This presentation is made by Dr Ashok Jaisingani, If any one like this please give your comments.

1. Dr. Ashok Jaisingani

2.  The hepatic portal circulation carries blood from
GI tract (i.e. from the distil esophagus to anorectal
junction) to the liver.
 Porto – systemic anastomosis occurs in junctional
areas of venous drainage.
 Portal venous blood drain into liver venous
sinusoids and hence in to the hepatic veins.

3.  Portal hypertension develop when there is
elevation of portal pressure is greater than 12
mmHg, while normal portal pressure is 5 –
10mmHg.
 As portal hypertension produce no symptoms it is
usually diagnosed following presentation with
decompensated chronic liver disease
encephalopathy, ascites or variceal bleeding.

4.  Pre – Hepatic:
1- Congenital portal atresia
2- Portal vein thrombosis (Neonatal sepsis)
3- Phlebitis of portal vein (abdominal infection)
4- Trauma or thrombosed porto – caval shunt.
 Hepatic:
1- Cirrhosis (alcoholic most frequently)
2- Chronic Active hepatitis
3- Parasitic diseases (Schiatosomiasis)
 Post – Hepatic:
1- Budd – Chiari syndrome (Hepatic venous thrombosis)
2- Constrictive pericarditis
3- Tricuspid valve incompetence

5.  Decrease or reverse portal blood flow to the liver promote
the development of the portosystemic anastomosis
between the portal system and systemic circulation.
1- Left gastric vein into the esophageal veins at gastro-
esophageal junction – esophageal and gastric varices.
2- Superior rectal vein into inferior rectal vein at lower
rectum rectal varices.
3- Obliterated umbilical vein into epigastric vein – capute
medusae.
 Esophageal and gastric varices may bleed torrentially
 Liver cell dysfunction/liver failure occurs in hepatic and
post – hepatic causes
 Splenomegaly (hypersplenism may be result)
 The child – pug classification use to asses the severity.

6. Conditions Point – 1 Point – 2 Point - 3
Bilirubin (µmol/L) <34 34 – 51 >51
Albumin (g/L) >35 28 – 35 <28
PT (sec) <3 3 – 10 >10
Ascites None Moderate Moderate – severe
Encephalopathy None Moderate Moderate – severe

7.  Many investigations may be used at different time
in portal hypertension such as
 1- FBC, Urea & electrolytes and clotting
 2- Screening tests for the causes of the cirrhosis
 3- CT & ultrasound scan to assess liver
morphology, diagnose Portal hypertension and
assess cause.
 4- Transabdominal Doppler ultrasound to assess
blood flow in the portal vein and hepatic artery.
 Gastroscopy in acute variceal bleeding

8.  General resuscitation
 Anti – coagulation for Budd – Chiari syndrome
 Treatment of hepatic cause
 Treatment Of Chronic Complication such as Esophageal gastric
varices:
1- Beta – blocker (propranolol or nadolol), reduce portal venous
pressure.
2- Repeated injection sclerotherapy or variceal ligation
3- Elective porto – systemic shunt (spleno – renal anastomosis)
4- Liver transplant may be considered for treatment if associated with
severe liver diseases.
 Rectal Varices: Injection sclerotherapy
 Symptomatic splenomegaly: laparoscopic or open splenectomy.
 Ascites: Oral spironolactone, in cases of ascites, paracentesis may be
required with IV albumin replacement.

9.  Hemorrhage from the varices is acute
complication of the portal hypertension.
 Mortality rate of first variceal bleed established
portal hypertension is 30%.
Causes & Features:
 Typical variceal bleeding is rapid in onset, copious
dark blood with little mixing with food.
 Feature of established portal hypertension e.g.
capute medusae
 Feature of developing hepatic encephalopathy
(ingested blood provide an extremely rich meal)

10.  Established large caliber IV access, give crystalloid fluid up
to 1000 mL, if tachycardic or hypotensive.
 Only use O - ve blood if the patient is in extremis,
otherwise wait for cross – match blood.
 Catheterize and place on fluid balance chart if hypotensive.
 Send blood for FBC, HB conc. WCC, U&E, Na, K, LFT,
albumin and clotting.
 Always consider HDU, variceal bleeding can deteriorate
extremely rapidly.
 Monitor pulse rate, BP and urinary output.
 Insertion Of sangstaken Blackmore gastro-esophageal tube
may be a life saving resuscitation manure, usually only
inserted without prior gastroscopy if the patient known to
have varices and has life – threatening bleeding.

11.  Blood transfusion
 Correct coagulopathy
 Esophageal balloon tamponade (sangstaken
Blackmore tube)
 Drug therapy (vasopressin or octreotide)
 Endoscopic sclerotherapy or banding
 Assess portal vein patency (Doppler ultrasound or CT)
 Transjuglar intrahepatic portosystemic stent shunt
Surgery:
 Portosystemic shunts
 Esophageal transection
 Splenectomy and gastric devescularization.