Portal Hypertension

1
Portal Hypertension

• Pressure gt 12 mmHg (5-10)

2
Common Causes

• Cirrhosis is the most common cause of portal
  hypertension in the US.
• Clinically significant portal hypertension is
  present in gt60 of patients with cirrhosis.
• Portal vein obstruction is the second most common
  cause.
• Cirrhosis
• infection
• Pancreatitis
• abdominal trauma
• Idiopathic

3
Pathophysiology

• Normally very low resistance flow
• Non-Valve system
• Any increase in resistance transmits to
  retrograde pressure
• Prehepatic portal/splenic obsruction, AV
  fistula
• Intrahepatic cirrhosis, metastases,
  schistosomiasis
• Posthepatic constrictive pericardidtis,
  tricuspid ins., CHF

4
Cirrhosis

• Decreased effective circulating volume due to
  massive splanchnic dilation.
• Increased lymph oncotic pressure leading to
  ascites.
• Activation of the renin-angiotensin system,
  further contributing to sodium and water
  retention.
• Systemic circulatory dysfunction
• Nitric oxide elevated in the splanchnic
  circulation
• reduce the effective arterial blood volume and
  activate compensatory vasoconstrictors.
• Fluid and sodium retention as well as renal
  dysfunction follow.
• Hypoalbuminemia and increased splanchnic
  lymphatic hydrostatic pressure combine with
  sodium retention to produce ascites and edema.

5
Clinical Features of Portal HTN

• splenomegaly with hypersplenism
• ascites
• acute and chronic hepatic encephalopathy
• Increased portal-systemic collateral flow

6
Portal-Systemic Anastomoses

• Left gastric ? azygous (esophageal)
• Superior ? inferior rectal (external hemorrhoids)
• Paraumbilical ? inferior epigastric (caput
  medusae)
• Retroperitoneal ? renal
• Retroperitoneal ? paravertebral

7
SMV
Splenic,Gastric IMV
Mixture
8
Treatment

• hypertension due to cirrhosis is not reversible
• Usually complication specific
• Decompression
• TIPS
• Nonselective beta blockers reduce cardiac
  output and splanchnic vasoconstriction
• Propranolol
• Nadolol
• Liver transplant

9
References

• Harrisons
• BRS Pathology
• FirstAid