What is the treatment for portal hypertension?

Treatment of Portal Hypertension

The treatment of portal hypertension should be tailored to the specific complication being addressed, with first-line therapy including non-selective beta-blockers (NSBBs) for variceal bleeding prophylaxis, and transjugular intrahepatic portosystemic shunt (TIPS) for refractory complications such as recurrent variceal bleeding and ascites. 1, 2

First-Line Management

Variceal Bleeding Management

• Acute variceal bleeding requires immediate administration of vasoactive agents (such as octreotide) followed by endoscopic therapy, with combination therapy improving 5-day hemostasis rates (77% vs 58% with endoscopy alone) 2
• Antibiotic prophylaxis should be administered to cirrhotic patients with acute upper gastrointestinal bleeding to reduce mortality, bacterial infections, and rebleeding 2
• For primary prophylaxis of variceal hemorrhage, NSBBs are preferred over endoscopic band ligation (EBL) as they reduce portal pressure and prevent other complications of portal hypertension 1
• For secondary prophylaxis (prevention of rebleeding), combined therapy with NSBBs plus EBL is recommended as it significantly decreases rebleeding compared to monotherapy 1

Ascites Management

• Medical management with diuretics (particularly spironolactone) is first-line for ascites, which reduces plasma volume and decreases splanchnic blood flow 2, 3
• For refractory ascites, TIPS should be considered in selected patients without contraindications 2

Portal Hypertensive Gastropathy

• NSBBs are recommended as initial treatment for portal hypertensive gastropathy, along with iron supplementation for chronic bleeding 1, 2
• In cases with active bleeding, endoscopic treatment with argon plasma coagulation can be used 1

Advanced Management: TIPS

Indications for TIPS

• TIPS is strongly recommended for gastro-esophageal variceal bleeding refractory to endoscopic and drug therapy 2
• Early or pre-emptive TIPS should be considered within 72 hours of a variceal bleed in high-risk patients (Child's C disease or MELD ≥19) 2
• TIPS is recommended for selected patients with refractory or recurrent ascites 2
• TIPS may be considered for hepatic hydrothorax, though further studies comparing it with standard of care are needed 1

Contraindications for TIPS

• Contraindications include bilirubin >50 μmol/L, platelets <75×10^9, pre-existing encephalopathy, active infection, severe cardiac failure, and severe pulmonary hypertension 2
• The presence of porto-pulmonary hypertension requires careful evaluation as TIPS may worsen pulmonary hypertension 1

TIPS Procedure and Follow-up

• Covered stents are preferred over bare metal stents due to superior patency rates 2
• Doppler ultrasound is recommended one week after TIPS implantation in patients with prothrombotic conditions, with regular follow-up at 6-12 month intervals 2

Complications and Management

Hepatic Encephalopathy

• Hepatic encephalopathy affects approximately one-third of patients after TIPS 2
• In most cases, hepatic encephalopathy responds to simple measures and medical therapy, but in severe cases, it may be necessary to reduce the diameter of or occlude the TIPS 1

Porto-Pulmonary Hypertension

• Patients with porto-pulmonary hypertension require supplemental oxygen to maintain arterial oxygen saturations >90% 1
• Cautious use of diuretics is recommended to control volume overload, edema, and ascites 1
• Anticoagulant therapy should be avoided in patients with impaired hepatic function, low platelet counts, or increased risk of bleeding due to gastroesophageal varices 1

Special Considerations

• Portal vein thrombosis is not an absolute contraindication to TIPS placement, although cavernoma presence is associated with higher failure rates 2
• In patients with esophageal varices or history of variceal bleeding, appropriate prophylaxis should be maintained with NSBBs or EBL 2
• Triple therapy with a beta-blocker, a nitrate, and spironolactone may enhance the decrease in portal pressure in selected patients 3
• Statins have emerged as promising new pharmacological therapy for portal hypertension, targeting both intrahepatic and extrahepatic mechanisms 4

Monitoring and Follow-up

• Regular endoscopic monitoring is necessary to evaluate treatment response and identify variceal recurrence early 5
• Hepatic venous pressure gradient (HVPG) measurement can guide therapy when available, with a target reduction to ≤12 mmHg or a ≥20% reduction from baseline 1, 3
• Imaging studies such as Doppler ultrasound should be used to assess portal system patency after interventions 5