Portal hypertension

Last updated: August 3, 2022

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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


Acute management of variceal hemorrhage

  • Resuscitation and stabilization
    • Bring patient into shock position
    • Place (at least) two peripheral venous catheters
    • Substitute crystalloids to maintain plasma volume
    • Intubate patient (with decreased consciousness) to prevent the possibility of aspiration or airway obstruction
    • Place a stomach tube → helps to remove the blood
    • Intensive care monitoring
    • Transfuse blood or blood products to stabilize coagulation, if indicated
  • Medical therapy
  • Endoscopic management
    • Erythromycin (a strong prokinetic agent) may be administered before gastroscopy.
    • Procedures
      • Endoscopic band ligation (procedure of choice)
        • Hemostasis
        • Used for primary prophylaxis and prevention of recurring hemorrhage
      • Alternative: injection sclerotherapy, absolute alcohol, and fibrin glue, as well as cyanoacrylate, to stop acute variceal bleeding
      • Balloon tamponade using a Sengstaken-Blakemore tube or Minnesota tube
        • Indication: alternative treatment in case of extreme hemorrhage, unsuccessful endoscopic treatment, or ineffective hemostatic medication; consider in hemodynamically unstable patients until they can be stabilized
        • Complication: risk of decubitus gangrene → prevention: deflation of balloon every 5 hours for 5 minutes
  • Interventional radiologic treatment: See “TIPS” above.

Bleeding prevention

Other complications


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

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