This document discusses portal hypertension, including its causes, symptoms, and treatment. Potential collaterals in portal hypertension are hypertrophied and hyperplastic due to angiogenic factors, not just increased pressure. Complications of portal hypertension include variceal hemorrhage, ascites, renal dysfunction, and hepatic encephalopathy. Cirrhosis is the most common cause worldwide. Treatment depends on variceal size, with band ligation for varices over 5mm to prevent bleeding. Drugs can be used initially for active bleeding but TIPS or surgery may be needed for severe cases.

1. PORTAL HYPERTENSION
Dr. Shirjeel
H/O M1

2. ANATOMY AT GLANCE
 Potential collaterals………!
 Are not merely passively dilated
vessels.
 These are also hypertrophied and
hyperplastic
 Reason is the role of angiogenic factors
rather than just the pressure

5. COLLATERALS
 Short gastric and coronary veins with esophageal azygous and intercostal veins
 Result…… esophageal and gastric varices
 Superior hemorrhoidal with middle and inferior hemorrhoidal
 Result……anorectal varices ( not hemorrhoids)
 Portal with epigastric veins through umbilical veins( caput medusae; cruvelheir
Baumgarten syndrome)
 Liver capsule
 Spontaneous splenorenal shunt
 Ectopic varices in duodenum

6. SEQUELE OF PORTAL HYPERTENSION
 Gastroesophageal varices
 Variceal hemorrhage
 Ascites
 Renal dysfunction
 Portal systemic encephalopathy
 Hypersplenism
 Hepatopulmonary syndrome

7. DIMENSIONS OF VEIN
 Length 55-80 mm
 Diameter 11 mm
 Increase is PATHOLOGICAL

8. PORTAL PRESSURE
 Normally 9 mm Hg
 Symptomatic at 12 mm Hg
 In between is Latent or pre clinical portal htn

9. MOST COMMON CAUSE WORLDWIDE
 Cirrhosis
 Most common noncirrhotic cause is
schistosomiasis

10. IDIOPATHIC PORTAL HTN
 INDIA and JAPAN
 30 % of HTNsives in INDIA
 HOW TO DIFFERENTIATE ?
 BIOPSY OF LIVER

11. PATHOPHYSIOOGY OF BLEED
 Damage to varices vs increased pressure ?
 Varices don’t bleed before 12 mm Hg
 BUT REMEMBER………. Not all those
above 12 mm Hg would bleed !!

12. REASONS FOR INCREASED PORTAL PRESSURE
 Pre hepatic
 Post hepatic
 Hepatic
 Our concern is hepatic………i.e……….
cirrhosis

13. CIRRHOSIS
 Damaged architecture is not all causing
portal htn
 Its more than that
 It’s the vasodynamics
Dilator (NO)--------------- Constrictors
 Result HTN

14. IN SPLANCHNIC CIRCULATION….!
 NO increases !!! due to local regulation
 And thus causes increased flow in portal vein
 So increased flow plus constriction of portal vein causes htn
 GUESS: WHY WE USE BETA BLOCKERS TO TREAT PORTAL
HTN ?
 ANS: to constrict splanchnic vessels and reduce the flow into the
portal…….
 Same is the mechanism of vasopressin, terlipressin,
somatostatins.

15. PRECAUTION
 Don’t give Isosorbide mononitrate
 Alpha agonists (prazosin or clonidine)
 Anti endothelins
 WHY???
 Dilators
 If necessary,,,, give with beta blockers

16. WHEN TO INTERVENE
 When varices are more than 5 mm diameter
 For Indefinite time
 OR BAND LIGATE

17. WHAT TO DO IN CASE OF ACTIVE BLEED ??
 Drugs or Endoscopy ?
 Drugs are safer to start with. No
specialization is required.
 TIPS is life saving for child class C……
 But only child pugh <8 can undergo surgery

18. TECHNIQUE
 HEPATIC CATH……
 Difference between
 Wedge pressure (WHVP) and free
pressure(FHVP) of hepatic vein
 Called as hepatic venous pressure gradient (
HVPG)

19. POINT TO PONDER
 ONCE BLEED………………. IS an indication
for liver transplant

20. SAVE YOUR LIVER
 Discard the syringes
 Beware of needles