Chronic liver disease, cirrhosis and portal hypertension: Viva

Branch 1: Assessing portal hypertension

The candidate should recognise that a child with biliary atresia and a Kasai portoenterostomy is at high risk for progressive fibrosis and portal hypertension, and that the thrombocytopenia of 78,000 per cubic millimetre is a strong clue to clinically significant portal hypertension from hypersplenism. The key is to interpret the platelet count not as an isolated abnormality but as a marker of splenic sequestration from portal venous congestion. ^[1]

A strong candidate would explain that the hepatic venous pressure gradient of 10 mmHg or more defines clinically significant portal hypertension, which is the threshold at which varices form and the risk of bleeding becomes real. The candidate should describe the focused examination looking for splenomegaly, ascites with shifting dullness, spider naevi, palmar erythema, and signs of chronic liver disease, and should request an abdominal ultrasound with Doppler to assess portal vein patency, flow direction, splenomegaly, and the presence of collaterals. ^[1]

If the examiner presses on the next step, the candidate should name upper gastrointestinal endoscopy as the gold standard for diagnosing and characterising varices, and should explain that the finding of large varices or red wale signs would prompt consideration of primary prophylaxis with either non-selective beta-blockers or endoscopic variceal ligation. ^[1]