Portal Hypertension

Question 1

Define Portal Hypertension?

Answer 1

Abnormally high pressure within the hepatic portal vein

Question 2

What is clinically significant Portal Hypertension is defined as?

Answer 2

a hepatic venous pressure gradient > 10 mm Hg

Question 3

What is the most common cause of Portal Hypertension?

Answer 3

Cirrhosis

Question 4

How can the other causes of Portal Hypertensionbe divided?

Answer 4

Pre-Hepatic
Hepatic
Post-Hepatic

Question 5

What do the subdivisions of the causes mean in Portal Hypertension?

Answer 5

Pre-Hepatic : Blockage of the portal vein before the liver

Post-Hepatic- Blockage of hepatic veins or venules

Question 6

What are the Pre-Hepatic causes of Portal Hypertension?

Answer 6

Congenital stenosis
Portal vein thrombosis
Splenic vein thrombosis
Extrinsic compression

Question 7

What are the Hepatic causes of Portal Hypertension?

Answer 7

Cirrhosis
Chronic hepatitis
Schistosomiasis
Myeloproliferative disease

Question 8

What are the Post-Hepatic causes of Portal Hypertension?

Answer 8

Budd-Chiari Syndrome (hepatic vein obstruction)
Constrictive pericarditis
Right heart failure

Question 9

What is the epidemiology of Portal Hypertension?

Answer 9

A common consequence of cirrhosis

Question 10

What are the presenting symptoms of Portal Hypertension?

Answer 10

Features of Liver Disease (likely to coexist with portal hypertension)
Complications of Portal Hypertension

Question 11

What are the features of Liver Disease?

Answer 11

Jaundice
History of Alcohol abuse
Risk factors for viral hepatitis
Family history (e.g. haemochromatosis)

Question 12

What are the risk factors for Viral Hepatitis?

Answer 12

E.g. tattoos, unprotected sex, IV drug use, travel abroad and blood transfusion

Question 13

What are the complications of Portal Hypertension that present as symptoms?

Answer 13

Haematemesis or Melaena
Lethargy, irritability, changes in sleep (hepatic encephalopathy)
Abdominal distension (ascites)
Abdominal pain and fever (spontaneous bacterial peritonitis)
Pulmonary involvement

Question 14

What are the signs of Portal Hypertension on physical examination?

Answer 14

Caput Medusae
Splenomegaly
Ascites
Signs of Liver Failure

Question 15

What are the Signs of Liver Failure?

Answer 15

Jaundice 
Spider naevi 
Palmar Erythema 
Confusion 
Asterixis 
Fetor Hepaticus 
Enlarged or small liver 
Gynaecomastia 
Testicular Atrophy

Question 16

What investigations do we do for Portal Hypertension?

Answer 16

Bloods 
Specific Tests 
Imaging 
Measure Hepatic Venous Pressure Gradient (HVPG)
Liver Biopsy - if indicated

Question 17

What bloods do we do for Portal Hypertension?

Answer 17

LFTs 
U&Es 
Blood Glucose 
FBC 
Clotting Screen

Question 18

Why do we do a Clotting Screen for Portal Hypertension?

Answer 18

Prolongation of PT is one of the earliest signs of liver failure

Question 19

What specific tests can we do for Portal Hypertension?

Answer 19

Ferritin - haemochromatosis 
Hepatitis serology 
Autoantibodies (e.g. anti-smooth muscle antibodies in autoimmune hepatitis) 
a1-antitrypsin levels 
Caeruloplasmin - Wilson's Disease

Question 20

What imaging can we do for Portal Hypertension?

Answer 20

Abdominal US
Doppler US
CT/MRI
Endoscopy

Question 21

Why would we do an Abdominal US for Portal Hypertension?

Answer 21

Check liver and spleen size and assess portal blood flow

Question 22

Why would we do a Doppler US for Portal Hypertension?

Answer 22

Assess direction of blood flow in vessels

Question 23

When do we do a CT/MRI for Portal Hypertension?

Answer 23

If other imaging methods are inconclusive

Question 24

Why would we do an Endoscopy for Portal Hypertension?

Answer 24

To check for oesophageal varices

Question 25

What is the problem with a management plan for Portal Hypertension?

Answer 25

Difficult to treat Portal Hypertension specifically

Question 26

What is the focus of treatment of Portal Hypertension?

Answer 26

Treat the underlying cause

Question 27

What is the conservative management plan for Portal Hypertension?

Answer 27

Salt restriction | Diuretics

Question 28

What are some of the few management plans that are used for Portal Hypertension?

Answer 28

Non-selective beta-blockers Terlipressin Transjugular Intrahepatic Portosystemic Shunt (TIPS) Liver transplant

Question 29

How do Non-Selective beta-blockers help with Portal Hypertension?

Answer 29

Reduce portal pressure and reduces risk of variceal bleeding

Question 30

How do Terlipressin help treat Portal Hypertension?

Answer 30

Can reduce portal venous pressure

Question 31

What is involved in a Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

Answer 31

Surgical shunt placed between the hepatic portal vein and the hepatic vein to ease congestion in the portal vein

Question 32

What are the possible complications of Portal Hypertension?

Answer 32

``` Bleeding from oesophageal varices Ascites + complications of ascites Pulmonary complications Liver Failure Hepatic Encephalopathy Cirrhotic Cardiomyopathy ```

Question 33

What are the complications of Ascites?

Answer 33

Spontaneous Bacterial Peritonitis Hepatorenal Syndrome Hepatic Hydrothorax

Question 34

What is Hepatorenal Syndrome?

Answer 34

A life-theratening condition that consists of a rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure

Question 35

What is Hepatic Hydrothorax?

Answer 35

A transudative pleural effusion in patients with portal hypertension without any underlying primary cardiopulminary cause

Question 36

What are some of the Pulmonary complications present in Portal Hypertension?

Answer 36

Portopulmonary hypertension | Hepatopulmonary Syndrome - a triad

Question 37

What is the triad of complications associated with Hepatopulmonary Syndrome?

Answer 37

``` Hepatic dysfunction Hypoxaemia Extreme Vasodilation (intrapulmonary vascular dilatation) ```

Question 38

What is the prognosis for patients with Portal Hypertension?

Answer 38

Depends on the underlying cause | Variceal haemorrhages have a 1-year mortality of 40%