The increase in blood pressure within a vein system called the portal venous system.
The veins from the stomach, intestine, spleen, and pancreas fuse with the portal vein, which branches into smaller vessels and travels through the liver.
If the vessels in the liver are blocked due to liver damage, the blood can not flow properly through it.
As a result, high pressure is developed in the portal system, causing hypertension. This increased pressure in the portal vein can lead to large swollen veins (varicose veins) within the esophagus, stomach, rectum, or umbilical area (navel).
Varicose veins can break and bleed, which can lead to life-threatening complications.
Cirrhosis of the liver is the most common cause of portal hypertension. Cirrhosis is the scarring that accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage.
In cirrhosis, scar tissue blocks the flow of blood through the liver.
Other portal hypertension causes include blood clots in the portal vein and obstructions of the veins that carry blood from the liver to the heart.
A parasitic infection called schistosomiasis, and focal nodular hyperplasia is a disease seen in people infected with HIV, the virus that can lead to AIDS. Sometimes the cause is unknown.
The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have a liver disease that leads to cirrhosis, developing portal hypertension is high.
The main symptoms and complications of portal hypertension include:
- Gastrointestinal bleeding is marked by black stools or blood in the stool or vomiting of blood due to spontaneous rupture and hemorrhage due to varicose veins.
- Ascites (an accumulation of fluid in the abdomen).
- Encephalopathy is caused by poor liver function.
- Reduced levels of platelets, blood cells that help form blood clots or white blood cells, cells that fight infections
In general, doctors diagnose portal hypertension based on the presence of ascites or dilated veins or varices as seen during a physical examination of the abdomen or anus.
Several laboratory tests, x-rays, and endoscopic examinations may also be used.
Unfortunately, most portal hypertension causes can not be treated. Instead, treatment focuses on preventing or controlling complications, especially bleeding varicose veins.
Diet, medications, endoscopic therapy, surgery, and radiology procedures have a role in the treatment or prevention of complications.
Another treatment depends on the severity of the symptoms and how well the liver is working.
The treatment may include:
- Endoscopic therapy: This is usually the first line of treatment for variceal bleeding and consists of ringing or sclerotherapy. Banding is a procedure in which a gastroenterologist uses elastic bands to block the blood vessel and stop bleeding.
- Medications: Nonselective beta-blockers can be prescribed alone or combined with endoscopic therapy to reduce varicose vein pressure and further reduce the risk of bleeding.
Nonselective beta-blockers are also prescribed to prevent first variceal bleeding in patients with varicose veins who are considered at risk of bleeding.
The band of esophageal varices has also been used for this purpose, especially in patients who can not take beta-blockers. The drug lactulose may help treat the confusion and other mental changes associated with encephalopathy.
Changes in lifestyle
Maintaining good eating habits and a healthy lifestyle can help you avoid portal hypertension. Some of the things you can do to improve the function of your liver include the following:
- Do not use alcohol or illegal drugs.
- Do not take over-the-counter, prescription, or herbal medicines without first talking to your doctor or nurse. (Some medications can make liver disease worse.)
- Follow the dietary guidelines indicated by your doctor, including a diet low in sodium (salt). You should probably consume no more than 2 grams of sodium per day. Reduced protein intake may be required if confusion is a symptom. A dietitian can create a meal plan for you.
Other treatment options for portal hypertension:
If endoscopic therapy, drug therapy, and dietary changes do not successfully control variceal bleeding, you may need one of the following procedures to reduce pressure in these veins:
Transjugular intrahepatic portosystemic shunt (TIPS): This procedure involves placing a stent (a tubular device) in the middle of the liver. The stent connects the hepatic vein to the portal vein, which reroutes the blood flow in the liver and helps relieve pressure in the abnormal veins.
Distal splenorenal shunt (DSRS): This procedure connects the vein from the spleen to the vein from the left kidney to reduce pressure on varicose veins and control bleeding.
Before receiving any of these procedures for portal hypertension, the following tests may be done to determine the extent and severity of your condition:
- Evaluation of your medical history.
- A physical exam
- Blood test.
- Angiogram (an x-ray test that takes pictures of the blood flow within a particular artery).
