Portal hypertension occurs when blood flow through the portal vein is obstructed, causing the portal pressure to increase above normal levels. This leads to the formation of collateral veins that allow blood to bypass the liver. Clinical signs include abdominal swelling, variceal bleeding, and anemia. Investigation involves blood tests, imaging, and endoscopy. Management depends on the underlying cause and can include medical therapy with beta-blockers, endoscopic variceal banding, transjugular intrahepatic portosystemic shunting (TIPS), and surgery such as shunt procedures. The only definitive treatment is liver transplantation.

1. PORTAL HYPERTENSION
Dr Winston Makanga, M.B.Ch.B., M.Med. (Surg)
Consultant General and Laparoscopic Surgeon

2. Outline
• Introduction and definition
• Pathogenesis
• Presentation
• Investigation
• Management

3. Introduction & definition
• Normal portal pressure – 5-6mmHg
• Portal HTN >12mmHg
• Resistance to flow through the portal vascular system
• ?Increase in blood flow through the portal system

4. Normal porto-venous circulation

6. Pathology
• 1.5L/min flows through the portal vein
• Obstruction to this flow increases the portal pressure
• Reversal of flow in the coronary vein
• Reopening of previously obliterated shunts
• Increase in caliber of previously low flow collateral veins
• Decreased reabsorption of peritoneal fluid
• Splenomegaly due to increased pressure/flow

7. Portal hypertension

8. Pathogenesis
• Risk of bleeding through ruptured esophageal varices
• Morbidity of ascites
• Bypassing the liver results in toxins getting into the systemic
circulation
• ?Hemorrhoidal disease

9. Etiology

11. Clinical assessment
• History: hematemesis, melaena stool, abdominal swelling, symptoms
of anemia
• General signs of liver disease
• Jaundice, finger clubbing, hair redistribution, spider naevi, testicular atrophy,
edema, palmar erythema, Duputryen’s contracture, encephalopathy
• Abdominal – Ascites, hepatomegaly, splenomegaly, caput
Multifactorial

12. Investigation
• Hemogram (hypersplenism and CLD)
• LFTs
• UEC
• Abdominal imaging (ultrasound and CT scan)
• Wedge portal pressure measurement
• Endoscopy (red wale, sherry red, hematocystic spots, G3 varices)

13. Management
• Variceal bleeding
• Hypersplenism
• Ascites

14. Variceal bleeding
• Primary prophylaxis vs prevention of recurrence
• Medical treatment
• Beta blockers – propranolol
• Endoscopic
• Variceal banding
• Variceal injection sclerotherapy
• Surgical/shunting
• Central/peripheral porto-venous shunting
• Interventional radiology
• Transjugular intrahepatic porto-venous shunting (TIPS)

15. Banding

16. Transjugular intrahepatic porto-systemic shunt (TIPS)

17. Surgical shunting

18. Emergency treatment of variceal bleeding
• Resuscitate with fluids and blood products
• Vasopressin
• Octreotide
• Beta blockers
• Balloon tamponade - Sengstaken-Blakemore tube
• Emergency banding/sclerotherapy

19. Balloon tamponade

20. Hypersplenism and splenomegaly
• Splenectomy (with other shunting procedure)
• Manage primary liver disease
• Paracentesis
• Shunting procedures
Ascites

21. Liver transplant is the only
true definitive management

22. Review
• Definitions
• Normal porto-venous circulation and pathogenesis of pHTN
• Etiology
• Clinical evaluation
• Investigation
• Management (symptomatic, emergency, definitive)

23. Thank you