Faculty of Medicine

Medicine & Surgery Program

Portal Hypertension

Dr. Mohamed Basyouni Date : 1/ 11 /2023

 Portal vein anatomy
The portal vein is formed behind the neck of the pancreas
(at the level of 2nd lumber vertebra) by union of the splenic
& superior mesenteric veins.

It is 6-8 cm in length & contains no valves.

It bifurcates into the Lt & Rt trunks in , or just below the

hilum of the liver (porta-hepatis).

Inside the liver, each portal branch gives segmental

branches that end at portal triads by forming liver
sinusoids .
Portal vein anatomy
Hepatic Blood Flow

Tortora and Derrickson, 2006

Hepatic Lobular Anatomy
 Portal hypertension
 The normal portal vein pressure is 5-10 mmHg.
 Hepatic vein pressure is 4-5 mmHg (free hepatic vein pressure)
 Hepatic venous pressure gradient (HVPG) : (Wedged hepatic vein pressure –
Free hepatic vein pressure)… More practical measure of portal pressure.
 Normal HVPG: 1-5 mm Hg
 Definition of Portal Hypertension:
- Portal vein pressure more than 12 mmHg.
- HVPG more than 10 mmHg.
 Bleeding from esophageal varices occur when HVPG >12 mmHg
 Aetiology
 Pre-hepatic: portal vein obstruction
1-Congenital stenosis.
2- Thrombosis of portal vein: e.g: HCC
3- Extrinsic compression (e.g : tumor, large LNs).
 Intra-hepatic:
1- Liver cirrhosis.
2- Bilharziasis: peri-portal fibrosis
 Post-hepatic:
1- Budd-Chiari syndrome.
2- Inferior vena cava thrombosis or stenosis
3- Constrictive pericarditis
4- Tricuspid valve disease.
5- Right-side heart failure.
 Clinical features & complications:
1- Splenomegaly:
 The earliest & most common feature
 c/p: heaviness or dragging pain in left hypochondrium
 May be associated with hypersplenism→ pancytopenia & bleeding tendency.

2- GIT congestion:
 Indigestion, dyspepsia
 Malabsorption, distension

3- Ascites: with SAAG > 1.1

4- Hepatic encephalopathy
5- Opening of Porto-systemic collaterals & bleeding varices:

In normal conditions  collapsed.

In portal hypertension  engorged  divert blood from the portal to systemic
circulation.
The important sites of these collaterals are:
a) lower end of esophagus & fundus of stomach:(esophageal & fundal varices)
- esophageal tributaries of Lt gastric vein (portal)
- esophageal tributaries of hemiazygous vein (systemic).

b) Around the umbilicus: (caput medusa)

- Para umbilical vein of left portal branch (portal)
- Superior & inferior epigastric veins (systemic)
c) Lower rectum & anal canal: (hemorrhoids)
- Superior rectal (hemorrhoidal) vein (portal): ends in inferior mesenteric vein
- Middle & Inferior rectal (hemorrhoidal) veins (systemic): end in internal iliac
veins

d) At the back of the colon: (Retroperitoneal)

- Rt & Lt colonic veins (portal)
- Rt & Lt renal veins (systemic)

e) Sub-diaphragmatic:
- Tributaries of superior & inferior mesenteric veins (portal)
- Posterior abdominal & sub-diaphragmatic veins (systemic)
Clinical features
 Investigations:
1. Fibre-optic upper GI endoscopy:
- detects site & size of varices
- treats variceal bleeding (sclerotherapy / band ligation)
2. Abdominal US with Doppler:
- shows dilated portal vein and collaterals.
- detects ascites & splenomegaly.
3. Detection of Hypersplenism:
- CBC : Mono-, bi- or pancytopenia.
- Bone marrow examination: hypercellularity
- Radioactive isotope studies: using the patient‘s own RBCs tagged with 51Cr.→
Showed diminished half life of RBCs
 VARICES INCREASE IN DIAMETER PROGRESSIVELY

Merli et al. J Hepatol 2003;38:266

Treatment of Bleeding from esophageal varices

I- General measures:
1. Admission to hospital, better to ICU.
2. Resuscitation.
TWO wide-bore cannulas are inserted, each in one arm.
A blood sample is taken for blood tests & cross-matching
Restoration of blood volume by volume expanders:
• Crystalloid solution e.g: Ringer acetate
• Colloid volume expanders e.g: hydroxyethyl starch (Hespan, Voluven),
plasma, human albumin .
Overexpansion of the circulation should be avoided.
3. Correct of coagulopathy:
Intravenous Vitamin K .
Fresh frozen plasma.

4. Prevention of encephalopathy: Repeated enema & lactulose

5. Drugs:
 Vasopressin:
 Action: vasoconstriction of the splanchnic circulation.
 Dose: 20 units in 200 ml of 5% dextrose, over 20 min.
 Side effects: coronary vasoconstriction & angina

 Glypressin: 2 mg/6h for 1-2 days

 Synthetic somatostatin analogues e.g: Sandostatin

 Dose: 50 ug bolus iv then 50 ug/ hour iv infusion
 Side effects: less than glypressin & vasopressin
6- Balloon tamponade:
- Using the tri-luminal Sungstaken-Blackmore tube
- Produce compression over varices till endoscopy is available

7- Endoscopic therapy: the most important line of therapy

 Sclerotherapy:
 using a sclerosant agent (ethanolamine oleate) or an adhesive glue (histoacryl
blue)
 injected Intra- or Peri-variceal →fibrosis & occlusion of varices.

 Band ligation: ligation of variceal neck by rubber bands

 Complications of endoscopy:
 Ulceration
 Perforation
 Retrosternal pain
 Dysphagia
 Aspiration pneumonia
Balloon tamponade
Endoscopic Banding Sclerotherapy
8- Transjugular intrahepatic porto-systemic shunt (TIPS)
o A shunt between hepatic and portal veins that is kept open by placement of a
fenestrated metal stent
o Used when pharmacologic and endoscopic treatment of acute bleeding is
unsuccessful.

9- Emergent surgery:
 Porto-caval shunt
 Lieno-renal shunt
 Splenectomy with devascularization (vasoligation): Hassab operation.
 THE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT

Transjugular Intrahepatic Portosystemic

Shunt

Hepatic
vein

TIPS

Splenic
Portal vein vein

Superior mesenteric
vein
Prophylaxis of variceal bleeding:

 Screening endoscopy: for all patients with cirrhosis, every 2 - 3 years.

 Beta blockers: Propranolol (Inderal), Nadolol & Carvidolol
- For small & medium-sized varices without bleeding:
- Portal vessels dilatation →↓ portal pressure.
- The dose is adjusted to decrease the resting heart rate by 25%

 Endoscopic band ligation