Portal hypertension refers to excessive pressure in the portal vein, the vena portae. The term portal hypertension is also used synonymously. The portal vein is responsible for carrying blood from the abdominal organs, such as the stomach, intestines, and spleen, to the liver. Any pressures that exceed 4 – 5 mmHg in the portal vein are considered portal hypertension.
What is portal hypertension?
Portal hypertension is said to occur when the pressure of the vein is 2 to 6 mmHg above the normal pressure, which should be between 6 and 10 mmHg in a healthy person. For a non-normal increase in pressure in the portal vein, an increase in resistance is the cause. Thus, portal hypertension is usually due to congestion of blood in the vein or decreased outflow of blood into the circulation. If there is an obstruction in the vein that blocks blood flow, this may be local, but it may equally extend over very large areas in entire vascular regions. The different cases are referred to as prehepatic, intrahepatic, or posthepatic obstructions, which are obstructions within the vein or vascular region.
Causes
Portal hypertension usually occurs as a result of cirrhosis of the liver. In rarer cases, causes also include pathologic changes in the hepatic vessels, blockages within the spleen, or the portal vein itself. Portal hypertension may progress to esophageal varices (life-threatening bleeding of the mucosa within the esophagus), which occur when venous pressure exceeds 12 mmHg, or hepatic encephalopathy. In a large number of cases, portal vein disease is related to alcohol abuse or hepatitis C infection.
Symptoms, complaints, and signs
Portal hypertension itself does not show any symptoms, but it can cause various disorders in the body, which are then accompanied by certain complaints. Typically, it affects the liver, whose function can be impaired. This is manifested by a feeling of fullness and pressure in the upper abdomen, as well as various skin signs. Dilated vessels become visible through the skin, which is referred to as bill skin. In addition, so-called spider nevi (liver asterisks) form, which are small red dots that converge in a star shape on the face and upper body. The palms of the hands and feet turn red, the lips become smooth and shiny and look as if they have been painted red, and the tongue also turns red. When the liver can no longer properly break down the harmful substances, they reach the brain and can trigger hepatic encephalopathy, which is accompanied by confusion and dizziness. Furthermore, there may be loss of appetite and weight loss, and water may form in the abdomen, which is called abdominal dropsy or ascites. The spleen may enlarge and cause pain in the upper left abdomen, sometimes radiating to the back. Varicose veins may develop in the esophagus and stomach. Because these tend to bleed more profusely, vomiting of a dark mass resembling coffee grounds and black, so-called tarry stools may occur.
Diagnosis and course
Complaints are often not felt with portal hypertension. Rather, the complications that follow from it cause problems. One of the most consequential is esophageal variceal hemorrhage, a bleeding from the mucosa within the esophagus that is often life-threatening. Such bleeding is due to dilatation of the veins within the esophagus. In most cases, such bleeding occurs without the presence of pain or other symptoms. If portal hypertension is present, it is not uncommon for bypass circulation to form in the blood. Enlargement of the spleen, abnormal accumulation of water in the abdominal cavity or hepatic encephalopathy, i.e. a functional disorder of the brain, may accompany the disease. The body’s detoxification functions may be impaired, and changes in the blood count are possible. The pressure in the portal vein can only be measured via a venous catheter, an examination that is associated with a high risk for the patient. Furthermore, a diagnosis can be made by computer tomography or ultrasound. Through an endoscopy, changes in the gastric mucosa or bleeding in this area can be detected.
Complications
Because of portal hypertension, there is a risk of serious complications. For example, blood and lymph from the liver can no longer drain as usual. The body attempts to maintain circulation and, for this purpose, resorts to the otherwise unused portocaval anastomoses, which are located between the systemic and hepatic circulation. However, this threatens various serious sequelae. Due to portal hypertension, bypass circulation occurs. They connect to the superior and inferior vena cava, respectively, bypassing the liver. Through the vena cava, blood from the entire digestive region, which otherwise uses the portal vein passage, flows directly to the heart. As a result, there is significant dilatation of the abdominal cutaneous veins (caput medusae). Also affected are the anal veins, which in turn results in the formation of hemorrhoids, and the gastric and esophageal veins. If sudden pressure or mechanical irritation occurs, there is a risk that the affected veins will burst. This can result in intense life-threatening bleeding. In this case, patients vomit blood or suffer circulatory shock. Another serious complication of portal hypertension is ascites. It occurs because the liver produces fewer proteins when it is not functioning properly. The lack of proteins leads to the squeezing of fluid originating from the portal vessels, which then causes the accumulation of water in the abdomen. Also possible is hepatic encephalopathy.
