Portal Hypertension - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

The portal vein (PV) is the main vessel of the portal venous system (PVS), which drains the blood from the GIT(gastrointestinal tract), pancreas, spleens, and upper quadrant of the abdomen, which originates behind the neck of the pancreas. This is the main vein that transports the blood, and an elevated pressure of this vein can lead to many complications in the portal venous system.

What Is Portal Hypertension?

Elevated pressure of the blood within the portal vein is termed portal hypertension. This is the main vein that transports the blood from the digestive tract to the liver. So elevated pressure of this vein may affect the liver. Portal hypertension is determined by the difference in pressures between the portal venous pressure and pressure of the inferior vena cava or the hepatic vein; this is known as portal pressure gradient. It is normally less than or equal to five mmHg; when it is six mmHg or more, it indicates portal hypertension. A portal pressure gradient of ten mmHg needs immediate care and needs hospitalization.

How Is Portal Hypertension Caused?

Portal hypertension occurs when resistance to the blood flow in the vein increases. This resistance develops within the liver due to a condition known as cirrhosis (end-stage serious liver disease); this can also occur outside the liver, such as prehepatic in portal vein thrombosis or post hepatic in case of constrictive pericarditis or Budd-Chiari syndrome. The intensity of resistance to portal blood flow allows the determination of the cause of this hypertension.

What Are the Causes of This Condition?

The main cause of this condition is cirrhosis (a serious disease of the liver). This can cause scarring in the liver. Hepatitis and excessive alcohol consumption can lead to this condition.

The various condition which causes cirrhosis is the responsible cause of this condition, such as:

• Primary biliary cholangitis: chronic bile duct disease of the liver.

• Primary sclerosing cholangitis: a primary chronic disease of the bile duct in which the inside and outside lining of the bile duct become inflamed and scarred.

• Autoimmune hepatitis: autoimmune liver disease in which the body’s immunity turns against liver cells.

• Non-alcoholic hepatitis: a disease caused due to fat deposition in the liver.

• Iron buildup in your body: increased level of iron in the body.

• Liver infections

• Cystic fibrosis: an inherited life-threatening disease that causes immense damage to the liver and lungs.

• Poorly developed bile ducts.

• Reactions to certain medications, like methotrexate.

These all above conditions can lead to cirrhosis and harm the functioning of the liver. The liver can heal itself when the liver attempts to heal, resulting in the formation of scars. Too much scarring affects liver functionality. Cirrhosis leads to irregularity in the smooth inner lining of the blood vessels, which in turn increases resistance to the blood flow. Thus, pressure in the portal vein increases. This condition can also be caused by thrombosis (a blood clot in the portal vein)

What Are the Signs and Symptoms?

The signs and symptoms are:

• Ascites (swelling due to fluid accumulation in the stomach).

• Edema (swelling of the leg).

• Jaundice (yellowish discoloration of mucous membrane, skin, and sclera of the eye).

• Encephalopathy (forgetfulness and confusion caused due to inefficient liver function).

• Gastrointestinal bleeding.

• Tarry black stools.

• Nausea and vomiting.

• Rupture and hemorrhage from the varices.

• Caput medusae (cluster of swollen dilated veins around the navel).

• Thrombocytopenia- Decreased platelet count in the blood.

How Is the Diagnosis Made?

• The diagnosis is made by physical examination, checking for the presence of ascites, varices, and dilated veins.

• An endoscopic examination can be done to confirm internal gastric bleeding or varices bleeding.

• Image screening procedures like MRI (magnetic resonance image), CT scan (computed tomography), and an ultrasound scan can be done to confirm the diagnosis.

• An angiogram is done.

• Studies on an elevated level of pressure of the hepatic vein can be done by interventional radiologists.

• X-rays: helps in examination of the state of dilated veins in the esophagus and abdomen.

• Blood tests: low platelet count is the most common sign to check the blood test.

What Is the Treatment for Portal Hypertension?

Management of portal hypertension can be done by bringing changes in diet, medications, surgery, endoscopic therapy, or radiology. Most of the time, management is dependent on the cause. Treatment is always directed to prevent more complications.

• Alcohol can damage the liver to a great extent, along with medication. Intake of both can increase the workload of the liver and reduce its work efficiency.

• Reduce the amount of salt intake in the diet; increased salt intake can accumulate fluid in the abdomen in conditions like ascites. Also, reducing the protein intake which makes its metabolism hard on the liver, and conditions like encephalopathy can be caused.

• Endoscopic therapy done by gastroenterologists like sclerotherapy or banding can be done. In this therapy, the internal bleeding is controlled by injecting a solution. Banding is done using rubber bands to tie up the varices (enlarged veins).

• Avoid taking over-the-counter drugs without consulting the physician. One must avoid self medication and consult a doctor online. Online prescription medications prescribed by the doctor are a better option.

• Avoid recreational drugs.

• Beta-blockers or nitrates are prescribed to reduce pressure in enlarged veins and reduce the risk of bleeding.

• Propanol and Isosorbide can also to given to reduce pressure in the portal vein.

• In conditions of Encephalopathy, Lactulose is used to treat confusion and other mental changes; this medication also increases bowel movements per day more than normal.

If the above changes do not control the condition, a second-level treatment known as decompression procedures is given:

• TIPS (Transjugular Intrahepatic Portosystemic Shunt): A procedure in which a tubular device (stent) is inserted in the middle of the liver. It is not a surgical procedure; it is done within the vessels under X-ray guidance. The procedure lasts for one to three hours and requires hospitalization for one to two days.

• DSRS (Distal Splenorenal Shunt): The procedure that connects the splenic vein to the left kidney helps in reducing pressure in enlarged veins and controls bleeding. It is a surgical procedure; GA (general anesthesia) is given before it. The surgery lasts about four hours and requires hospitalization for seven to ten days. It controls bleeding. 90 % provides good long-term bleeding control.

• Liver Transplantation: When the disease has reached the end stage, this is the only option.

• Paracentesis: In case of more ascites, the direct removal of fluid is done from the abdomen.

Conclusion:

Cirrhosis can not be reversed, but the treatment of portal hypertension can be done, and the condition can be controlled. Avoiding alcohol is the first and foremost step to a healthier life. A combination of a healthy lifestyle, medications, and interventions can make treatment successful. Follow-ups are necessary to follow to monitor the progress of the TIPSS procedure and the health of the liver. Maintaining a good nutritional habit and a good lifestyle can lead to a healthy life for the liver. Survival rate can be maintained with good liver function; worsening liver function can lead to a poor prognosis.