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Portal Hypertension and Oesophageal Varices

1. PORTAL HYPERTENSION

  • Defined as sustained elevation of portal pressure above 12mmHg (normal is 8-12mmHg)

Etiology

Presinusoidal

  • Sinistral/extrahepatic
    • Splenic vein thrombosis
    • Splenomegaly
  • Intrahepatic
    • Schistosomiasis
    • Congenital hepatic fibrosis
    • Myeloproliferative disorder

Sinusoidal – cirrhotic

  • Viral hepatitis
  • Alcohol abuse
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis

Postsinusoidal

  • Intrahepatic
    • Vascular occlusive disease
  • Posthepatic
    • Budd-Chiari syndrome
    • Congestive heart failure

Pathophysiology

  • The portal venous system drains blood from the spleen, pancreas, gallbladder and abdominal portion of the GIT into the liver sinusoids
  • Tributaries from the portal vein communicate with veins draining directly into the systemic circulation via portosystemic collaterals
  • At normal portal vein pressure (5-10mmHg), little amount of blood is shunted from the portal venous circulation to systemic circulation
  • A rise in portal venous pressure causes the portosystemic collaterals to dilate – so a large amount of blood can be shunted around the liver and into the systemic circulation
Sites of portosystemic collaterals  

 

  • Gastro-oesophageal – left gastric and short gastric veins anastomose with azygous vein
    • Leads to oesophageal varices
  • Umbilical – paraumbilical vein anastomosis with anterior abdominal vein
    • Leads to caput medusae
  • Anorectal – superior rectal vein anastomosis with middle and inferior rectal vein
    • Leads to anorectal varices
  • Retroperitoneal

Clinical features

  • Classical triad – oesophageal varices, splenomegaly, acites
    • Splenomegaly leads to functional hypersplenism – leukopenia, thrombocytopenia, anemia
  • Caput medusae – appearance of distended and engorged paraumbilical veins, seen radiating from the umbilicus
  • Anorectal varices
  • Jaundice
  • Encephalopathy
  • Recurrent infections

Investigations

  • Liver function test
  • Ultrasound – dilated portal vein, collateral pathways
  • Doppler US – to outline anatomy of the portal vein, establish direction of blood flow, exclude thrombosis
  • CT/MRI – shows collateral pathways, splenomegaly, ascites
  • Hepatic venous pressure gradient (HVPG) – balloon catheter is placed directly into the hepatic vein
    • Free hepatic venous pressure (FHVP) is measured with the balloon deflated
    • Wedged hepatic venous pressure (WHVP) is measured with the balloon inflated
    • HVPG = WHVP – FHVP
    • HVPG >10mmHg means there is clinically significant portal hypertension

Treatment

General measures

  • Correct anemia
  • Nutritional supplementation
  • Vitamin K injection

Specific measures

  • Treatment of oesophageal varices – see below
  • Prevention of hepatic encephalopathy – lactulose, enema, antibiotics
  • Treatment of ascites – diuretics, paracentesis, TIPS

Measures to reduce portal pressure

  • Transjugular intrahepatic portosystemic shunt (TIPS) – stent to establish communication between the inflow portal vein and the outflow hepatic vein
  • Surgical portocaval shunt – less common because of TIPS
  • Drugs – propanolol, nadolol

Liver transplant

  • Best option for patients with end stage liver disease

2. OESOPHAGEAL VARICES

Etiology

  • Dilated and tortuous submucosal veins in the lower third of the oesophagus, most commonly due to portal hypertension
  • Occur in 50% of patients with portal hypertension, especially in those with cirrhosis

Clinical features

  • Patients are usually asymptomatic until a variceal haemorrhage
  • Variceal haemorrhage – features of upper GI bleed
    • Hematemesis
    • Melena
  • Syncope

Complications

  • Hypovolemic shock
  • Cardiac arrest

Investigations

  • Oesophagogastroduodenoscopy – gold standard
  • XR and barium swallow
  • CT/MRI

Treatment

Emergency management in severe haemorrhage

  • Drugs
    • Vasopressin injection
    • Somatostatin – reduces sphlanchnic and hepatic blood flow
    • Propanolol = decreases portal pressure
  • Endoscopic variceal banding (EVB) – gold standard
    • Banded varices thrombose and slough off
  • Endoscopic variceal sclerotherapy (EVS)
    • Sclerosants (ethanolamine oleate, STDS) are injected into the varices
    • ‘Seals’ off varices by vessel thrombosis, ulceration and submucosal fibrosis
    • Procedure is done weekly for 6-8 weeks until varices are obliterated
  • Balloon tamponade – with a Sengstaken-Blakemore tube

    • Gastric balloon is inflated to compress the GOJ, later the oesophageal balloon is inflated
    • Oesophageal balloon should not be inflated for over 6 hours to avoid necrosis
    • Complications – aspiration, airway obstruction, oesophageal perforation

Definitive management

  • TIPS
  • Surgical portocaval shunt
  • Splenectomy – for sinistral portal hypertension
  • Liver transplant
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