Portal Hypertension

Definition : Portal venous pressure > 7mmHg Clinical features & complications usually occur after pressure > 12mmHg

Clinical features

1.Hematemesis (esophagus or gastric- variceal bleeding)

2. 3. 4. 5. 6. Ascites Splenomegaly Abdominal collaterals (caput medusae) Fetor hepaticus Other clinical features of the etiology of portal HT

Investigations
*** diagnosis of portal HT often made on clinical grounds***
(supportive investigations) 1. Upper GI endoscopy for varices 2. Ultrasound 3. FBC -thrombocytopenia (due to hypersplenism) -leucopenia -anemia (due to bleeding) 4. Wedged hepatic venous pressure 5. CT/MRI

Case Study
Mr John, a 62 y/o accountant, has had a "drinking problem" throughout most of his adult life. He drinks 4 large bottles of beer each day. He was rushed to the emergency room with severe vomiting of bright red blood. The bleeding and vomiting started abruptly while he was eating some hard, dry French bread. On examination, he had a blood pressure of 60 mmHg / 30 mmHg.

Patient Assessment Quick history of previous bleed and etiology

NSAID, antiplatelet and warfarin usage Also enquire about alcohol intake/forceful retching, hep B/C history and renal failure

Look for signs of shock:

Agitation, cold clammy peripheries, Tachycardia, postural hypotension **presence of shock indicates >40% blood loss

 Look for features of chronic liver disease or decompensation

Spider naevi Splenomegaly Ascites

Clinical features of chronic liver disease

Compensated 1) Jaundice 2) Bleeding tendency 3) Palmar erythema (maybe) 4) Flapping tremor (maybe) 5) Parotid swelling (maybe) 6) Gynecomastia, reduced axillary hair pubic hair in male (maybe) 7) Breast atrophy in female (maybe) 1) 2) 3) 4) 5) 6) Decompensated Bleeding varices Spider naevi Splenomegaly Ascites Encephalopathy Fetor hepaticus

Resuscitation and investigation Insert 2 large bore cannulae, one on each arm(16G) Draw 20ml of blood to test for
Cross match 2-4 units of whole blood/packed cells LFT, Clotting profile prothrombin time FBC BUSE & Creatinine Glucose level

 Supplemental O2 to keep O2 saturation above 90%

Fluid resuscitation can be commenced with rapid colloid infusion if systolic BP < 100 mmHg. Crystalloid solution if not in shock.

Blood transfusion (whole blood, platelet, FPP, packed cell) should be given if:
Systolic BP < 100mmHg Persistant tachycardia (110/min) Significant postural hypotension Hb < 8/dl or haematocrit of 24%.

Interventional Therapy Endoscopic variceal ligation-preferred Endoscopic therapy if EVL difficulty **risk of perforation, bleeding/ulceration and stricture Balloon tamponade using SengstakenBlakemore tube if endoscopic treatment fails or unavailable.

 Transjugular Intrahepatic Portosystemic Shunts (TIPS) is the treatment modality when bleeding is not responsive to endoscopic and pharmacological treatment.

Pharmacologic Therapy Terlipressin given as 2mg IV bolus and then 12mg 4-6 hourly until bleeding is controlled up to 24-48 hr Somatostatin infusion at 250ug/hr can be given after a bolus of 250ug IV and continued for 5 days Alternatively, octreotide can be infused at 2550 ug/hr for 5 days after a loading dose of 50ug.

 Short-term antibiotic prophylaxis for 7 days irrespective of the type of haemorrhage (variceal or non-variceal) or the presence or absence of ascites Third generation cephalosporins (cefoperazone, ceftazidime) given intravenously or oral quinolones (norfloxacin/ciprofloxacin) are generally recommended.

Primary prophylaxis
40-80mg of Propanolol

*treatment with propanolol reduces variceal bleeding by 47%, death from bleeding
by 45% and overall mortality by 22% (Hayes PC, et al. Lancet 1990; 336:153 156)

Secondary Prophylaxis Start propanolol(if no contraindication) at 20mg and increase to 40-80mg TDS until resting HR is reduced by 25% to reduce portal venous pressure. Further endoscopic banding or injection sclerotherapy until varices are obliterated Referral for liver transplant

Variceal Bleeding
25-35% of the cirrhosis 30% of initial bleed is fatal 70%of survival will have recurrent bleed Key management -prevention
NEJM1988;319

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Congestive Gastropathy
Long standing PHT causes chronic gastric congestion Recognizable at endoscopy multiple areas of punctate erythema (snake skin gastropathy) May cause bleeding from multiple sites (minor bleeding) causing anemia

***** prevent anemia by oral iron

supplements

Ascites
Pathological accumulation of fluid in the peritoneal cavity (normal people have a small amount of peritoneal fluid) Causes of ascites is based on Serum-ascitic albumin gradient (SAAG) which correlates directly with portal pressure.

Causes of Ascites
High gradient (SAAG = or > 1.1g/dL) Cirrhosis (Portal HPT)
Alcoholic hepatitis Cardiac failure Budd-Chiari syndrome Fulminant hepatic failure

Low gradient (SAAG < 1.1g/dL) Nephrotic syndrome Peritoneal carcinomatosis

Peritoneal tuberculosis Serositis Pancreatic/ Biliary ascites

Pathogenesis
Cirrhosis

Treatment
Transplant

Portal hypertension

TIPS

Arteriolar dilatation

Systemic vasoconstrictors

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Decreased effective blood volume

PVS, TIPS

Activation of neurohumoral systems

Sodium restriction & Diuretics Paracentesis, PVS

Sodium and water retention

Ascites

Management of Ascites

Ascites Sodium restriction Sodium 1.5-2gm/day

Diuretic therapy Spironolactone & frusemide Refractory ascites

1st line therapy

2nd line therapy

3rd line therapy

Investigational therapy

LVP plus Albumin

TIPS

Peritoneal Venous Shunt

LVP plus vasoconstrictor

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Algorithm of Ascites management

Treatment
(1) Sodium and water restriction <100mmol/day (1.5 2g) no added salt diet Restrict water to 1 -1.5L/day (2) Diuretics Spironolactone 100 -400mg/day (caution: may cause painful gynaecomastia and hyperkalemia) Frusemide up to 160mg

(3) Large Volume Paracentesis (LVP) with IV albumin replacement

If ascites is refractory (up to 3 5L daily is safe) Supported by an IV colloid such as human albumin (6-8g/L of ascites removed)

(4) Peritoneal venous Shunt (PVS) Rare, indicated in ascites resistant to conventional treatment Complications: infection, SVC thrombosis, pulmonary oedema, bleeding from oesophageal varices and DIVC.
(5) Transjugular intrahepatic portosystemic shunt (TIPSS)