PORTAL HYPERTENSION

Dr. Shekhar Poudel

MBBS(BPKIHS), MD(PGIMER, Chandigarh)
DM Gastroenterology (AIIMS, New Delhi)
Introduction:
 Increased portal venous pressure

 Resistance to portal blood flow

 Aggravated by increased collateral flow

 Cirrhosis as most common cause

 Other: NCPF, EHPVO, BCS
Anatomy of Portal Vein
Porto-systemic Collateral Pathways
DEFINITION

 Normal portal blood flow: 1000-1200ml/m

 Portal pressure: 7mm Hg (5-10)

resistance in sinusoids minimal

 Portal hypertension, when > 10mmHg.

Pathophysiology:
 Increased resistance to portal blood flow
 Two components to resistance

A. Structural: distortion of the liver microcirculation by fibrosis,

nodules, angiogenesis, and vascular occlusion

B Dynamic: contraction of activated hepatic stellate cells and

myofibroblasts that surround hepatic sinusoids

Increased production of vasoconstrictors (eg, endothelins,

angiotensin-II, norepinephrine, thromboxane A2) and reduced
release of endothelial vasodilators (eg, nitric oxide)
Sites of collaterals in PHT

Blood flow reversed

 Rectum : IMV and pudendal vein- rectal varices

 Umbilicus : vestigeal umbilical vein & left portal
vein – Caput medusae.
 Retroperitoneum:
 Distal oesophagus, proximal stomach:
Oesophageal & fundal varices
Clinical Features
 Often asymptomatic until complications develop

 Porto-systemic anastomosis
Oesophageal varices
Caput medusae
Haemorrhoids

 Splenomegaly

 Ascites and its complications

Etiology and Classification:
Diagnosis

Portal hypertension in a patient of liver disease is

revealed by
1. Splenomegaly
2. Ascites
3. Encephalopathy
4. Oesophageal varices
5. Portal venous pressure measurement
6. Transient elastography
 HVPG (Hepatic Venous Pressure Gradient):

Measured to approximate the gradient in pressure between the

portal vein and the inferior vena cava (IVC)

 Quantify the degree of portal hypertension due to sinusoidal

resistance to blood flow
- Normal HVPG: between 1 and 5 mmHg
- HVPG ≥6 mmHg: clinically significant
- HVPG ≥10 mmHg - varices may develop
- HVPG ≥12 mmHg - risk for variceal bleeding and the
development of ascites
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