Portal Hypertension

• • Etiologies include:

  • -Cirrhosis

    -Congenital hepatic fibrotic disorders

    -Acute liver failure

    -Budd-Chiari syndrome

    -Heart failure

    -Congenital atresia

    -Portal or splanchnic vein thrombosis

  • Bleeding gastroesophageal varices most important complication

  • 30% bleed

  • 50% mortality for those who bleed

  • 30% re-bleed in 6 weeks

  • 70% re-bleed in 1 year

  • Bleeding most commonly from esophageal varices

  • 10-15% have associated gastric varices

  • Presence of varices related to degree of liver dysfunction

  • Portal vein-hepatic vein gradient invariably > 12 mm Hg

Epidemiology

• • Most patients with history of cirrhosis

  • Presenting symptom of cirrhosis in many patients

Symptoms and Signs

• • Hematemesis

  • Melena

  • Jaundice

  • Encephalopathy

  • Distended abdominal wall veins (caput medusa)

  • Ascites

  • Edema

  • Shock

  • Palmar erythema

Laboratory Findings

• • Hyperbilirubinemia

  • Elevated international normalized ratio (INR)

  • Anemia

  • Azotemia

Imaging Findings

• • CT scan: Dilated venous collaterals, possible venous thrombosis (hepatic, portal, superior mesenteric vein, splenic, etc.)

  • US: Dilated portal vein, possible thrombosis of portal vein or hepatic veins

  • Mesenteric venography: Dilated collaterals, thrombi, or blush from bleeding

  • Hepato-portal venography: Wedge pressure generally > 12 mm Hg in presence of varices

  • Esophagogastroscopy for diagnosis of varices and possible sclerotherapy

• • Presence of thrombi

  • Childs classification or Model of End-Stage Liver Disease (MELD) to determine transjugular intrahepatic portosystemic shunt (TIPS) vs surgical shunt

  • Mesenteric venography if diagnoses other than cirrhosis being considered (eg, Budd-Chiari syndrome or portal vein thrombosis)

Rule Out

• • Other sources of upper GI bleeding using esophagogastroscopy

• • ABCs if patient has upper GI bleeding

  • Assessment of MELD or Child class

  • Assessment of underlying etiology

  • Early gastroesophagoscopy for banding or sclerotherapy

  • Octreotide to control bleeding

  • Blood products as necessary

  • Invasive monitoring as necessary

  • Sengstaken-Blakemore tube if necessary

  • Portal venography if diagnosis in doubt or patient is a candidate for surgical shunt

When to Admit

• • All patients with bleeding varices

• • Sclerotherapy or banding of varices

  • TIPS

  • Sengstaken-Blakemore tube placement

Surgery

• • Liver transplantation

  • Surgical portosystemic shunt (TIPS vs total vs partial vs selective)

  • Gastric devascularization (Segura)

Indications

• • Liver transplantation: Availability of donor, no medical comorbidities, not currently drinking alcohol

  • Surgical shunt: Childs A failed endoscopic therapy elective (selective) or emergent (partial)

  • Gastric devascularization: Gastric varices and failed endoscopic therapy

Medications

• • β-Blockers

  • Nitrates

  • Vasopressin (during bleeding)

  • Octreotide (during bleeding)

Treatment Monitoring

• • Repeat gastroesophagoscopy for suspicion of bleeding

  • Duplex US for suspicion of shunt ...