MBBS OSCE · General Surgery
OSCE — Portal Hypertension
Eight-minute OSCE station on Portal Hypertension: focused history, examination priorities, investigations, emergency and definitive management.
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Brief (to candidate)
You will assess a patient with a presentation consistent with Portal Hypertension. You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags.
[2]Clinical context
Portal hypertension is an HVPG higher than 5 mmHg. Commonest cause worldwide is cirrhosis (sinusoidal); the commonest pre-sinusoidal cause globally is schistosomiasis. Four consequences: varices, ascites, splenomegaly with hypersplenism, and hepatic encephalopathy. Acute variceal bleed: restrictive transfusion (transfuse under 7 g/dL; target 7 to 8 g/dL), a vasoactive drug before endoscopy continued 2 to 5 days, antibiotic prophylaxis from admission, and endoscopic band ligation within 12 hours. Refractory bleeding: balloon tamponade or a covered metal stent as a bridge, then TIPSS. Primary prophylaxis: carvedilol (preferred NSBB) or EVL. Secondary prophylaxis: NSBB plus serial EVL. Pre-emptive TIPSS within 72 hours for Child-Pugh C under 14, Child-Pugh B greater than 7 with active bleeding, or HVPG over 20 mmHg.[17][2][5][7][10]
Candidate tasks
- Clarify onset, severity, associated features, and red-flag symptoms.
- State focused examination priorities.
- List first-line investigations and any named score/criteria.
- Give immediate resuscitation steps.
- Outline definitive management with doses/routes where standard.
- Name complications and disposition (ward / HDU / theatre / discharge safety-net).
- Mention one special-population modifier (pregnancy, child, elderly, CKD).
Examiner checklist
| Domain | Pass behaviours |
|---|---|
| Definition | HVPG higher than 5 mmHg; CSPH at 10 mmHg or more |
| Assessment | Focused, prioritised, red flags sought |
| Investigations | Endoscopy, Doppler ultrasound, Child-Pugh/MELD; SAAG 1.1 g/dL (11 g/L) |
| Emergency care | Restrictive transfusion, vasoactive drug, antibiotic from admission, OGD within 12 h |
| Definitive care | EVL; pre-emptive or salvage TIPSS with named criteria; NSBB plus EVL after the bleed |
| Safety | Haematemesis or melaena in chronic liver disease is a variceal bleed until proven otherwise |
| Safety | HVPG 16 mmHg or more raises short-term mortality after non-hepatic abdominal surgery |
| Safety | Refractory variceal bleed despite vasoactive drug plus EVL — balloon tamponade or covered stent as a bridge to TIPSS |
| Communication | Clear plan and safety-netting |
Model outline
Lead with the working diagnosis and life threats. Resuscitate before definitive tests when unstable. Use guideline-standard therapy with named agents and doses. Document escalation criteria and follow-up. A safe candidate is specific, structured, and never delays critical care for non-urgent imaging.[2]
References5ShowHide
- [2]de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - Renewing consensus in portal hypertension J Hepatol, 2022.PMID 35120736
- [5]Da Silva LC, Carrilho FJ Hepatosplenic schistosomiasis. Pathophysiology and treatment Gastroenterol Clin North Am, 1992.PMID 1568771
- [7]Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding N Engl J Med, 2013.PMID 23281973
- [10]Garcia-Tsao G, Abraldes JG, Rich NE, et al. AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review Gastroenterology, 2024.PMID 37978969
- [17]Procopeţ B, Tantau M, Bureau C Are there any alternative methods to hepatic venous pressure gradient in portal hypertension assessment? J Gastrointestin Liver Dis, 2013.PMID 23539394