What is Portal Hypertension?

Portal hypertension is one of the main consequences of chronic liver disease. The portal vein is the main vein that carries nutrient rich blood from the bowel, pancreas and spleen to the liver. The pressure of blood in this vein may rise because of a blockage, such as a blood clot, or more commonly because the flow of blood through the liver is restricted due to scarring (fibrosis) or cirrhosis. This elevated blood pressure is abnormal and is called portal hypertension.

As a result of portal hypertension, blood in the portal vein has to find another route back to the heart. To do this, tiny, naturally occurring blood vessels become swollen forming abnormally large vessels called varices. Varices that run along the lining of the stomach and in the lower end of the oesophagus can protrude and bleed internally into the gut. Bleeding may be a slow ooze, in which case anaemia can occur, but it is often acute and brisk.

A person may thus present with a major haemorrhage, either vomiting up fresh blood or passing a large amount of blood through their bowels. This blood may give the stool a black colour, since it is altered as it passes through the intestines. This is termed melaena.

Portal hypertension also causes the body to alter the way it processes salt and water. Through a variety of complex mechanisms, a buildup of fluid can occur. Most commonly fluid accumulates in the abdomen, and this is called ascites. It can also accumulate in other areas such as the lower legs.

Prevention of bleeding from varices

Not everyone with cirrhosis has varices and not all varices will necessarily bleed. The risk of bleeding from varices relates in part to how big they are. In general, small varices rarely bleed but varices may grow in size over time. It is thus important to perform an endoscopy of the oesophagus and stomach to look for varices in anyone with a new diagnosis of cirrhosis, and important to survey for varices in those people with established cirrhosis at time intervals of between 1-2 years.

Treatment of varices

Patients identified with varices may be commenced on medication called beta-blockers to reduce the risk of their bleedings. Commonly used beta-blockers include propranolol and carvediolol. Varices may also be treated at the time of endoscopy to reduce the risk of future bleeding.

Active bleeding from varices is a medical emergency and patients require immediate admission to hospital. After a period of stabilization, patients will usually undergo an endoscopy under sedation or anaesthesia to locate and treat the source of bleeding. This can involve the application of a tiny device on the bleeding varix, called ‘banding’, to stop it bleeding and shrink its size, or an injection of a type of biological ‘glue’ to cause the blood flow in the varix to clot. In this scenario, further endoscopies are likely to be required over the following weeks to reduce the risk of further bleeding episodes.

Management of fluid retention

The development of ascites or fluid retention is the most common complication of cirrhosis. Patients will be advised on their diet to reduce the tendency to accumulate fluid, primarily looking at a reduction in salt intake.

Medication can be given to reduce fluid retention. These medicines are called diuretics and commonly used ones are spironolactone and furosemide. They stimulate the body to get rid of extra salt and fluid via the kidneys. Patients who are started on diuretic medication require regular blood tests to monitor that the dosage is correct and that side effects are not occurring.

In some patients the rate of accumulation of fluid in the abdomen (ascites) is such that the most practical short-term option is to insert a small drain into the abdomen through the skin to allow the fluid to come out over a period of 4-6hrs. This is a straightforward procedure performed under local anaesthetic and is usually arranged on a daycase basis.

Trans-jugular Intrahepatic Portal Systemic Shunt (TIPPS)

This technique is usually carried out by an interventional radiologist. In this procedure, a metal stent (tube) is inserted into the liver of a patient with cirrhosis to allow blood to flow directly from the portal vein to the hepatic vein and so bypass the high resistance to blood flow through the scarred liver. This reduces portal hypertension. The procedure is performed under general anaesthesia and access to the liver is obtained via the main vein in the neck, the jugular vein, without needing to make a surgical incision in the skin.

TIPSS can be performed to help manage ascites that is difficult to control with diet and medication. It is also occasionally performed as an emergency procedure to stop bleeding from varices where endoscopy has failed to achieve this. Your doctor will need to assess the severity of your portal hypertension and risk of potential complications to judge whether a TIPS is the best treatment option for you.

 

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