Portal Hypertension 

Definition

Portal hypertension (PHT) is defined as a pathological increase in portal venous pressure, clinically significant when the hepatic venous pressure gradient (HVPG) ≥ 10 mmHg, and severe when ≥ 12 mmHg, at which point variceal bleeding occurs.

Normal HVPG: 1–5 mmHg
Clinically significant portal hypertension (CSPH): ≥10 mmHg


Pathophysiology (High-yield Core Concept)

Portal hypertension results from increased resistance to portal blood flow ± increased portal venous inflow.

1️⃣ Increased Portal Resistance

Occurs due to:

  • Structural factors: fibrosis, cirrhosis, nodules
  • Dynamic factors: increased intrahepatic vasoconstriction (↓ NO, ↑ endothelin)

2️⃣ Increased Portal Inflow

  • Splanchnic vasodilation (↑ NO)
  • Hyperdynamic circulation

➡️ Leads to:

  • Portosystemic collateral formation
  • Ascites
  • Varices
  • Hypersplenism


Etiological Classification (Exam Favourite)

A. Pre-hepatic

  • Portal vein thrombosis
  • Splenic vein thrombosis
  • Extrinsic compression

B. Intra-hepatic

Most common

🔹 Presinusoidal

  • Schistosomiasis
  • Congenital hepatic fibrosis
  • Primary biliary cholangitis

🔹 Sinusoidal

  • Cirrhosis (alcoholic, viral, NASH)
  • Acute alcoholic hepatitis

🔹 Postsinusoidal

  • Sinusoidal obstruction syndrome

C. Post-hepatic

  • Budd–Chiari syndrome
  • Right heart failure
  • Constrictive pericarditis


Hemodynamic Measurement – HVPG

Parameter

Value

WHVP

Reflects sinusoidal pressure

FHVP

Reflects IVC pressure

HVPG = WHVP − FHVP


Key Interpretation

  • Elevated HVPG → cirrhotic portal hypertension
  • Normal HVPG with PHT → presinusoidal cause


Clinical Manifestations

A. Portal Hypertension Related

  • Ascites
  • Esophageal & gastric varices
  • Splenomegaly
  • Hypersplenism (↓ platelets first)

B. Portosystemic Shunting

  • Hepatic encephalopathy
  • Spider angiomas
  • Caput medusae


Portosystemic Collaterals 

Portal System

Systemic Drainage

Clinical

Left gastric vein

Esophageal veins

Esophageal varices

Para-umbilical

Epigastric veins

Caput medusae

Superior rectal

Middle/inferior rectal

Hemorrhoids

Retroperitoneal

Lumbar veins

Silent


Complications

 Life-threatening

  • Variceal hemorrhage
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome

 Chronic

  • Refractory ascites
  • Hepatic encephalopathy
  • Portal hypertensive gastropathy


Diagnosis

Laboratory

  • Thrombocytopenia (earliest marker)
  • Prolonged INR (synthetic dysfunction)

Imaging

  • Doppler USG: portal vein diameter >13 mm, reduced flow
  • CT/MRI: collaterals, splenomegaly

Endoscopy

  • Gold standard for detecting varices


Management (Guideline-Based)

Primary Prophylaxis of Variceal Bleed

  • Non-selective beta blockers (NSBBs)
    • Propranolol / Nadolol
  • OR Endoscopic variceal ligation (EVL)

Acute Variceal Bleeding

  1. Resuscitation (restrictive transfusion Hb 7–8 g/dL)
  2. Vasoactive drugs (terlipressin / octreotide)
  3. Urgent endoscopy with EVL
  4. Antibiotic prophylaxis (ceftriaxone)

Secondary Prophylaxis

  • NSBB + EVL


TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Indications

  • Refractory variceal bleed
  • Refractory ascites

Contraindications

  • Severe hepatic failure
  • Severe pulmonary hypertension
  • Recurrent encephalopathy