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The Digestive SystemPortal hypertension - Cirrhosis Synonyms : Clinical features, Diagnosis, Management, Prognosis, Nutrition, Herbs, Portal hypertension is
a condition characterised by prolonged elevation of the portal venous pressure
above 12 mm Hg (normally 2-5 mm Hg). In cirrhosis, which causes 90% or more of
portal hypertension in adults (other cause is thrombosis of hepatic veins),
there is intrahepatic obstruction to blood flow leading to increased venous
pressure in the portal system. This leads to the development of collateral
vessels allowing portal blood to bypass the liver and enter the systemic
circulation (principally in the GI tract - oesophagus, stomach and rectum, and
in the anterior abdominal wall). Increased portal pressure is also responsible
for increased filtration of fluid into the abdominal cavity, eventually
causing ascites. Clinical features: < BACK TO TOP >
Splenomegaly (enlargement of the spleen) is a cardinal finding; patients complain of
pain in the left upper abdominal quadrant and often experience fullness after
eating very little because the enlarged spleen is pressing against the
stomach.
Hypersplenism (spleen overactivity caused by splenomegaly) with thrombocytopenia (platelet counts usually around 100x109/L)
is common (normally 150-400 x109/L); leukopenia is also found (leukocyte count below 4 x109/L).
Collateral
vessels may be visible on the anterior abdominal wall and occasionally several
radiate from the umbilicus to form a characteristic appearance known as ‘caput medusae?/i> (jellyfish head).
The
most important collateral vessels occur in the terminal oesophagus and stomach
cardia (varices), where they can
cause severe bleeding, haematemesis and melaena.
Rectal
varices also cause bleeding and are often mistaken for simple haemorrhoids.
Fetor hepaticus (characteristic offensive breath, sometimes referred to as ‘liver
breath? results from portal-systemic shunting of blood which allows
mercaptans to pass directly to the lungs, from where they are exhaled. Very often ascites develops mainly due to increased filtration pressure in the portal system. Hypoalbuminaemia due to decreased liver synthesis of albumin (reduced colloid-osmotic pressure) and sodium and water retention due to activation of renin-angiotensin-aldosterone system are also important factors in the development of ascites. Diagnosis: < BACK TO TOP >
Ascites
may be discovered on physical examination (percussion) of the abdomen.
Ultrasonography
can demonstrate cirrhosis
and ascites, Doppler ultrasound can show and measure
portal venous flow.
Portal
blood pressure can be estimated if necessary by passing a catheter into the
hepatic vein through the jugular vein, although this procedure is rarely done
due to its invasiveness.
The
presence of varices in the oesophagus and stomach can be demonstrated by
barium swallow and meal examination, or preferably during endoscopy. Paracentesis is a technique used to obtain ascitic fluid for analysis and is done by inserting a needle into the peritoneal cavity, sometimes under ultrasonic guidance. Withdrawn fluid is examined to exclude malignant and infective causes of ascites. Management < BACK TO TOP >
Underlying
liver condition should be treated.
Bleeding
from the oesophageal or gastric varices can be stopped by sclerothereapy (injection of corrosive chemicals into dilated veins
to cause their closure), balloon tamponade, application of laser energy
through the endoscope or rubber band ligation (tying) at endoscopy.
Ascitic
fluid can be removed, but only if it causes significant discomfort (fluid is
withdrawn gradually).
Diuretic
drugs are used in addition to sodium restriction (e.g., frusemide [Lasix,
Urex], bumetanide [Burinex], bendrofluazide [Aprinox], hydrochlorothiazide [Diclotride]),
ACE inhibitors (e.g., captopril [Capoten], enalapril [Renitec], lisinopril [Prinvil],
fosinopril [Monopril], ramipril [Tritace, Ramace]) and angiotensin II
antagonists (e.g., losartan [Cozaar], irbesartan [Avapro]) can also be of
value in some patients. Portal-systemic shunt surgery is used in selective cases to form a communication between the splenic and renal veins (distal splenorenal shunt), but this surgery carries significant mortality rate. Prognosis < BACK TO TOP >
Nutrition < BACK TO TOP > Nutrition that alleviate or prevent Portal hypertension :- Herbs < BACK TO TOP > Herbs that alleviate or prevent Portal hypertension :- (source : -) |
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