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PORTAL HYPERTENSION

Dimas Aji Perdana


Ulfa Kholili

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Introduction
Portal hypertension (PH) is a common clinical syndrome defined as the elevation of hepatic
venous pressure gradient (HVPG) above 5 mm Hg.

PH is caused by a combination of two simultaneous occurring hemodynamic processes:


(1) Increased intrahepatic resistance to passage of blood flow through the liver due to cirrhosis
and
(2) Increased splanchnic blood flow secondary to vasodilatation within the splanchnic vascular
bed.

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Epidemiology

International incidence of portal In Western countries, alcoholic cirrhosis


hypertension is also unknown, as well as and viruses are the main cause of portal
population-based prevalence data for hypertension and esophageal varices.
portal hypertension in the United States
According to the National Institute on
(US) are not available, but portal
Alcohol Abuse and Alcoholism (NIAAA),
hypertension is the most common
liver cirrhosis accounted for nearly 30,000
manifestation of liver cirrhosis.
deaths in the United States in 2007,
making it the 12th leading cause of death
in the US.

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Portal Hypertension
• PH can be due to many different causes at prehepatic, intrahepatic, and posthepatic sites (Table 1)

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Pathophysiology
Portal
Hypertension

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Clinical Manifestations

Gastrointestinal Manifestations Renal Manifestations Neurological Manifestations


- Gastroesophageal (GE) Varice - Hepatorenal Syndrome - Hepatic Encephalopathy
- Ectopic Varices (EcV) Pulmonary Manifestations Other Organ Manifestations
- Portal Hypertensive Intestinal - Hepatopulmonary Syndrome - Cirrhotic Cardiomyopathy
Vasculopathies
- Portopulmonary Hypertension - Hepatic Osteodystrophy
- Ascites and Spontaneous
Bacterial Peritonitis (SBP) - Hepatic Hydrothorax - Hypersplenism

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Anamnesis and Physical Examination

Anamnesis

Hematemesis is the most common presentation.


Melena, without hematemesis, may result from variceal bleeding. Absence of
dyspepsia and previous normal epigastric and endoscopic tenderness helps to get rid
of peptic ulcer bleeding.
Stigmata of cirrhosis include jaundice, vascular spiders, and palmar erythema.

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Physical Examinations

Abdominal wall vein Splen Rectal


- Caput Medusae - Spenomegaly - Varices Anorectal

- Ascites Hepar Other Organ Manifestations


- Cruveilhier-Baumgarten Syndrome - Hepatomegaly - Cirrhotic Cardiomyopathy

- Hepatic Osteodystrophy

- Hypersplenism

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Radiology
- UGS : Spenomegaly, Bull’s Eye
- MRI: Gamna-Gandy body
- CT-Scan: Portosystemic collateral
- PillCam ESO capsule endoscopy can
detect esophageal varices and portal
hypertension gastropathy with sensitivity
and specificity of 80-90%.
- Shear-wave elastography

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Measurement of Portal Pressure
Measurement of portal pressure in patients with portal hypertension is important in the evaluation of
the efficacy of different portal-hypotensive pharmacologic therapies.

The most used method to assess portal Normal HVPG is 3 to 5 mm Hg.


pressure is the catheterization of the hepatic
In patients with compensated cirrhosis, an
vein with determination, via a balloon
HVPG greater than or equal to 10 mm Hg
catheter, of the hepatic vein pressure
predicts the development, not only of
gradient (HVPG), which is the difference
varices, but of complications that mark the
between the wedged (or occluded) hepatic
transition from compensated to
venous pressure and the free hepatic venous
decompensated cirrhosis.
pressure.

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Measurement of Portal Pressure
Changes in HVPG during pharmacologic therapy have also been shown to be predictive of clinical
outcomes. In patients with a history of variceal hemorrhage, a decrease in HVPG to less than 12
mm Hg or a decrease greater than 20% from baseline significantly reduces the risk of recurrent
hemorrhage, ascites, encephalopathy, and death.

In patients with compensated cirrhosis, even Recent studies show that separate HVPG
lower reductions in HVPG (>10% from procedures to assess response to therapy
baseline) have been associated with a can be obviated by assessing the acute
reduction in the development of varices, first hemodynamic response to intravenous (IV)
variceal hemorrhage, and ascites. propranolol (0.15 mg/kg) during a single
procedure.

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“ Pharmacologic therapies should thus be ideally tailored to a target decrease in
HVPG. Even though the HVPG procedure is simple and safe, its use is not widespread
in the United States because it is invasive and because it has not been appropriately
standardized.

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Pharmacologic Therapy for
Portal Hypertension
Drugs that Act by Reducing Portal Flow
- Vasopressin and analogues
- Vasopressin is the most potent
splanchnic vasoconstrictor available,
but it has been abandoned in the
therapy for portal hypertension
because of its numerous side effects.
- Somatostatin and analogues
- Somatostatin and analogues
(octreotide, vapreotide) cause
splanchnic vasoconstriction not only
through an inhibitory effect on the
release of the vasodilator glucagon
but also by a local mesenteric
vasoconstrictive effect.

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Pharmacologic Therapy for
Portal Hypertension
Drugs that Act by Reducing Resistance to Blood
Flow
- Vasodilators such as nitrates, prazosin,
clonidine, angiotensin receptor blockers
(ARBs) and angiotensin-converting enzyme
inhibitors have resulted in significant
reductions in HVPG.
- The use of vasodilators alone is currently not
recommended.
- Other therapies have been shown, in
experimental animals, to improve nitric
oxide bioavailability in the liver and to
reduce portal pressure

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Pharmacologic Therapy for
Portal Hypertension
Drugs that Act by Reducing Flow and Resistance

- The combination of intrahepatic vasodilators


and splanchnic vasoconstrictors results in an
additive portal pressure–reducing effect.
- This effect was first shown in a hemodynamic
study performed in patients with cirrhosis in
whom the addition of nitroglycerin to
vasopressin led to a further reduction in
HVPG, not associated with a further
decrease in portal flow
- Carvedilol is a nonselective β-blocker with
weak anti-α1 adrenergic (vasodilator) activity
and therefore acts as a combination of NSBB
and vasodilator.

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Prognosis

“ Patients with portal hypertension have a not too good prognosis and often
experience the most common complications in the form of bleeding in esophageal
varices with a mortality rate of around 30% - 50%.

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Summary
- Portal hypertension is a condition where the portal pressure gradient (the difference in pressure
between the portal vein and hepatic vein) is greater than 5 mm Hg.
- The most direct consequence of portal hypertension is the occurrence of gastroesophageal
varices which can rupture and lead to varicose veins.
- Portal hypertension is caused by a combination of two simultaneous hemodynamic processes.
- Clinical features of portal hypertension are often asymptomatic until complications occur.
- Pharmacological therapy for portal hypertension is to reduce portal blood flow and reduce
vascular resistance.

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THANK YOU
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