Treatments for portal hypertension

Portal hypertension is a condition where there is increased pressure in the major blood vessel carrying blood from the digestive system and spleen to the liver. There can be a variety of causes including blood clots or cirrhosis of the liver, and a variety of complications, including ascites (fluid in the abdomen) and varices (dilated veins in the oesophagus or stomach caused by backed up pressure).

Preventative (primary) treatments for portal hypertension

Portal hypertension is treated by trying to reduce portal vein blood pressure so that the formation of new varices and the build-up of ascites are prevented as far as possible. It can be difficult to maintain a reduction in portal blood pressure, but it is often possible to reduce the risk and severity of internal bleeding.

Drug therapy usually includes beta-blockers, which reduce blood flow to the portal vein and so decrease portal hypertension. Beta-blocker therapy also lowers the risk of internal bleeding from any varices that have formed. These can be given in tablet form to prevent the varices from bleeding in the long-term.

Endoscopic, minimally invasive techniques are also used to seal off bleeding vessels. This can be done as an emergency, but is also done in the non-emergency situation to prevent varices from bleeding in the future.

Endoscopic banding is now the most common treatment of choice in most countries. A rubber band is introduced to seal any bleeding vessels or those at high risk of bleeding near the top of the stomach via an endoscope which is passed down through the oesophagus. Endoscopic sclerotherapy in which a sclerosing agent is injected directly into an enlarged blood vessel to seal it off to prevent bleeding can also be used in cases of active bleeding.

Emergency treatment for bleeding varices (the swollen veins around the oesophagus) often involves a blood transfusion while the source of the bleeding can be identified. Treatment of the underlying portal hypertension is then continued. Drugs that can be used to reduce the blood flow to the varices include Terlipressin (Glypressin®) or Octreotide in an emergency situation. These are given by direct injection into a vein. Endoscopic treatments to reduce the size of the varices or to obliterate them are also used in an emergency situation (see below).

Shunts to treat portal hypertension

Portal hypertension can also be treated successfully using a shunt inside the body to re-route blood.

A Transjugular Intrahepatic Portosystemic Shunt (TIPS) can be placed in the liver using a curved catheter that is introduced through the skin. The shunt connects the portal vein directly to one of the hepatic veins, allowing blood to bypass the liver to lower portal hypertension. Usually inserted by a radiologist, it reduces blood pressure in all affected veins and is used to treat ascites, and oesophageal and gastric varices that have not responded to other treatments.

Not all experts are convinced that TIPS is effective in all patients with portal hypertension, particularly because over time, shunts can block off if patients are not kept under regular review with ultrasound examinations every few months to ensure that the shunts are still in place.

In some extreme cases portal hypertension may be an indication for liver transplantation.

Trade names quoted are given as examples only of the drug types described, alternatives may be available.

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