Portal Hypertension

Complications

• Hepatic encephalopathy ensues because suffcient blood is no longer being detoxified by the liver (and the liver is usually diseased to begin with.) Ammonium levels increase. Sx: asterixis (wrist flap), confusion, psychiatric changes, lethargy, coma

• Splenomegaly occurs as a direct result of increased venous pressure.

• Ascites occurs due to increased hydrostatic pressure in the abdominal circulation. This fluid is pushed into the peritoneal space.

• Malnutrition may co-present with portal hypertension as a symptom of liver disease.

• Hemorrhoids occur as a direct result of increased venous pressure.

• GI bleeding, namely from esophageal varices, occurs because blood is shunted through the esophageal veins. These can rupture and result in massive hematemesis. Gastric or rectal varices may form, too.

Management

• non-selective β-blockers (propanolol, nadolol) decrease risk of bleeding from varices

• transjugular intrahepatic portosystemic shunt (TIPS): to ↓ portal venous pressure

  • shunt between portal and hepatic vein via transjugular vein catheterization and percutaneous puncture of portal vein

  • can be used to stop acute bleeding or prevent rebleeding or treat ascites

  • shunt usually remains open for <1 yr

  • complications: hepatic encephalopathy, deterioration of hepatic function

  • contraindicated with severe liver dysfunction

  • most commonly used as a "bridge" to liver transplant

• other surgically created shunts (rare): portacaval, distal spleno-renal (Warren shunt)