Liver: Portal Hypertension & Sequelae

Portal Hypertension

Definition

  • Elevated Pressure Within the Portal System Due to Flow Resistance

Causes

  • Presinusoidal
    • Intrahepatic:
      • Schistosomiasis (Most Common Presinusoidal Cause)
      • Sarcoidosis
      • Primary Sclerosing Cholangitis
      • Tumor Occluding Intrahepatic Portal Vein
      • Idiopathic Noncirrhotic Portal Hypertension
    • Extrahepatic:
      • Portal/Splenic Vein Thrombosis
      • Splanchnic Arteriovenous Fistula
  • Sinusoidal
    • Cirrhosis (Most Common Cause in US)
    • Acute Liver Failure Induced Sinusoid Injury
  • Postsinusoidal
    • Budd-Chiari Syndrome
    • Congenital Webs
    • Constrictive Pericarditis

Hepatic Venous Pressure Gradient (HVPG)

  • Less Invasive Than Direct Portal Pressure Measurement
  • HVPG = Wedged Hepatic Venous Pressure – Free Hepatic Venous Pressure
  • Values:
    • Normal: 1-5 mmHg
    • Portal Hypertension:
      • Portal Hypertension Definition: ≥ 6 mmHg
      • Clinically Significant Portal Hypertension: ≥ 10 mmHg
        • Predictive of the Development of Complications
    • Threshold for Variceal Rupture: ≥ 12 mmHg

Complications/Sequelae

  • Ascites (Most Common Complication)
  • Collateral Vessel Dilation
    • Esophageal Varices
    • Gastric Varices
    • Hemorrhoids & Rectal Varices
    • Caput Medusae – Veins of Lower Abdominal Wall, From Opening of Obliterated Umbilical Vein
  • Variceal Bleeding
  • Hepatorenal Syndrome
  • Hepatic Hydrothorax

Diagnosis

  • Dx: Hepatic Venous Pressure Gradient
  • Not Necessary if Clinical Presentation Strongly Suggestive

Treatment

  • Treat Underlying Cause & Prevent Complications

Portal Hypertension – Sequelae

Ascites

  • Accumulation of Fluid in the Peritoneal Cavity
  • Cause: Portal Hypertension & Splanchnic Vasodilation
    • Activation of Vasoconstrictive Agents Cause Na/Water Retention
  • Tx: Sodium Restriction & Diuresis (Spironolactone & Furosemide)
    • If Hyponatremic: Fluid Restriction
    • If Diuresis Fails: Serial Paracentesis
      • Give Albumin if ≥ 5 Liters are Removed
    • If Unable to Tolerate Serial Paracentesis: TIPS
    • Definitive Tx: Liver TXP
    • Consider SBP Prophylaxis

Hepatic Hydrothorax

  • Cause: Ascites Seeps Through Small Diaphragmatic Defects
    • From Negative Pressure During Inspiration
  • Most Common Side: Right (Left-Side Thicker)
  • Treatment: Liver Transplant if Candidate
    • Mild-Moderate Symptoms: Medical Management of Ascites
    • Severe Symptoms: Thoracentesis
    • Do NOT Place a Chest Tube
      • Causes Massive Protein Loss, Renal Failure & Bleeding

Esophageal Varices

Other Varices

  • Gastric Varices
    • If Isolated – Consider Splenic Vein Thrombosis
    • Bleeding Tx: Endoscopic Cyanoacrylate Injection
      • TIPS if Unavailable
  • Ectopic Varices
    • Sites: Intestine, Rectum, etc.
    • Bleeding Tx: TIPS
      • Consider Concurrent Variceal Embolization

Hepatorenal Syndrome