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Portal Hypertension

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Aalholm, Laumann, Molo Agustín Paterno and Pigg

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Photo from The Paternos (2005, p. 11): https://www.scribd.com/document/450498423/Paternos-book-reduced-size-pdf Original file: https://ibb.co/vB2b6t2 or https://imgbox.com/ooxcpRET or https://pixhost.to/show/516/358351962_maximino-paterno.jpg This work was first published in the Philippines and is now in the public domain because its copyright protection has expired by virtue of the Intellectual Property Code of the Philippines. The work meets one of the following criteria: It is an anonymous or pseudonymous work and 50 years have passed since the year of its publication It is an audiovisual or photographic work and 50 years have passed since the year of its publication It is a work of applied art and 25 years have passed since the year of its publication It is another kind of work, and 50 years have passed since the year of death of the author (or last-surviving author) Important note: Works of foreign (non-U.S.) origin must be out of copyright or freely licensed in both their home country and the United States in order to be accepted on Commons. Works of Philippine origin that have entered the public domain in the U.S. due to certain circumstances (such as publication in noncompliance with U.S. copyright formalities) may have had their U.S. copyright restored under the Uruguay Round Agreements Act (URAA) if the work was under copyright in its country of origin on the date that the URAA took effect in that country. (For the Philippines, the URAA took effect on January 1, 1996.)

Maximino Paterno (1863 - 1929)
Maximino Paterno was a Filipino physician. He served as the Minister of Public Works and Communications from January 21, 1899 to November 13, 1899. He was also representative of Bongao to the Malolos C...
Laura Olivia Aalholm (1820 - 1881)
William Pigg (1831 - 1902)
Marriage Death certificate

About

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Portal hypertension is an increase in the pressure within the portal vein, which carries blood from the digestive organs (stomach, intestine, spleen, & pancreas) to the liver. The increase in pressure is caused by a blockage in the blood flow through the liver.

Increased pressure in the portal vein causes large veins (varices) to develop across the esophagus and stomach to get around the blockage. The varices become fragile and can bleed easily.

Many times, people suffering from portal hypertension do not realize that there is a problem until they experience an episode of pain on one side of their body. This could be in the form of a dull ache or throbbing pain that spreads across the lower portion of the arm, or perhaps it happens when you flex your wrist.

Causes

The most common cause is cirrhosis (scarring) of the liver, but thrombosis (clotting) might also be the cause.

Cirrhosis is scarring which accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage. In cirrhosis, the scar tissue blocks the flow of blood through the liver.
Other causes include blood clots in the portal vein, blockages of the veins that carry the blood from the liver to the heart, a parasitic infection called schistosomiasis, and focal nodular hyperplasia, a disease seen in people infected with HIV, the virus that may lead to AIDS. Sometimes the cause is unknown.

Symptoms

Gastrointestinal bleeding: You may notice blood in the stools, or you may vomit blood if any large vessels around your stomach that developed due to portal hypertension rupture.
Ascites: When fluid accumulates in your abdomen, causing swelling
Increased spleen size (splenomegaly)
Encephalopathy, or confusion and fogginess in thinking
Jaundice, the yellowing of the skin and the whites of the eyes
Edema, (swelling) of the legs
Caput medusa, a visible network of dilated veins surrounding your navel
Swollen veins on the anterior abdominal wall (sometimes referred to as caput medusae)

Diagnosis

Imaging studies-duplex Doppler ultrasound (uses sound waves to see how the blood flows through the portal vein)
Blood tests
Pressure measurement studies
Endoscopic diagnosis
- During a gastrointestinal endoscopy, the doctor can see the mucous lining of the upper gastrointestinal tract, including the esophagus, stomach and duodenum (first part of the small intestine).

Complications

'Ascites'- excess fluid in your abdominal cavity
- Early feeling of fullness
- Increase in size of abdomen
- Feeling out of breath (if the fluid begins pushing on your lungs)
Varices - varicose veins associated with portal hypertension
- Varices most often occur in the esophagus or stomach as a result of portal hypertension. This is often because the liver tissue is scarred and blood cannot flow through normally. As the portal blood is rerouted due to the increased resistance, varices develop.
Encephalopathy - impairment in neuropsychiatric function associated with portal hypertension
- Symptoms are usually mild, with subtle changes in behavior, changes in sleep pattern, mild confusion & forgetfulness or slurred speech. However, it can progress to more serious symptoms, including severe lethargy and coma.
Reduced levels of platelets, blood cells that help form blood clots, or white blood cells, the cells that fight infection.

Treatment

Unfortunately, most causes of portal hypertension cannot be treated. Instead, treatment focuses on preventing or managing the complications, especially the bleeding from the varices. Diet, medications, endoscopic therapy, surgery, and radiology procedures all have a role in treating or preventing the complications. Other treatment depends on the severity of the symptoms and on how well your liver is functioning.

Prognosis / Mortality & Morbidity

Without treatment, portal hypertension can lead to severe complications, such as chronic bleeding, abdominal swelling, and liver failure. Doctors typically treat portal hypertension with a combination of blood pressure-lowering medication, lifestyle changes, and surgery.

From: https://www.medscape.com/answers/182425-95873/what-are-the-mortalit... Medscape - What are the mortality and morbidity of portal vein obstruction? By: Adnan Said, MD, MSPH; Chief Editor: BS Anand, MD, Jul 09, 2020]

In the absence of cirrhosis, the 2-year bleeding risk from esophageal varices is reported to be 0.25% and of those that bleed the mortality rate is approximately 5%. Those with cirrhosis and varices have a 20-30% 2 year bleeding risk with a mortality rate of 30-70%. This difference is primarily a consequence of the normal hepatic function in the noncirrhotic patient. The variceal size is the major predictive factor for bleeding.
In adults with portal vein thrombosis, the 10-year survival rate has been reported to be 38-60%, with most of the deaths occurring secondary to the underlying disease (eg, cirrhosis, malignancy).

From: NIH – Natural history of portal hypertension in patients with cirrhosis. By R de Franchis & M Primignaani

All patients with cirrhosis will eventually develop portal hypertension and esophagogastric varices. Bleeding from ruptured esophagogastric varices is the most severe complication of cirrhosis and is the cause of death in about one third of patients.
- The rate of development and growth of esophageal varices is poorly defined but in general seem to be related to the degree of liver dysfunction.
- Once varices have formed, they tend to increase in size and eventually to bleed. In unselected patients, the incidence of variceal bleeding is about 20% to 30% at 2 years.
Variceal size is the single most important predictor of a first variceal bleeding episode.
Portal hypertensive gastropathy can progress from mild to severe and vice-versa or even disappear completely. Acute bleeding from portal hypertensive gastropathy seems to be relatively uncommon, and less severe than bleeding from varices.

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