What is portal hypertension?
Portal hypertension is a serious increase in blood pressure in the portal vein system in the liver.
Portal hypertension can be a complication of cirrhosis of the liver or alcoholic hepatitis.
If the vessels in the liver are blocked by disease, it is hard for the blood to flow, causing high pressure in the portal system.
When this pressure becomes too high, the blood backs up and finds other ways to return to the heart.
The blood can travel to veins in the oesophagus, the skin of the abdomen, and the rectum and anus to get around blockages in the liver.
What causes portal hypertension?
The most common cause of portal hypertension is cirrhosis of the liver. Cirrhosis results from scarring of liver injuries caused by hepatitis, alcohol abuse or other sources of 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 chances of developing portal hypertension are high.
The main symptoms of portal hypertension are therefore those of liver disease, or of the complications that may result. These include:
- Gastrointestinal bleeding: black, tarry stools or blood in the stools; or vomiting of blood due to the spontaneous rupture and haemorrhaging of enlarged blood vessels, often in the oesophagus (oesophageal varices).
- Ascites (an accumulation of fluid in the abdomen).
- Encephalopathy (brain disease/injury) or confusion and forgetfulness caused by poor liver function.
- Reduced levels of platelets, the blood cells that help to form blood clots, or of white blood cells, which fight infection.
How is portal hypertension diagnosed?
Usually doctors make the diagnosis of portal hypertension based on the presence of ascites or of dilated veins (varices) as detected in a physical examination of the abdomen or the anus. Various laboratory tests, scans, X-ray tests and endoscopic examinations may also be used. Sometimes a biopsy of the liver may be taken to try to identify the cause of the problem.
How Is portal hypertension treated?
Unfortunately, most causes of portal hypertension cannot be treated. Instead, treatment focuses on preventing or managing the complications, especially bleeding from the varices. Diet, medications, endoscopic therapy, surgery and radiology procedures all have a role in treating or preventing the complications. Other treatment depends on the severity of the symptoms and on how well the liver is functioning.
Endoscopic therapy. This is usually the first line of treatment for variceal bleeding and consists of either banding or sclerotherapy. Banding is a procedure in which a gastroenterologist uses rubber bands to block off the ruptured blood vessel. Sclerotherapy is occasionally used when banding is not feasible. In this procedure, a solution is injected into the bleeding varices, causing them to scar.
Medication. Non-selective beta-blockers such as nadolol or propranol are usually prescribed alone or in combination with endoscopic therapy to reduce the pressure in varices and further reduce the risk of re-bleeding. Non-selective beta-blockers are also prescribed to prevent a first variceal haemorrhage in a patient with varices that are felt to be at risk of bleeding. Oesophageal variceal banding has been used for the same purpose, especially in patients with an intolerance to beta-blockers.
The drug lactulose can help to treat confusion and other mental changes associated with encephalopathy. Diuretics may be used to reduce ascites.