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Portal Hypertension

Topic updated on 09/01/17 10:22pm

Snapshot
  • A 46-year-old male presents to his primary care physician for a health maintenance examination. The patient talks about how he is struggling to cut back on his alcohol intake. The patient currently has no complaints, but feels as though he is gaining weight despite early satiety. On physical exam, the patient has mild scleral icterus. Gynecomastia is noted. Abdomen is distended, with a fluid wave.
Introduction
  • ↑ portal blood flow resistance at the level of the sinusoids → portal hypertension
    • etiologies can be divided into the following:
      • prehepatic
        • portal vein thrombosis
        • malignancy
        • compression
          • e.g., pancreatic cancer
      • intrahepatic
        • cirrhosis (most common)
        • schistosomiasis
        • Wilson disease
      • posthepatic
        • Budd-Chiari syndrome
        • right-sided heart failure
        • constrictive pericarditis
  • Hyperdynamic circulation ↑ portal blood flow → portal hypertension
    • mainly due to arterial splanchnic vasodilation
      • leads to increased blood flow to the portal venous system
Presentation
  • Manifestations
    • jaundice
    • ascites
      • excess fluid accumilation in peritoneal cavity
    • portosystemic shunting
      • due to portal blood flow reversal
        • complications where capillary beds are shared between the systemic and portal circulation
          • hemorrhoids
            • superior rectal - middle and
              inferior rectal
          • esophageal varices
            • left gastric vein -  tributaries of the azygous vein
            • can cause massive hematemesis → risk of death
          • caput medusae at the umbilicus
            • parapumbilical veins - anterior abdominal wall veins
    • splenomegaly
      • secondary to congestions
      • can lead to hypersplenism thrombocytopenia
    • hyperestrinism
      • impairment in estrogen metabolism → sex hormone imbalance
        • gynecomastia
        • palmar erythema
        • spider angiomata
        • testicular atrophy
Evaluation
  • Upper endoscopy
  • Doppler ultrasonography
    • can identify collateral vessels, alterations in portal blood flow
  • Serum-ascites albumin gradient (SAAG)
    • ≥ 1.1 g/dL can suggest portal hypertension
Treatment
  • Treatment aimed at ameliorating the complications of portal hypertension, examples include:
    • varices but no bleeding
      • primary prophylaxis with nonselective beta blocker (e.g., propranolol, nadolol) (preferred)
        • β1 blockade - decreased cardiac output
        • β2 blockade - splanchnic vasoconstriction
      • endoscopic variceal ligation
    • ascites
      • want to decrease ascitic fluid and peripheral edema
        • stop alcohol intake
        • sodium restriction
        • diuretics
          • spironolactone and furosemide
            • before using furosemide, check for hypokalemia
              • add when hypokalemia is adequately corrected
              • hypokalemia → renal ammonia production
        • large-volume therapeutic paracentesis
          • in those with tense ascites
    • spotaneous bacterial peritonitis
      • ascitic fluid infection
        • positive bacterial culture and ≥ 250 cells/mm3 absolute polymorphonuclear leukocyte count in the ascitic fluid
          • ascitic fluid culture first, and then broad spectrum antibiotics (e.g., cefotaxime)


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