Phys · hepatic
Portal Hypertension
Also known as portal HTN · portosystemic hypertension · variceal bleeding · oesophageal varices · gastric varices · portal hypertensive gastropathy · refractory ascites · spontaneous bacterial peritonitis · hepatorenal syndrome · hepatic encephalopathy
Consultant-physician-depth guide to portal hypertension — HVPG thresholds, pathophysiology, variceal bleeding, ascites, SBP, hepatorenal syndrome, and hepatic encephalopathy — structured for FRACP DWE and DCE preparation.
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Red flags
- Acute variceal haemorrhage with haemodynamic instability
- Refractory variceal bleeding failing standard therapy within 72 hours
- Hepatorenal syndrome-AKI with rising creatinine despite albumin challenge
- Spontaneous bacterial peritonitis with renal impairment
- New or worsening hepatic encephalopathy (possible precipitant or decompensation)
- Suspected Budd-Chiari syndrome (acute ascites, hepatomegaly, abdominal pain)
Portal Hypertension
Meet the patient
A 58-year-old man with known alcoholic cirrhosis is admitted at 2 am with haematemesis. He is pale, tachycardic, and dropping his blood pressure. The nurse has two large-bore cannulae in and the registrar wants to give fluids.[1]
Two questions decide his next six hours: is he bleeding from a varix? (endoscopy answers within 12 hours) and what is going to stop it before he dies? (vasoactive drugs, antibiotics, and band ligation together — plus a pre-emptive TIPS assessment if he is high-risk). Everything in this topic hangs off those two questions.[1]
References11ShowHide
- [1]de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - Renewing consensus in portal hypertension J Hepatol, 2022.PMID 35120736
- [2]Villanueva C, Albillos A, Genescà J, et al. β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial Lancet, 2019.PMID 30910320
- [3]García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding N Engl J Med, 2010.PMID 20573925
- [4]Wong F, Pappas SC, Curry MP, et al. Terlipressin plus Albumin for the Treatment of Type 1 Hepatorenal Syndrome N Engl J Med, 2021.PMID 33657294
- [5]Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy N Engl J Med, 2010.PMID 20335583
- [6]Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis N Engl J Med, 1999.PMID 10432325
- [7]Fernández J, Ruiz del Arbol L, Gómez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage Gastroenterology, 2006.PMID 17030175
- [8]Sarin SK, Wadhawan M, Agarwal SR, et al. Endoscopic variceal ligation plus propranolol versus endoscopic variceal ligation alone in primary prophylaxis of variceal bleeding Am J Gastroenterol, 2005.PMID 15784021
- [9]Angeli P, Ginès P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites J Hepatol, 2015.PMID 25638527
- [10]Kaplan DE, Ripoll C, Thiele M, et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis Hepatology, 2024.PMID 37870298
- [11]Bosch J, Abraldes JG, Berzigotti A, et al. The clinical use of HVPG measurements in chronic liver disease Nat Rev Gastroenterol Hepatol, 2009.PMID 19724251