doses may be titrated up as tolerated to maximum recommended doses; goal resting HR of 55 to 60 bpm
  • P.833

  • Therapy for acute variceal hemorrhage:
    • Vasopressin: start with 0.2 to 0.4 U/min IV; increase to maximum dose 1 U/min as needed; pediatric dose: 0.002 to 0.005 U/kg/min; do not exceed 0.01 U/kg/min. After bleeding stops, continue at same dose for 12 hours and then taper off over 24 to 48 hours.
    • Octreotide: 50&mgr;g IV bolus, followed by 25 to 50 &mgr;g/hr continuous infusion; pediatric dose: 1 &mgr;g/kg bolus followed by 1 &mgr;g/kg/hr is used traditionally; treat for up to 5 days.
  • For prevention of recurrence and for overall reduction in mortality:
    • Propranolol: 10 to 60 mg/day PO BID to QID; pediatric dose: 0.5 to 1 mg/kg/day PO divided q6-8h
    • Nadolol: 40 to 80 mg/day PO reduces portal venous blood inflow by blocking the adrenergic dilatation of the mesenteric arterioles.
    • Tetrandrine, a calcium channel blocker, also has been found to reduce the rate of rebleeding with fewer side effects.
  • Initial treatment for ascites (along with salt and fluid restriction):
    • Furosemide: 20 to 40 mg/day PO; pediatric dose: 1 to 2 mg/kg/dose PO ± IV albumin infusion
    • Spironolactone: 50 to 100 mg/day PO; pediatric dose: 1 to 3 mg/kg/day PO
Second Line
  • Terlipressin (2 mg IV q4h; titrate down to 1 mg IV q4h once hemorrhage is controlled; may be used for up to 48 hours) is a more selective splanchnic vasoconstrictor and may be associated with fewer complications. It is currently used when standard therapy with somatostatin or octreotide fails.
  • Addition of nitrates, such as nitroglycerin or isosorbide mononitrate, reduces portal pressures and bleeding rates and has been shown to reduce mortality. Because the risk-benefit ratio is not clear, nitrates are not considered first-line treatment.
  • Studies are ongoing for possible benefits of other agents including simvastatin, clonidine, verapamil, and losartan.
Patients with portal hypertension should be managed longitudinally by both a primary care physician and a gastroenterologist.
  • Treatments available for specific complications of portal hypertension (in addition to or if refractory to medications):
    • Gastroesophageal varices with hemorrhage
      • Endoscopic variceal banding or sclerosis (the first-line treatment in many cases for acute hemorrhage) within 12 hours of presentation (4)[A]
      • Balloon tamponade (not used commonly when endoscopic treatment is available)
      • Transjugular intrahepatic portosystemic shunt (TIPS)
      • Portocaval shunting
    • Ascites refractory to medical management
      • Large-volume paracentesis
      • Peritoneovenous shunt
      • TIPS
  • Liver transplantation should be considered for patients with advanced disease.
  • Acute GI bleeding should be managed in the inpatient setting, either on the regular medical floor if the patient is hemodynamically stable or occasionally in the ICU if the patient is unstable.
  • Patients with mental status changes from encephalopathy need to be evaluated in the inpatient setting.
Admission Criteria/Initial Stabilization
  • Acute bleeding from the intestinal tract, either vomiting or per rectum
  • Acute confusional state/mental status changes
  • If acute variceal bleeding:
    • Type and cross patient's blood.
    • Initial resuscitation with isotonic fluid until packed RBCs are available
    • Correct coagulopathy with vitamin K and fresh frozen plasma (FFP).
    • Endoscopy as soon as the patient is stabilized (for diagnosis and treatment)
  • Avoid sedatives that may precipitate encephalopathy.
  • Limit sodium administration because cirrhotic patients avidly retain sodium.
  • Restrict protein only if encephalopathic.
IV Fluids
Use isotonic fluid for hydration.
Discharge Criteria
  • For GI bleeding:
    • No active bleeding in 24 hours
    • Stable hemoglobin and hematocrit
    • Hemodynamically stable (especially heart rate)
  • For encephalopathy: improvement in or resolution of mental status changes to baseline
In patients with cirrhosis, sodium restriction is important because cirrhotic patients avidly retain sodium.
Refrain from drinking alcohol. Resources for patients who have difficulty with not drinking alcohol can be obtained from Alcoholics Anonymous at http://www.aa.org/.
  • Hepatic reserve defined by Child-Pugh classification: rating based on encephalopathy, ascites, bilirubin, albumin, prothrombin
  • Variceal bleeding
    • 1/3 of patients with known varices will bleed eventually.
    • 50% rebleed, usually within 2 years, unless portal pressure is reduced by surgical or TIPS procedure.
    • 15-20% mortality rate
  • Ascites and encephalopathy often recur.
  • Prognosis of patients with ascites is poor: 50% 1-year survival without liver transplant (compared with 90% for patients with cirrhosis and no ascites)
1. Llop E, Berzigotti A, Reig M, et al. Assessment of portal hypertension by transient elastography in patients with compensated cirrhosis and potentially resectable liver tumors. J Hepatol. 2012;56(1):103-108.
2. Hayes PC, Davis JM, Lewis JA, et al. Meta-analysis of value of propranolol in prevention of variceal haemorrhage. Lancet. 1990;336(8708):153-156.
3. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-938.
4. De Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743-752.
Additional Reading
  • Abraldes JG, Angermayr B, Bosch J. The management of portal hypertension. Clin Liver Dis. 2005;9(4):685-713.
  • Bloom S, Kemp W, Lubel J. Portal hypertension: pathophysiology, diagnosis and management. Intern Med J. 2015;45(1):16-26. doi:10.1111/imj.12590.
  • Bosch J, Berzigotti A, Garcia-Pagan JC, et al. The management of portal hypertension: rational basis, available treatments and future options. J Hepatol. 2008;48(Suppl 1):S68-S92.
  • Sanyal AJ, Bosch J, Blei A, et al. Portal hypertension and its complications. Gastroenterology. 2008;134(6):1715-1728.
K76.6 Portal hypertension
Clinical Pearls
  • Portal hypertension can be diagnosed based on physical examination in the setting of known risk factors, specifically cirrhosis.
  • Endoscopic treatment is successful for acute variceal hemorrhage 85% of the time.
  • Prognosis of patients with ascites is poor: 50% 1-year survival without liver transplant (compared with 90% for patients with cirrhosis and no ascites).
  • Advantages and disadvantages of balloon tamponade for acute variceal bleed:
    • Advantages include rapid and often effective control of bleeding (30-90%) and common availability of device.
    • Disadvantages include recurrence of bleeding when balloon is deflated, patient discomfort, and risk of esophageal perforation.