Portal hypertension is a serious complication of chronic liver disease, most commonly seen in cirrhosis. It is defined as an increase in blood pressure within the portal venous system, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver.
When the liver becomes scarred (fibrosis or cirrhosis), blood flow through the portal vein is obstructed, leading to increased portal pressure. This elevated pressure results in a variety of complications including ascites, variceal bleeding, and splenomegaly, all of which contribute to significant morbidity and mortality.
To easily remember the key features of portal hypertension, the mnemonic “ABCDE” is used, as shown in the image.
Mnemonic for Features: ABCDE
The mnemonic ABCDE summarizes the major clinical manifestations of portal hypertension:
| Letter | Feature | Explanation |
|---|---|---|
| A | Ascites | Accumulation of fluid in the peritoneal cavity due to increased portal pressure and reduced albumin synthesis. |
| B | Bleeding (Hematemesis / Piles) | Esophageal or gastric varices rupture causing vomiting of blood (hematemesis); hemorrhoids may also occur. |
| C | Caput Medusae | Dilated abdominal wall veins around the umbilicus due to collateral circulation. |
| D | Diminished Liver (Atrophy) | Shrunken, scarred liver from cirrhosis leading to impaired function. |
| E | Enlarged Spleen (Splenomegaly) | Back-pressure effect on the spleen causes enlargement, leading to hypersplenism (low platelets, anemia, leukopenia). |
This mnemonic helps both students and clinicians quickly recall the hallmark signs of portal hypertension.
Pathophysiology of Portal Hypertension
The portal venous system normally has a pressure of 5–10 mmHg. Portal hypertension is diagnosed when the hepatic venous pressure gradient (HVPG) exceeds 12 mmHg.
Key mechanisms:
1. Increased resistance to portal blood flow – Caused by cirrhosis, fibrosis, or thrombosis.Causes of Portal Hypertension
Portal hypertension can be classified based on the site of obstruction:
1. Pre-hepatic causes
- Portal vein thrombosis
- Splenic vein thrombosis
2. Hepatic causes (most common)
- Cirrhosis (alcoholic, viral hepatitis, NASH, autoimmune hepatitis)
- Hepatic fibrosis
- Schistosomiasis (parasitic infection common in tropical countries)
3. Post-hepatic causes
- Budd-Chiari syndrome (hepatic vein thrombosis)
- Right-sided heart failure
- Constrictive pericarditis
Clinical Features
The hallmark features of portal hypertension can be remembered by ABCDE. In addition:
Gastrointestinal Varices: Enlarged veins in the esophagus and stomach may rupture, leading to massive bleeding.Diagnosis of Portal Hypertension
Diagnosis involves clinical signs, imaging, and invasive pressure measurement:
Clinical Examination: Ascites, splenomegaly, caput medusae.Complications of Portal Hypertension
1. Variceal bleeding – Life-threatening gastrointestinal hemorrhage.Management of Portal Hypertension
Management involves preventing complications, controlling bleeding, and treating underlying liver disease.
1. General Measures
- Salt restriction and diuretics for ascites.
- Avoid alcohol and hepatotoxic drugs.
- Vaccination against hepatitis viruses.
2. Pharmacological Therapy
Non-selective beta-blockers (Propranolol, Nadolol): Reduce portal venous inflow, preventing variceal bleeding.3. Endoscopic Therapy
Endoscopic Variceal Ligation (EVL): Rubber bands applied to varices.4. Radiological / Surgical Procedures
TIPS (Transjugular Intrahepatic Portosystemic Shunt): Creates a shunt between the portal and systemic circulation to lower portal pressure.Prognosis
The prognosis of portal hypertension depends on the severity of the underlying liver disease. Patients with cirrhosis are often graded using Child-Pugh Score and MELD Score to predict survival and need for transplantation.
Early detection, regular screening for varices, and preventive therapy can improve outcomes and reduce mortality.
Tabular Overview of Portal Hypertension
| Aspect | Details |
|---|---|
| Definition | Increased pressure in the portal venous system (>12 mmHg) |
| Mnemonic | ABCDE – Ascites, Bleeding, Caput medusae, Diminished liver, Enlarged spleen |
| Common Causes | Cirrhosis, portal vein thrombosis, Budd-Chiari syndrome, right heart failure |
| Complications | Variceal bleeding, ascites, splenomegaly, encephalopathy, hepatorenal syndrome |
| Diagnosis | Clinical features, Doppler ultrasound, endoscopy, HVPG measurement |
| Treatment | Beta-blockers, EVL, TIPS, liver transplantation |
Frequently Asked Questions (FAQs)
Q1: What is the most common cause of portal hypertension worldwide?
Cirrhosis is the leading cause in developed countries, while schistosomiasis is a major cause in developing regions.
Q2: What is caput medusae?
Caput medusae refers to dilated veins radiating from the umbilicus, resembling the snake-haired head of Medusa in Greek mythology.
Q3: Can portal hypertension be cured?
Portal hypertension cannot be completely cured without treating the underlying liver disease. Liver transplantation offers the best long-term solution.
Q4: What is the difference between esophageal varices and hemorrhoids in portal hypertension?
Esophageal varices are dilated veins in the esophagus due to portal hypertension, while hemorrhoids occur due to dilated rectal veins. Both are complications of increased portal pressure.
Q5: What is TIPS, and when is it used?
TIPS (Transjugular Intrahepatic Portosystemic Shunt) is used in patients with recurrent variceal bleeding or refractory ascites when medical and endoscopic therapy fails.
