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Portal Hypertension; Definition, Etiology and Management!

 PORTAL HYPERTENSION

Definition:

"Portal Hyperension is present when the hepatic venous pressure gradient exceeds 10mmHg and risk of variceal bleeding increases beyond a gradient of 12mmHg."



Classification: According to The Site of Action:

1. Pre-Hepatic, Pre-Sinusoidal:

    Caused by;

  •          Portal vein thrombosis due to sepsis
  •          Abdominal trauma including surgery.


2. Intra-hepatic pre-sinusoidal:

   Caused by; 

  •         Schistosomiasis
  •         Congenital hepatic fibrosis
  •         Drugs
  •         Sarcoidosis


3. Sinusoidal:

    Caused by; 

  •         Cirrhosis
  •         Polycystic liver disease
  •        Nodular regenerative hyperplasia
  •        Metastatic malignant disease


4. Intrahepatic Post-sinusoidal:

    Caused by; 

  •       Veno-occlusive disease


5. Post-hepatic post-sinusoidal:

  Caused by;

  •       Budd-Chiari syndrome


Etiology:

  1. Cirrhosis
  2. Schistosomiasis
  3. Portal vein thrombosis
  4. Drugs
  5. Fibrosis


Clinical Features:

  1. Variceal bleeding
  2. Congestive gastropathy
  3. Renal failure
  4. Iron deficiency anemia
  5. Hepatic encephalopathy
  6. Splenomegaly


Pathophysiology:

  • Increased portal vascular resistance leads to gradual reduction in flow of portal blood to liver and simultaneously to the development of collateral vessels, allowing portal blood to bypass liver and enter systemic circulation directly.
  • Poly systemic shunting occurs, particularly in the GIT and especially in the distal esophagus, stomach and rectum, in the anterior abdominal wall and in the renal, lumbar, ovarian and testicular vasculature.



Investigations:

  1. Portal venous Pressure is measured: by using a balloon catheter inserted using a trans jugular route.
  2. Endoscopy
  3. Ultrasonography
  4. CT scan
  5. MRI


Management of Bleeding:

1. IV Fluids: To replace the extracellular volume.

2. Vasopressor: To reduce the portal pressure, acute bleeding and risk of early bleeding.

3. Prophylactic Antibiotics (Cephalosporins IV): To reduce incidence of spontaneous bacterial peritonitis.

4. Emergency Endoscopy: To confirm variceal rather than ulcer bleeding.

5. PPI: To prevent peptic ulcer.

6. Variceal Band Ligation: To stop bleeding.

7. Phosphate Enema/ Lactulose: To prevent hepatic encephalopathy.


Management of Acute Bleeding From Esophageal Varices:

  1. If suspected variceal hemorrhage.
  2. Start IV Terlipressin (Vasopressor) and Antibiotics prophylaxis.
  3. Urgent Upper GI Endoscopy:
  4. If Varices present, go for, Endoscopic Therapy. (If no varices present; stop Terlipressin.)
  5. Is there hemostasis. If yes; continue Terlipressin to 72hr. Introduce Beta-blocker as secondary prophylaxis. Enter the patient to endoscopic banding program to obliterate varices. (If no Hemostats; Further endoscopic therapy or Ballon Tamporate and Emergency Trans jugular Intrahepatic Portosystemic Stent Shunt (TIPSS)).



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