Portal Hypertension — Viva

Q1: HVPG (2 min)

"What is HVPG and what thresholds matter?"

• HVPG = wedged hepatic venous pressure minus free hepatic venous pressure
• Higher than 5 mmHg = portal hypertension (sinusoidal when the block is at the sinusoid)
• 10 mmHg or more = clinically significant portal hypertension
• Fall to under 12 mmHg, or by more than 20 percent, on an NSBB = haemodynamic response
• After TIPS, PPG under 12 mmHg is the haemodynamic-success target
• 16 mmHg or more = increased short-term mortality after non-hepatic abdominal surgery — not a variceal-bleed mortality cut-off. The mantra "over 16 kills" is that surgical figure, misapplied

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Q2: Acute variceal bleed (3 min)

"A cirrhotic patient is vomiting blood. Walk me through management."

• AIRWAY + two large-bore IV lines
• RESTRICTIVE transfusion: transfuse when Hb falls under 7 g/dL; Baveno target 7–8 g/dL
• VASOACTIVE DRUG before endoscopy, continued 2–5 days (terlipressin 2 mg IV q4h, or octreotide on safety grounds)
• ANTIBIOTIC from admission. Ceftriaxone 1 g/24 h in advanced cirrhosis / high quinolone-resistance settings. Do not say "reduces mortality by 10%" — a 2025 Bayesian meta-analysis found shorter or no prophylaxis noninferior for all-cause mortality, while infections were fewer with prophylaxis
• OGD within 12 hours for EVL (sooner if unstable)
• Refractory: balloon tamponade or covered metal stent as bridge only, then TIPSS
• Pre-emptive TIPSS within 72 hours (ideally under 24) if Child-Pugh C under 14, Child-Pugh B greater than 7 with active bleeding, or HVPG over 20 mmHg

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Q3: TIPSS (2 min)

"What is TIPSS and what are its complications?"

• PTFE-covered stent between an intrahepatic portal branch and a hepatic vein via a transjugular route
• Early TIPS trial: 97 versus 50 percent one-year freedom from failure-to-control-bleeding-or-rebleeding; 86 versus 61 percent one-year survival
• Haemodynamic target: PPG under 12 mmHg (a 50 percent relative fall is an alternative)
• Key complication versus paracentesis: hepatic encephalopathy, odds ratio 2.24 — lactulose plus rifaximin 550 mg twice daily
• Also: shunt stenosis/thrombosis, heart failure

^{[3] [2] [15] [9]}

Q4: Schistosomiasis (2 min)

"A patient from an endemic area has variceal bleeding but normal liver function tests. What is the diagnosis?"

• Hepatosplenic schistosomiasis — intrahepatic pre-sinusoidal portal hypertension with a well-preserved parenchyma
• Eggs in the portal venules: granulomas, pipe-stem (Symmers) fibrosis
• Liver synthetic function preserved (normal albumin, INR, bilirubin) unless a second liver disease coexists
• Treatment: praziquantel or oxamniquine plus variceal management (EVL, NSBB). Splenectomy with gastro-oesophageal devascularisation is a recognised surgical option. Transplant is not required for a structurally preserved liver

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References9ShowHide

1. [2]de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - Renewing consensus in portal hypertension J Hepatol, 2022.PMID 35120736
2. [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
3. [5]Da Silva LC, Carrilho FJ Hepatosplenic schistosomiasis. Pathophysiology and treatment Gastroenterol Clin North Am, 1992.PMID 1568771
4. [7]Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding N Engl J Med, 2013.PMID 23281973
5. [9]Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy N Engl J Med, 2010.PMID 20335583
6. [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
7. [15]Saab S, Nieto JM, Lewis SK, et al. TIPS versus paracentesis for cirrhotic patients with refractory ascites Cochrane Database Syst Rev, 2006.PMID 17054221
8. [16]Prosty C, Noutsios D, Dubé LR, et al. Prophylactic Antibiotics for Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A Systematic Review and Bayesian Meta-Analysis JAMA Intern Med, 2025.PMID 40788637
9. [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