Portal Hypertension (Disease of Liver)

Portal hypertension can be classified based on the location of the obstruction

• Intrahepatic (within the liver): The most common cause is cirrhosis, where scar tissue replaces healthy liver tissue, impeding blood flow. Other causes include hepatic fibrosis, fatty liver disease, alcohol abuse, hepatitis B and C infections, Wilson’s disease, cystic fibrosis, hemochromatosis, primary sclerosing cholangitis, biliary atresia, and schistosomiasis
• Prehepatic (before the liver): Obstructions such as portal vein thrombosis and congenital portal vein atresia can increase pressure in the portal vein before it enters the liver
• Posthepatic (after the liver): Conditions like hepatic vein thrombosis (Budd-Chiari syndrome), inferior vena cava thrombosis, and restrictive pericarditis can cause blood to back up into the portal system, raising pressure

The manifestations of portal hypertension vary but commonly include

• Varices: Swollen veins, particularly in the esophagus and stomach, which can rupture and lead to life-threatening bleeding. Symptoms may include hematemesis (vomiting blood) and melena (black, tarry stools)
• Ascites: Accumulation of fluid in the abdomen due to decreased protein levels and increased pressure in the portal vein
• Hepatic Encephalopathy: A decline in brain function resulting from the liver’s inability to remove toxins from the blood, leading to confusion, lethargy, and in severe cases, coma
• Splenomegaly: Enlargement of the spleen due to increased pressure in the splenic vein, which can lead to a decrease in blood cells and platelets

Diagnosing portal hypertension involves a combination of clinical evaluation and diagnostic test:

• Imaging Studies Ultrasound, CT scans, and MRI can visualize the portal vein and detect signs of increased pressure, such as a dilated portal vein or collateral vessel.
• Endoscopy Used to identify varices in the esophagus or stomach that may be at risk of bleedin.
• Hepatic Venous Pressure Gradient (HVPG) Measurement Considered the gold standard for assessing portal pressure, where a gradient above 5 mmHg indicates portal hypertension, and values above 10-12 mmHg are clinically significan.

Management of portal hypertension focuses on treating the underlying cause and preventing complication:

• Medications Non-selective beta-blockers can reduce portal pressure and the risk of variceal bleeding. Diuretics may be used to manage ascite.
• Endoscopic Therapy Procedures like band ligation can control bleeding from varice.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS) A minimally invasive procedure that creates a channel within the liver to redirect blood flow, reducing portal pressur.
• Surgical Shunts In cases where TIPS is not feasible, surgical creation of shunts between the portal and systemic circulation may be considere.
• Liver Transplantation For patients with advanced liver disease, transplantation may be the definitive treatmen.

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