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Portal hypertension

Last updated: April 26, 2021

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Portal hypertension refers to a pathological elevation of portal venous pressure resulting from obstructions in portal blood flow, which may be either prehepatic (e.g., portal vein thrombosis), hepatic (e.g., liver cirrhosis), or posthepatic (e.g., right-sided heart failure). The subsequent backflow of blood may lead to portosystemic anastomoses, splenomegaly, and/or ascites. While portal hypertension may be diagnosed purely based on the presence of clinical signs and potential risk factors, medical imaging and laboratory tests are used to support the diagnosis in suspected cases. Management requires treating the underlying condition and reducing portal pressure with nonselective beta-blockers and portosystemic shunts.

A potentially life-threatening complication is acute hemorrhage of the esophageal varices caused by increased blood flow via portosystemic anastomoses. Patients present with sudden hematemesis and melena, as well as hypovolemic shock in some cases. In addition to stabilizing the patient, acute management of variceal bleeding includes reducing splanchnic blood flow with octreotide and endoscopic variceal band ligation. Prevention of (recurring) bleeding involves nonselective beta-blockers, endoscopic variceal ligation, or placement of transjugular intrahepatic portosystemic shunts (TIPS).

  • Portal hypertension is defined as a hepatic venous pressure gradient (HVPG) of ≥ 6 mm Hg.
  • HVPG > 10 mm Hg is clinically significant and > 12 mm Hg is associated with complications.


Depending on the cause, portal hypertension may be either acute or chronic. Acute portal hypertension arises from acute portal vein thrombosis, while chronic portal hypertension may be due to chronic thrombosis, cirrhosis, or schistosomiasis.


Clinical manifestations of portal hypertension (e.g., ascites) in a patient with a known risk factor (e.g., cirrhosis) may already suffice for diagnosis. In addition to investigating underlying conditions, diagnostic steps may include:


Medical therapy

Beta-blocker treatment in patients suffering from advanced liver cirrhosis (Child-Pugh class C) may lead to circulatory dysregulation. If negative effects outweigh the benefits, beta-blocker treatment should be reconsidered!

Portosystemic shunts


Esophageal variceal hemorrhage


Esophageal variceal hemorrhage refers to the bleeding of dilated sub-mucosal veins (varices) of the distal esophagus; and is a dangerous consequence of portal hypertension. It is the most common form of upper gastrointestinal (GI) bleeding in patients presenting with cirrhosis.

Clinical features

Clinical diagnosis

  • Sudden onset of severe upper GI bleeding in a patient with signs of portal hypertension, typically in combination with liver failure
  • If bleeding occurs following retching or vomiting, consider a Mallory-Weiss tear as a differential diagnosis.


Acute management of variceal hemorrhage

Bleeding prevention

Other complications


We list the most important complications. The selection is not exhaustive.

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