Before the TIPS or DSRS procedure, your doctor may ask you for other tests, including an electrocardiogram (a test that records your heart’s electrical activity), a chest x-ray, or additional blood tests.
If your doctor thinks you will need additional blood products (such as plasma), they will be requested.
What happens during the TIPS procedure?
During the TIPS procedure, a radiologist tunnels through the liver with a needle, connecting the portal vein to one of the hepatic veins (veins connected to the liver). A metal stent is placed in this tunnel to keep it open.
The procedure reroutes the blood flow in the liver and reduces the pressure in the abnormal veins, not only in the stomach and esophagus but also in the intestine and liver.
This is not surgery; the radiologist performs the procedure inside the vessels under X-ray guidance. The process lasts from one to three hours, but you should expect to stay in the hospital overnight after the procedure.
How successful is the TIPS procedure?
The TIPS procedure controls bleeding immediately in more than 90% of patients with portal hypertension.
However, in about 20% of patients, the shunt may be reduced, causing the varicose veins to bleed later.
What complications are associated with TIPS?
Shunt narrowing or blockage may occur within the first year after the TIPS procedure.
Follow-up ultrasound exams are often done after the TIPS procedure to detect these complications.
A blockage sign includes an increase in ascites (accumulation of fluid in the abdomen) and a new hemorrhage.
A radiologist can treat this condition which again expands the shunt, or repeat the procedure to place a new stent.
Encephalopathy, or abnormal brain functioning, can occur with severe liver disease.
Hepatic encephalopathy can worsen when TIPS reduces blood flow to the liver, which can cause toxic substances to reach the brain without being first metabolized by the liver.
This condition can be treated with medications, diet, or making the bypass inaccessible.
What happens in the DSRS procedure?
The DSRS is a surgical procedure during which the splenic vein (called the splenic vein) separates from the portal vein and attaches to the left side of the kidney.
This surgery selectively reduces varicose pressure and controls the bleeding associated with portal hypertension. It is usually done only in patients with good liver function.
General anesthesia is administered before surgery, which lasts approximately four hours. The patient should expect to remain in the hospital for seven to 10 days after the surgery.
How successful is DSRS surgery?
The DSRS procedure provides reasonable long-term bleeding control in many people with portal hypertension. DSRS controls bleeding in more than 90% of patients, with the most significant risk of new bleeding occurring in the first month.
What complications are associated with DSRS surgery?
Ascites, an accumulation of fluid in the abdomen, can occur with DSRS surgery. This can be treated with diuretics and restricting sodium in the diet.
Follow-up care following TIPS or DSRS procedures
Follow-up care for TIPS and DSRS may differ depending on the procedures performed. Here are basic guidelines:
- Ten days after discharge, meet with your surgeon or hepatologist (liver specialist) to assess your progress. Laboratory work will probably be done at that time.
- Six weeks after the TIPS procedure (and again three months after the procedure), an ultrasound is often done so your doctor can verify that the shunt works correctly. Angiography (an x-ray of the blood vessels) may be done if the ultrasound indicates a problem.
- Six weeks after the DSRS procedure (and again three months after the procedure), the surgeon will evaluate your progress. The laboratory work can be done at that moment.
- Six months after the TIPS or DSRS procedure, an ultrasound can be performed to ensure the shunt works correctly.
- Twelve months after any of the procedures, another ultrasound of the shunt is often performed. In addition, angiography may be done so your doctor can control the pressure inside the veins through the shunt.
- If the referral works well, every six months after the first year of follow-up appointments, you may have an ultrasound, perform a laboratory test and visit your doctor.
- The most frequent follow-up visits may be necessary, depending on your condition.
Attend all follow-up appointments as scheduled to make sure the referral works appropriately.
Be sure to follow the dietary recommendations provided by your health care providers.
Other treatments for portal hypertension
- Liver transplant: This is done in cases of end-stage liver disease.
- Devascularization: A surgical procedure that eliminates bleeding varicose veins; This procedure is performed when a TIPS or a surgical bypass is impossible or does not succeed in controlling the bleeding.
- Paracentesis: This is a procedure in which fluid accumulation in the abdomen (ascites) is eliminated directly. The results are usually temporary, and the process should be repeated as necessary.