All about Portal Hypertension (P-HTN) 
Normal Portal venous pressure — 5-6 mmHg.
Clinically significant when pressure excceds — 10 mmHg.
Patient is in risk of variceal bleeding when pressure excceds — 12 mmHg.
Most Common cause of P-HTN is — Cirrhosis of liver(90%).(Developed countries).
Worldwide most common cause — Schistosomiasis.
Cardinal feature of P-HTN is — Splenomegaly.
A diagnosis of P-HTN is very unusual when splenomegaly is not detected clinically or by USG.
Once Diagnosis is made Upper GI endoscopy should be perform to screen for oesophageal varices.
Most important consequence of P-HTN is — Variceal bleeding.
Prophylactic use of Propanolol significantly reduced the risk of variceal bleeding.
non-bleeding varices are identified at endoscopy, β-adrenoceptor antagonist (β-blocker) therapy with propranolol (80–160 mg/ day) or nadolol (40–240 mg/day) is effective in reducing portal venous pressure.Administration of these drugs at doses that
reduce the heart rate by 25% has been shown to be effective in the primary prevention of variceal bleeding. In patients with cirrhosis, treatment with propranolol reduces variceal bleeding by 47% ), death from bleeding by 45% and overall mortality by 22%
Terlipressin use in case of Acute variceal bleeding, it reduce portal pressure by reducing the portal blood flow.
Complication of P-HTN
…ARCHIVE…
A… Ascitis.
R… Renal Failure.
C… Congestive gastropathy.
H… Hypersplenism.
I… Iron deficiency Anaemia.
V… Variceal bleeding.
E… Encephalopathy
Regarding management of acute variceal bleeding
Acute hemorrhage from esophageal varices should be managed with
1-fluid and/or blood resuscitation, To replace extracellular volume
2-prophylactic antibiotics such as oral ciprofloxacin or iv cephalosporin OR Prpiracillin\tazobactem To reduce incidence of spontaneous bacterial peritonitis
3- pharmacotherapy. Pharmacotherapy is directed at reducing portal pressure with vasoconstrictors or reducing intrahepatic vascular resistance with vasodilators that includes the following
Iv terlipressin The dose of terlipressin is 2 mg IV 4 times daily until bleeding stops, and then 1 mg 4 times daily for up to 72 hours. Caution is needed in patients with severe ischaemic heart disease or peripheral vascular disease because of the drug’s vasoconstrictor properties
Octreotide is the synthetic analogue of somatostatin. It selectively reduces splanchnic blood flow without producing the systemic cardiac effects of vasopressin dosage is 50mcg iv boulus and 50mcg/hour maintinince for 2-5 days it can be used when terlipressin is not available
4- endoscopic identification followed by one of Emergency endoscopic therapy that includes
Endoscopic banding ligation : Banding is best suited to the treatment of oesophageal varices. It is associated with a lower risk of oesophageal perforation or stricturing than sclerotherapy
Injection sclerotherapy
If haemostasis is achieved then Continue terlipressin to 72 hrs Introduce β-blocker as secondary prophylaxis ,Enter patient into endoscopic banding programme to obliterate varices
If bleeding is continues Further endoscopic therapy or Balloon tamponade or Emergency TIPSS
5- Proton pump inhibitor To prevent peptic ulcers because Prophylactic acid suppression with proton pump inhibitors reduces the risk of secondary bleeding from bandinginduced ulceration.
6- Phosphate enema and/or lactulose To prevent hepatic encephalopathy