Portal hypertension is raised pressure in the portal vein system that carries blood from the gut to the liver, most often caused by cirrhosis. The pressure opens bypass veins and leads to varices, ascites, a large spleen and a risk of life-threatening bleeding.
Key symptoms
- Belly swelling from fluid (ascites)
- Vomiting blood or black stools from varices
- Confusion or sleepiness (hepatic encephalopathy)
- Fatigue, easy bruising and leg swelling
What you find on exam
- Shifting dullness or a fluid wave from ascites
- Enlarged spleen
- Dilated veins around the navel (caput medusae)
- Jaundice, spider angiomas, palmar erythema
- Asterixis (flapping tremor)
Tests
- Liver tests, albumin, INR, platelets (low from a large spleen)
- Ultrasound with Doppler: liver, spleen, portal vein flow and clots
- Upper endoscopy to screen for varices
- Diagnostic paracentesis: SAAG 1.1 or higher points to portal hypertension
Treatment basics
- Treat the cause: stop alcohol, treat viral hepatitis
- Nonselective beta blocker such as carvedilol or propranolol to prevent variceal bleeding
- Low-salt diet with spironolactone and furosemide for ascites
- Variceal bleed: octreotide, IV ceftriaxone, endoscopic band ligation
- TIPS or liver transplant referral for refractory cases
Red flags
- Vomiting blood or black stools
- Fever or belly pain with ascites (spontaneous bacterial peritonitis)
- New confusion or drowsiness
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.