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 

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 

A. Pre-hepatic(Normal HVPG)

• 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

• WHVP = Wedged hepatic venous pressure (≈ portal vein pressure)
• FHVP = Free hepatic venous pressure (≈ IVC pressure)

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 

Complications

 Life-threatening

• Variceal hemorrhage
• Spontaneous bacterial peritonitis
• Hepatorenal syndrome

 Chronic

• Refractory ascites
• Hepatic encephalopathy
• Portal hypertensive gastropathy

Diagnosis

Diagnostic Cut-offs 

 Diagnostic Criteria 

1️⃣ Hemodynamic (Gold Standard)

✔️ HVPG >5 mmHg  Measurement via:-Transjugular catheterization of hepatic vein

2️⃣ Clinical Criteria (Strong Indicators)

Major clinical features:

• Splenomegaly
• Ascites
• Portosystemic collaterals
• Hypersplenism
• Thrombocytopenia (earliest sign)
• Variceal bleeding

3️⃣ Endoscopic Criteria 

Presence of portosystemic collaterals:

• Esophageal varices
• Gastric varices
• Portal hypertensive gastropathy

Presence of varices = CSPH (HVPG ≥10 mmHg)

4️⃣ Radiological Criteria

Ultrasound Doppler findings:

• Portal vein diameter >13 mm
• Reduced portal flow velocity (<16 cm/s)
• Reversal of flow (hepatofugal flow)
• Splenomegaly
• Ascites

CT/MRI findings:

• Portosystemic collaterals
• Splenorenal shunts
• Recanalized umbilical vein

5️⃣ Non-invasive Criteria ( Baveno VII)

Clinically Significant Portal Hypertension (CSPH) can be diagnosed WITHOUT HVPG:

Based on elastography + platelets:

• Liver stiffness >25 kPa → CSPH confirmed
• Liver stiffness <15 kPa + platelets >150,000 → CSPH excluded

PORTAL HYPERTENSION – TREATMENT

• Reduce portal pressure (HVPG < 12 mmHg or ↓ ≥20%)
• Prevent variceal bleeding-non selective B blockers, endoscopic variceal ligation
• Manage complications (ascites, HE, HRS)
• Treat underlying cause
• Consider definitive therapy (TIPS / Liver transplant)

 TREATMENT OF UNDERLYING CAUSE 

TIPS (TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT)

Concept:

• Artificial shunt between portal vein & hepatic vein

Indications:

• Refractory variceal bleeding
• Refractory ascites
• Early use in high-risk bleed

Contraindications:

• Severe HE
• Right heart failure
• Severe pulmonary hypertension

Complications:

• Hepatic encephalopathy
• Shunt stenosis

 SURGICAL SHUNTS 

 Largely replaced by TIPS

 LIVER TRANSPLANT (DEFINITIVE THERAPY)

Indications:

• Decompensated cirrhosis
• MELD score high
• Refractory complications

 Only curative treatment