Portal Hypertension

Portal hypertension is abnormally high blood pressure in branches of the portal vein, the large vein that brings blood from the intestine to the liver.

The portal vein receives blood from the entire intestine and from the spleen, pancreas, and gallbladder. After entering the liver, the vein divides into right and left branches and then into tiny channels that run through the liver. When blood leaves the liver, it flows back into the general (systemic, or body-wide) circulation through the hepatic vein (see Blood Vessel Disorders of the Liver : Introduction).

Two factors can increase blood pressure in the portal blood vessels:

  • Increased volume of blood flowing through the vessels

  • Increased resistance to the blood flow through the liver

In Western countries, the most common cause of portal hypertension is increased resistance to blood flow caused by extensive scarring of the liver in cirrhosis, which is most often due to chronic excessive alcohol intake.

Portal hypertension leads to the development of new veins (called collateral vessels) that directly connect the portal blood vessels to the general circulation, bypassing the liver. Because of this bypass, substances (such as toxins) that are normally removed from the blood by the liver can pass into the general circulation. Collateral vessels develop at specific places. The most important are located at the lower end of the esophagus and at the upper part of the stomach. Here, the vessels become engorged and full of twists and turns—that is, they become varicose veins of the esophagus (esophageal varices) or stomach (gastric varices). These engorged vessels are fragile and prone to bleeding, sometimes seriously and occasionally with fatal results. Other collateral vessels may develop on the abdominal wall and at the rectum.

Portal hypertension often causes the spleen to enlarge because the pressure interferes with blood flow from the spleen into the portal blood vessels. Pressure in the portal blood vessels may cause protein-containing (ascitic) fluid from the surface of the liver and intestine to leak into the abdominal cavity. This condition is called ascites.

What Causes Portal Hypertension?

The most common cause of portal hypertension is cirrhosis. Cirrhosis results from scarring of a liver injury caused by hepatitis, alcohol abuse or other causes of liver damage. In cirrhosis, scar tissue blocks the flow of blood through the liver.

Other causes of portal hypertension include blood clots in the portal vein, blockages of the veins that carry the blood from the liver to the heart, and a parasitic infection called schistosomiasis. Sometimes the cause is unknown.

What Are the Symptoms of Portal Hypertension?

The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have liver disease that leads to cirrhosis, the chance of developing portal hypertension is high.

The main symptoms and complications of portal hypertension include:

  • Gastrointestinal bleeding: Black, tarry stools or blood in the stools; or vomiting of blood due to the spontaneous rupture and hemorrhage from varices.

  • Ascites (an accumulation of fluid in the abdomen).

  • Encephalopathy or confusion and forgetfulness caused by poor liver function.

  • Reduced levels of platelets, blood cells that help form blood clots, or white blood cells, the cells that fight infection.

How Is Portal Hypertension Diagnosed?

The presence of significant portal hypertension is implied by ascites, collaterals, or encephalopathy that occurs in the presence of known chronic liver disease or peripheral clinical evidence of chronic liver disease (firm liver, enlarged spleen, spider angiomas, clubbing of fingers, palmar erythema).

An ultrasound test can assess the presence of collaterals (gastric varices or umbilical vein dilatation), the width of the portal vein, and portal blood flow with deep Doppler. Improvement in certain ultrasound techniques, including the FM ultrasound, may allow assessment of the degree of hepatic fibrosis. The CT scan can be used to assess the presence but not the degree of portal hypertension.

The demonstration of esophageal varices by endoscopy or barium swallow implies portal hypertension, as do significant intraabdominal collaterals at any site.

What Lifestyle Changes Should Be Made?

Maintaining good nutritional habits and keeping a healthy lifestyle will help your liver function properly. Some of the things you can do to improve the function of your liver include the following:

  • Do not use alcohol or street drugs.

  • Do not take any over-the-counter or prescription drugs without first consulting your doctor or nurse. (Some medications may make liver disease worse.)

  • Follow the dietary guidelines given to you by your doctor or nurse, including: eating a low-sodium (salt) diet. You will probably be required to consume no more than 2 grams of sodium per day. Reduced protein intake may be required and only if confusion is a symptom. A dietitian can create a meal plan for you.

Treatment

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