Portal hypertension

The symptoms of portal hypertension include:

• Ascites: Accumulation of fluid in the abdomen.
• Variceal bleeding: Large veins in the oesophagus or stomach can rupture, leading to excessive bleeding.
• Splenomegaly: Enlarged spleen due to blood pooling.
• Hepatic encephalopathy: Confusion or altered level of consciousness due to toxins in the brain (often a result of liver failure); sometimes, the patient might also slip into a coma.
• Caput medusae: Visible distended veins on the abdomen.
• Portal system collaterals: Development of new blood vessels to bypass blocked areas, which can lead to abnormal blood flow.
• Fatigue and weakness: Liver dysfunction and decreased blood flow to vital organs can result in fatigue and weakness.

Portal hypertension can be diagnosed using the following modalities:

• Physical examination: Enlarged spleen (splenomegaly), ascites, or abdominal veins visible.
• Blood tests:
  • Liver function tests to assess liver damage.
  • Complete blood count (CBC) to look for anaemia or signs of bleeding.
• Imaging:
  • Ultrasound to detect ascites, enlarged spleen (splenomegaly), and assess liver structure.
  • CT or MRI to visualise liver damage and hepatic blood flow.
  • Endoscopy to detect oesophageal or gastric varices (dilated blood vessels at risk of bleeding).
  • Endoscopic ultrasound to assess the portal vein and surrounding structures.
• Portal pressure measurement: Hepatic venous pressure gradient (HVPG) is the most accurate test for confirming portal hypertension (measuring the pressure in the portal vein).
• Liver biopsy: This can confirm liver cirrhosis or other liver conditions.

• Medical management:
  • Beta blockers: Medications like propranolol or nadolol are used to lower portal pressure and prevent variceal bleeding.
  • Diuretics: They are used to manage ascites by removing excess fluid from the body.
  • Antibiotics: They are used to prevent infections in patients with cirrhosis, especially if ascites is present.
  • Lactulose or rifaximin: They are used to manage hepatic encephalopathy as they reduce toxins in the blood that affect brain function.
• Endoscopic treatment:
  • Endoscopic band ligation (EBL): This modality is used to prevent or treat oesophageal variceal bleeding; it involves placing rubber bands around the varices to stop bleeding.
  • Sclerotherapy: This involves injecting a sclerosing agent (irritant that has the ability to damage the endothelial layer of blood vessels) into varices to reduce bleeding risk.
• Surgical treatment:
  • Transjugular intrahepatic portosystemic shunt (TIPS): In this procedure, a stent is placed in the liver to divert blood flow, thereby reducing portal pressure.
  • Liver transplantation: This intervention is used in cases of severe cirrhosis or liver failure where other treatments are not effective.
• Lifestyle and diet:
  • Low-salt diet: To reduce fluid retention and manage ascites.
  • Avoidance of alcohol: Crucial to prevent worsening liver damage.
• Managing the underlying liver disease: Addressing (managing) conditions like hepatitis or N/AFLD.
• Managing complications of portal hypertension: Complications of portal hypertension, such as variceal bleeding (a potentially life-threatening complication where the dilated veins in the oesophagus or stomach rupture), ascites (fluid build-up in the abdomen, which can lead to infection (spontaneous bacterial peritonitis) or kidney failure), hepatic encephalopathy (altered brain function due to accumulation of liver toxins in the bloodstream), and portal vein thrombosis (a blood clot in the portal vein), should be managed to ensure a good quality-of-life for the patient.