What is the primary management for patients with portal hypertension?

Primary Management of Portal Hypertension

The primary management of portal hypertension centers on non-selective beta-blockers (NSBBs) as the cornerstone therapy, with transjugular intrahepatic portosystemic stent-shunt (TIPSS) reserved for specific indications when medical therapy fails. 1

First-Line Pharmacological Management

• NSBBs (propranolol, carvedilol) reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction 1
• Carvedilol at a target dose of 12.5 mg/day has shown superior efficacy compared to traditional NSBBs in lowering portal hypertension 2
• A reduction of hepatic venous pressure gradient (HVPG) between 10-12% with beta-blockers protects against acute variceal bleeding at 2 years 1
• Early administration of vasoactive agents followed by endoscopic therapy is recommended for acute variceal bleeding 3

Management Based on Clinical Presentation

For Variceal Bleeding:

• Combination therapy with endoscopic treatment plus vasoactive drugs significantly improves 5-day hemostasis rates (77% vs 58% with endoscopy alone) 3
• Antibiotic prophylaxis in cirrhotic patients with acute upper gastrointestinal bleeding reduces mortality, bacterial infections, and rebleeding 3
• TIPSS is strongly recommended for gastro-oesophageal variceal bleeding refractory to endoscopic and drug therapy 3
• Early or pre-emptive TIPSS should be considered within 72 hours of a variceal bleed in patients with Child's C disease or MELD ≥19 3

For Ascites:

• Medical management with diuretics is first-line for ascites 3
• In selected patients with refractory or recurrent ascites, TIPSS is strongly recommended, provided there are no contraindications 3
• Contraindications for TIPSS in ascites include bilirubin >50 μmol/L, platelets <75×10^9, pre-existing encephalopathy, active infection, severe cardiac failure, and severe pulmonary hypertension 3

For Portal Hypertensive Gastropathy:

• Non-selective beta blockers and iron therapy are recommended as initial treatment 3
• Bleeding from portal hypertensive gastropathy should be managed with portal hypertension-lowering measures 1

TIPSS Procedure and Indications

• TIPSS involves placing a covered metal stent inside the liver by inserting a wire through the jugular vein in the neck, then threading and guiding it through the liver 4
• All TIPSS should be performed using PTFE-covered stents as they are associated with better patency rates than bare stents 4
• The portal pressure gradient should be reduced to <12 mmHg or by ≥20% of baseline in the case of variceal bleeding 4
• A Doppler ultrasound is recommended a week after TIPSS implantation in patients with prothrombotic conditions, and in other patients where TIPSS dysfunction is suspected 4

Monitoring and Follow-up

• HVPG monitoring can be useful to stratify risk and guide therapy choice 1
• Patients are protected from acute variceal bleeding if HVPG decreases to values <12 mmHg or if HVPG decreases by >10% 1
• Regular Doppler ultrasound follow-up at 6-12 month intervals is recommended after TIPSS placement 3

Complications and Pitfalls

• Hepatic encephalopathy affects approximately one-third of patients after TIPSS 3
• Other complications of TIPSS include bleeding, infection, heart failure, liver failure, kidney failure, fever, and damage to blood vessels and bile ducts, occurring in less than 5% of patients 4
• Administering large volumes of blood products may paradoxically increase portal pressure and worsen bleeding 1
• In patients with ascites and gastroesophageal varices, carvedilol is safe and may improve survival, as long as no impairment of the systemic hemodynamic or renal dysfunction occurs 2

Special Considerations

• Removal of the etiological factor (particularly alcohol consumption and hepatitis B or C virus infection) is associated with decreased risk of decompensation and increased survival 1
• Portal vein thrombosis is not an absolute contraindication to TIPSS placement, although cavernoma presence is associated with higher failure rates 3
• In patients with esophageal varices or history of variceal bleeding, appropriate prophylaxis should be maintained with non-selective beta blockers or endoscopic band ligation 3