When should you see a doctor?
If stomach pain or gastrointestinal bleeding occurs, it may indicate portal hypertension. A visit to the doctor is necessary if symptoms do not resolve on their own or rapidly increase in intensity. If fever, renal or splenic discomfort, and other signs of portal hypertension occur, medical attention is recommended. Persons suffering from ascites or from a chronic cardiovascular condition should inform their family doctor. Medical advice is needed at the latest when the condition affects well-being. In addition to the general practitioner, patients with portal hypertension can go to a cardiologist or a gastroenterologist. Other contacts are the nephrologist and the ENT specialist. Initially, the condition can be consulted with the general practitioner, who can make a tentative diagnosis based on an examination of the cardiovascular system. If the symptoms are severe, inpatient hospitalization is necessary. Patients should also consult closely with a physician after treatment and inform him or her of any unusual symptoms and any side effects or interactions of prescribed medications.
Treatment and therapy
Because portal hypertension is always caused by other conditions, such as hepatitis C or alcoholism, these should be treated first, taking into account nutrient deficiencies, a tendency to increased bleeding, and damage to the liver and cardiovascular system. If esophageal variceal hemorrhage occurs, mortality is approximately one-third. Surviving patients face a risk of rebleeding within the following two years, which is 50 to 70 percent. This risk can be reduced with medication. If the patient’s treatment responds poorly, improvements in the condition may be possible with a stent connection in the liver or a shunt. Nevertheless, the long-term prognosis may be poor. In some cases, liver transplantation may help the patient.
Prevention
To prevent portal hypertension, it is imperative that the patient maintain absolute abstinence from alcohol. Only in this way can pathologic changes in the tissues of the liver be prevented, stopped, or at least slowed. Beta-blockers can be prescribed as a precautionary measure to prevent rebleeding in patients who have survived esophageal mucosal hemorrhage.
Follow-up
Portal hypertension can be treated quite well during the follow-up phase. First, patients should be aware that certain habits, such as alcohol consumption and unhealthy diet, are triggers for the disease. By completely avoiding alcohol and high-fat foods, they can spare their cardiovascular system and also their liver.This can slow down or even completely prevent the pathological changes in the liver tissue. Depending on the individual case, doctors may prescribe beta blockers, which patients must take as recommended. Furthermore, diet affects high blood pressure. Too much salt stresses the body and drives up blood pressure. That is why it is important to greatly reduce the consumption of salt and instead resort to other spices. Healthy foods like fruits, vegetables and nuts help lower high blood pressure. Successful follow-up also includes physical activity. Regular, gentle outdoor exercise gradually normalizes blood pressure. A combination of a diet plan and exercise provides a better sense of well-being. This is particularly interesting for overweight patients, who can reduce their weight by exercising more and thus put less strain on their hearts.
Here’s what you can do yourself
Those affected can counteract portal hypertension on their own by rearranging their daily routine a little. Self-help in everyday life is certainly possible. For example, it is advisable for patients to pay attention to their diet. Salty foods in particular have a negative effect on blood pressure. It is therefore advisable to avoid salt as much as possible and to use other spices instead. In addition, the diet can be supplemented with nuts. Sufferers who resort to nuts in moderation achieve a positive effect on their high blood pressure. In addition to diet, the focus should be on sporting activities. This does not mean that sufferers should take part in high-performance sports, but regular exercise in the fresh air can normalize blood pressure. Both diet and exercise are of key importance if the affected person is overweight. Often, being overweight, even slightly, is a possible cause of high blood pressure. Those who weigh too much and suffer from portal hypertension should try to reduce their weight a little. Otherwise, those affected should take it easy. Stress and excessive exertion lead to high blood pressure. If these two potential causes can be eliminated, this too will lead to blood pressure normalizing.
