What is Portal Hypertension (including oesophageal varices)

Portal Hypertension is a disease affecting the liver, portal system of veins, and also the oesophagus and spleen.

The portal vein takes blood from the gut to the liver. In the case of liver cirrhosis, and a few other causes, there is an impedance to portal blood flow to the liver which causes and increase in pressure in the portal vein.

This causes the spleen to enlarge, for fluid to drain into the abdomen (ascites) but also the formation of enlarged veins where there is a communication between the portal and systemic circulation. Most notably – this is in the lower oesophagus and upper stomach -called oesophageal and gastric varices.

Statistics on Portal Hypertension (including oesophageal varices)

No specific data – but the incidence is very similar to the incidence of cirrhosis.

Risk Factors for Portal Hypertension (including oesophageal varices)

Cirrhosis is the commonest cause of portal hypertension.

There may be other causes, such as:

  • Thrombosis of the portal vein
  • Schistosomiasis: a parasitic infection seen in central Africa where there is fibrosis of the liver sinusoids (channels);
  • Budd Chiari syndrome: thrombosis of a hepatic vein (the veins taking blood away from the liver)

Progression of Portal Hypertension (including oesophageal varices)

Depends on the cause. Most cases are secondary to cirrhosis and in most of these there is no medical treatment that alters disease history. However, abstaining from alcohol does stop progression of alcoholic cirrhosis. Patients with well compensated cirrhosis who abstain may have a survival similar to normal.

How is Portal Hypertension (including oesophageal varices) Diagnosed?

 

  • Liver function tests and coagulation profile – abnormal if associated cirrhosis.
  • Full blood count – Anaemia of chronic disease with cirrhosis, low platelets with hypersplenism.
  • Serum electrolytes: a low serum sodium may signify severe liver disease.

    Prognosis of Portal Hypertension (including oesophageal varices)

    The prognosis for the patient depends on the prognosis of the cirrhosis (see cirrhosis), but also on the development of certain complications such as acute variceal bleeds.

    Following an acute episode of variceal bleeding, the risk of recurrence is 60-80% over a two year period, with the mortality of each episode being 20%.

    How is Portal Hypertension (including oesophageal varices) Treated?

    Management involves the same management as per cirrhosis, but also specific importance of treating the complications and preventing further complications.

    Measures used to reduce the portal pressure include the long-term use of beta blockers (e.g. propranolol) and surgical procedures – most commonly the Transjugular Intrahepatic Porto-systemic shunting. The latter involves creating a bypass connection between the portal system and the hepatic outflow system – this bypasses the liver.

    Acute haemorrhage due to bleeding oesophagogastric varices is managed with:

    1. Acute resuscitation: IV fluids and transfusion,strict fluid balance;IV octreotide and vasopressin can be used to control the bleeding;
    2. Endoscopy – this will diagnose the cause of bleeding and the bleeding points can be treated, and the varices banded to hopefully stop further bleeding;
    3. Rarely balloon compression of the varices using a Minnesotta tube passed through the mouth;
    4. Surgery may be indicated very rarely – oesophageal transection with left gastric vein devascularization to control acute haemorrhage.

    Liver transplantation can be performed in many patients with cirrhosis depending on the cause, the compliance of the patient, and their general health.

    Portal Hypertension (including oesophageal varices) References

    [1] Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison’s Principles of Internal Medicine. 15th Edition. McGraw-Hill. 2001
    [2] Cotran, Kumar, Collins 6th edition. Robbins Pathologic Basis of Disease. WB Saunders Company. 1999.
    [3] Haslet C, Chiliers ER, Boon NA, Colledge NR. Principles and Practice of Medicine. Churchill Livingstone 2002.
    [4] Hurst JW (Editor-in-chief). Medicine for the practicing physician. 4th edition Appleton and Lange 1996.
    [5] Kumar P, Clark M. CLINICAL MEDICINE. WB Saunders 2002
    [6] Longmore M, Wilkinson I, Torok E. OXFORD HANDBOOK OF CLINICAL MEDICINE. Oxford Universtiy Press. 2001
    [7] McLatchie G and LEaper DJ (editors). Oxford Handbook of Clinical Surgery 2nd Edition. Oxford University Press 2002.
    [8] MEDLINE Plus
    [9] Raftery AT Churchill’s pocketbook of Surgery. Churchill Livingsone 2001.
    [10] Tjandra, JJ, Clunie GJ, Thomas, RJS,; Textbook of Surgery, 2nd Ed, Blackwell Science, Asia. 2001.