This document provides information on portal hypertension. It begins by defining portal hypertension and describing the anatomy of the portal vein system. It then discusses the causes of portal hypertension including prehepatic causes like extrahepatic portal vein obstruction (EHPVO) and non-cirrhotic portal fibrosis (NCPF), hepatic causes like cirrhosis and posthepatic causes like sinistral portal hypertension. It describes the clinical presentation of portal hypertension including variceal bleeding. It provides details on the management of acute variceal bleeding and long term treatment options for portal hypertension including pharmacotherapy, TIPS procedure, shunt operations and liver transplantation.

1. P O R TA L H Y P E R T E N S I O N
D R V I P I N V N A I R M B B S , M S ,
M C H
P L A S T I C S U R G E O N A F M C P U N E

2. P O R T A L
S Y S Y T E M

3. P O R T A L
V E I N
A N A T O M Y

4. PORTAL
HYPERTENSION
P O R TA L V E N O U S P R E S S U R E > 5
M M H G
C O L L AT E R A L S > 1 0 M M H G
B L E E D I N G > 1 2 M M H G

5. C A U S E S O F
P O R TA L
H Y P E R T E N S I
O N

6. P R E H E PAT I C
C A U S E S
•EHPVO
•NCPF

7. P R E H E P A T I
C C A U S E S
EHPV
O

8. H E PAT I C
C A U S E S

11. Portal
hypertension
Loss of cell mass -
hepatocellular failure
Hepatocellular
necrosis - fibrosis &
nodular
regeneration
Increased hepatic
vascular resistance

12. P O S T H E P A T I C C A U S E S

13. S I N I S T R A L P O R TA L
H Y P E R T E N S I O N

14. C L I N I C A L
P R E S E N TAT I O N

18. B L E E D I N G
ESOPHAGEAL
VARICES 80 %
GASTRIC VARICES
20 %

19. EXPLOSION
THEORY
EROSION
THEORY
T H E O R I E S F O R VA R I C E A L B L E E D

27. S I G N S O F C H R O N I C L I V E R
FA I L U R E

30. Complete hemogram
LFT
Coagulation Profile
Viral Markers

31. I M A G I N G

34. T R E AT M E N T

35. Hemodynamic stabilization
- PT
- Platelets
- Electrolytes
- Creatinine
I M M E D I AT E M A N A G E M E N T

36. P H A R M A C O T H E R A
P Y
Splanchnic vasoconstrictors
Vasopressin
(hypertension, bradycardia, decreased
cardiac output, coronary vasoconstriction)
Tx combined with nitroglycerin
Glypressin – terlipressin
Somatostatin - octreotide

37. B A L L O O N
TA M P O N A D E
Sengstaken – Blakemore tube

38. P O R TA L
B L O O D
Cerebral toxins - ammonia
bypass of the liver prevents
inactivation
Hepatotrophic elements – insulin
diversion causes atrophy

39. E N C E P H A L O PAT H Y
neomycin –
suppresses urease containing
bacteria
lactulose –
acidifies colonic contents
cathartic effect

40. I M M E D I AT E M A N A G E M E N T
Endoscopy
- Diagnostic
- Therapeutic

41. E N D O S C O P I C
T R E AT M E N T
Variceal sclerosis – sclerotherapy
Variceal ligation – banding
control of bleeding – 85 %

43. F U R T H E R
T R E AT M E N T
Rebleeding – 70 %
Options
Pharmacotherapy – propranolol
Repeat endoscopic therapy
TIPS
Porto -systemic shunt operations
Devascularization procedures
Liver transplantation

44. P O R T O S Y S T E M
I C S H U N T S
Effective
decompression of
portal system
Effective in preventing
recurrent bleeding
Diversion of portal
blood
Encephalopathy

45. S U R G I C A
L
S H U N T S

46. H E PAT I C F U N C T I O N A L R E S E R V E
Child’s classification
A B C
albumin (g/dl) > 3.5 3 – 3.5 < 3
bilirubin (mg/dl) < 2 2 – 3 > 3
ascites none mild moderate
encephalopathy none minimal marked
nutritional state excellent good poor

47. T I P S

48. N O N S E L E C T I V E S H U N T S
• ECK’S FISTULA

49. O T H E R N O N S E L E C T I V E
S H U N T S

50. S E L E C T I V
E S H U N T S
D I S T A L
S P L E N O -
R E N A L
( W A R R E N
S H U N T )

51. D E VA S C U L A R I Z AT I O N
P R O C E D U R E S
Transection & Re-
anastomosis

55. TA K E H O M E M E S S A G E
• First level treatment
• Dietary and lifestyle changes
• Do not use alcohol or street
drugs.
• Low -sodium (salt) diet.
• Endoscopic therapy or
medications
• Second level of treatment
• Decompression procedures
• Devascularisation
• Liver transplant
• Paracentesis

56. M U L T I P L E
C H O I C E
Q U E S T I O N
S

58. C O N G E S T I
V E
C A R D I A C
F A I L U R E

60. S Y S T E M I C VA S O D I L ATAT I O N
T H E O R Y

62. S E V E R E H E PAT I C I N S U F F I C I E N C Y

64. A C U T E PA I N
A N D F E V E R

66. N A D A L O L

68. O C T E R O T I D E

69. H I G H E R
O R D E R
T H I N K I N G
Q U E S T I O N
S