Portal Hypertension

• increased pressure in the portal venous system

Causes

• Prehepatic
  • Congenital malformations
  • neonatal umbilical sepsis
  • exchange transfusion via umbilical catheter
  • Tumour
• Hepatic
  • cirrhosis,
  • schistosomiasis
• Post-hepatic
  • Budd-Chiari syndrome
  • constrictive pericarditis

Complications

• oesophageal varices

  • risk of bleeding

• rectal varices

• Portosystemic Encephalopathy

Symptoms and Signs

• Jaundice
• Mental changes
• Flapping tremor
• Haematemesis and melaena
• Ascites
• spider naevi
• liver palms
• clubbing
• gynaecomastia
• testicular tumour
• caput medusae
• peripheral oedema
• leuconychia
• Dupuytren's contracture
• Xanthoma
• Keyser-Fleischer rings
• Bruising

Investigations

• Hb
• FBC
• LFTs
• OGD

Complications

• oesophageal varices
• splenomegaly
• ascites
• encephalopathy

Portal Hypertension

Complications

• varaiceal bleeding(2/3 of patients die of this) 
• acute bleeding
• encephalopathy
• acities
•  

Primary prophylaxis

• propranolol (causes splachnic vasoconstriction, decreases portal flow, decreasing bleeding)
• Glypressin
• Somatostatin
• octreotide
• anitbiotics

Secondary prevention

• propranolol + nitrates (nitrates  dilate portal \¯ resistance)
• endoscopy (banding)
• Losartan

Ascities

Aim of treatment is to lower sodium intake, increases renal excretion of sodium therefore encouraging net reabsorption of fluid back into circulating volume.

Treatment

• low salt diet (<20 mmol a day)
• spironolactone(200mg a day) – aldosterone antagonist (S/E: hyperkalaemia, gynacomastia, cramp, dehydration)
• Amiloride – Na/K Channel blockers. Used if S/E of spironolactone not tolerated (0-15mg a day)
• Frusemide. Used if need additional diuresis than with treatment above (80mg a day)
• OLT

Treat liver disease, stop alcohol

Encephalopathy

Although the mechanism of this is not known, in most patients there seems to be  progression of encephalopathy with increased blood ammonia levels.

• Avoid precipitants             -decrease dietary protein to 20g a day

-avoid sedatives

-avoid potassium loing diuretics

-avoid drugs that cause constipation

-avoid drugs with hepatotoxic effects

• Empty lower bowels by enemas+ purgatives to ¯ bacterial source of ammonia.
• Lactulose

(orally). Humans have no lactulase. Digested by bacteria. Produce lactate. ¯ pH. Trap ammonia. ¯ colonic transit time \¯ absorption. 

• Neomycin (bromocriptine).

Administered orally/rectally. Not absorbed in gut. ¯ bacterial population

• OLT

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