Portal hypertension

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Portal hypertension is defined as portal venous pressure greater than 12 mmHg.

Pathology

Causes can be split in their relation to the hepatic sinusoids:

pre-sinusoidal
- portal vein thrombosis
- extrinsic compression of portal vein
- Schistosomiasis (S. mansoni or S. japonicum)
sinusoidal
- cirrhosis
post-sinusoidal

Subtypes

sinistral portal hypertension ⁵

Radiographic features

Ultrasound

dilated portal vein (>13 mm): non-specific
biphasic or reverse flow in portal vein (late stage): pathognomonic
recanalisation of paraumbilical vein: pathognomonic
portal-systemic collateral pathways (collateral vessels/varices)
splenomegaly
ascites
cause of portal hypertension often identified, most commonly liver cirrhosis

CT and MRI

dilated portal vein +/- mesenteric veins
contrast enhancement of paraumbilical vein: pathognomonic
collateral vessels/varices: these are many and can include ⁴
- coronary venous collaterals: considered one of the commonest⁴
- oesophageal collaterals
- paraumbilical collaterals
- abdominal wall collaterals
- perisplenic collaterals
- retrogastric collaterals
- paraoesophageal collaterals
- omental collaterals
- retroperitoneal colleterals
- mesenteric colleterals
- splenorenal collaterals
- gastrorenal collaterals
splenomegaly
ascites
cause of portal hypertension often identified, most commonly liver cirrhosis

Treatment and prognosis

dietary restriction
medication: propranolol, diuretics
interventional procedures
- transjugular intrahepatic portosystemic shunt (TIPSS)
- surgical portosystemic shunt
- balloon dilatation of hepatic vein (in case of thrombosis/web in hepatic vein)
- transhepatic clot thrombolysis (in portal vein thrombosis)
- splenic artery embolisation ³
- liver transplantation
treatment of complications

Complications

ascites
variceal bleeding (30-50% mortality with each bleed)
portal hypertensive gastropathy/enteropathy/colopathy
hepatic encephalopathy
hepatorenal syndrome
congestive splenomegaly and hypersplenism

Differential diagnosis

Dilatation of splenic veins at the splenic hilum without splenomegaly may occur in situations such as state of increased perfusion of splenic tissue associated with an immune response ⁶.

~~-<li>~~
~~-<a href="/articles/right-heart-failure">right heart failure</a> or <a href="/articles/biventricular-cardiac-failure">biventricular cardiac failure</a>~~
~~-</li>~~
+<li><a title="Congestive cardiac failure" href="/articles/congestive-cardiac-failure">congestive cardiac failure</a></li>

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