Portal hypertension

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Portal hypertension

• By
• Prof. Dr. Aliaa Aly El Aghoury
• Professor of Internal Medicine
• Endocrinology Unit
• Faculty of Medicine, Alex. University

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Definition

• Is the prolonged elevation of the portal venous
  pressure above 12 mmHg.
• N.B. Normal portal venous pressure is 2-5 mmHg.

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Etiology pathogenesis

• Portal venous pressure is determined by
• Portal blood flow.
• Portal vascular resistance.

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• N.B.
• ? vascular resistance is usually the main factor
  producing portal hypertension irrespective of its
  cause. Therefore the causes of portal
  hypertension are classified according to the main
  sites of obstruction to blood flow in the portal
  venous system.

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Causes of portal hypertension

• Extrahepatic postsinusoidal e.g. Budd-chiari
  syndrome.
• Intrahepatic postsinusoidal e.g. veno-occlusive
  disease.
• Sinusoidal cirrhosis, metastasis.
• Intrahepatic presinusoidal schistosomiasis-
  drugs.
• Extrahepatic presinusoidal
• portal vein thrombosis.
• Abdominal trauma including surgery.
• Malignant disease of pancreas or liver.
• Pancreatitis.

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• N.B.
• Cirrhosis causes 90 of portal hypertension in
  adults in developed countries.

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• ? Portal vascular resistance leads to ? in the
  flow of portal blood of the liver the
  development of collateral vessels that allow
  portal blood to bypass the liver and enter the
  systemic circulation directly.
• Collateral vessel formation is particularly in
  the gastrointestinal tract especially the
  esophagus, stomach, and rectum in the anterior
  abdominal wall.

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Clinical picture

• Splenomegaly is the cardinal sign for diagnosis.
• Hypersplenism is common cause thrombocytopenia.
• Collateral vessel may be visible on the anterior
  abdominal wall occasionally radiate from the
  umbilicus to form caput medusae.
• Fetor hepaticus results from Porto-systemic
  shunting of blood which allows mercaptans to pass
  directly to the lungs.

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Investigations

1. Radiological endoscopic examination of the
   upper GIT can show varices.
2. Ultrasonogrphy.
3. Portal venography demonstrate the site and the
   cause of portal venous obstruction.

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Complications

1. Variceal bleeding (esophageal, gastric).
2. Congestive gastropathy.
3. Hypersplenism.
4. Ascites.
5. Renal failure.
6. Hepatic encephalopathy.

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• N.B.
• Variceal bleeding occurs from esophageal varices
  that are usually located with in 3-5 cm of the
  esophagogastric junction or from gastric varices.
• Variceal bleeding is often severe and recurrent
  bleeding occurs if preventive treatment is not
  given.
• The mortality from bleeding esophageal varices is
  high ( up to 50 in those with advanced liver
  disease.)

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Management

• Management of acute variceal bleeding
• Local measures include
• Endoscopic therapy (banding or sclerotherapy).
• Balloon tamponade this technique employs a
  Sengstakein Blakemore tube possessing 2 balloons
  which exerts pressure in the fundus of the
  stomach and in the lower esophagus respectively.
• Esophageal transaction transaction of the
  varices by stapling gun.

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• Pharmacological treatment
• Terlipressin is the current drug of choice used.
• Octreotide the synthetic form of somatostatin.

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• Prevention of recurrent bleeding
• Band ligation.
• Sclerotherapy.
• Porto-systemic shunt surgery

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• Thank you