From the Guidelines
The treatment for portal hypertension should prioritize Transjugular Intrahepatic Portosystemic Shunt (TIPS) creation as a crucial therapeutic option to manage complications, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, as supported by recent studies 1.
Initial Management
Initial management includes non-selective beta-blockers such as propranolol (starting at 20mg twice daily) or nadolol (20-40mg daily), which reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction.
Acute Variceal Bleeding
For acute variceal bleeding, emergency measures include vasoactive drugs like octreotide (50mcg IV bolus followed by 50mcg/hour infusion) or terlipressin (2mg IV every 4 hours), combined with endoscopic therapy such as band ligation or sclerotherapy.
Refractory Ascites
Patients with refractory ascites may require diuretics (spironolactone 100mg daily with furosemide 40mg daily, adjusted as needed) or periodic large-volume paracentesis.
TIPS Consideration
TIPS is considered for patients with recurrent variceal bleeding despite medical and endoscopic therapy, or for refractory ascites, as it has been shown to improve clinical outcomes in high-risk patients 1.
Underlying Liver Disease
For patients with cirrhosis, treating the underlying liver disease is crucial, which may include alcohol abstinence, antiviral therapy for viral hepatitis, or weight loss for fatty liver disease.
Supportive Measures
Dietary sodium restriction (less than 2g daily) and fluid restriction in hyponatremic patients are important supportive measures. Regular surveillance endoscopy is recommended to monitor for varices and guide prophylactic treatment.
Multidisciplinary Approach
A multidisciplinary approach involving gastroenterologists, hepatologists, and interventional radiologists is essential for the successful use of TIPS in managing portal hypertension, as emphasized by the North American practice-based recommendations 1. Some key points to consider:
- TIPS creation has emerged as a crucial therapeutic option to treat complications of portal hypertension.
- The decision to perform TIPS involves a multidisciplinary approach and technical expertise to optimize outcomes.
- New procedural techniques, TIPS stent technology, and indications for TIPS have emerged, and practices and outcomes vary greatly across institutions.
- Significant knowledge gaps exist, and further research is needed to develop practice-based recommendations for the use of TIPS in persons with any cause of portal hypertension.
From the Research
Treatment for Portal Hypertension
The treatment for portal hypertension is based on the stage of the disease and the presence of complications.
- In patients with compensated cirrhosis, the aim of treatment is to prevent clinical decompensation, and treatment is limited to etiologic treatment of cirrhosis and a healthy lifestyle 2.
- When clinically significant portal hypertension (CSPH) is present, the association of a non-selective beta-blocker (NSBB), including carvedilol, should be considered 2, 3, 4.
- NSBBs are mandatory if moderate or large varices are present, and patients should also enter a screening program for hepatocellular carcinoma 2.
- In decompensated patients, the goal is to prevent further bleeding and liver transplantation, and treatment is based on the same principles as in compensated patients, associated with administration of NSBBs in combination with endoscopic band ligation if there has been variceal bleeding, and complemented with simvastatin administration 2, 5.
- Recurrence shall be treated with transjugular intrahepatic portosystemic shunt (TIPS), which might be indicated earlier in patients with difficult or refractory ascites, or patients who have bled under NSBBs or shown no hepatic venous pressure gradient (HVPG) response 2, 5.
Pharmacological Therapy
Pharmacological therapy for portal hypertension includes:
- Non-selective beta blockers, which are the treatment of choice for primary and secondary prevention of variceal bleeding 6, 3, 4.
- Carvedilol, which has shown superior efficacy than traditional NSBBs in lowering portal pressure and may be the NSBB of choice for the treatment of clinically significant portal hypertension 3, 4.
- Simvastatin, which may improve survival in patients with ascites and gastroesophageal varices 2, 5.
Interventional Therapy
Interventional therapy for portal hypertension includes:
- Endoscopic variceal band ligation, which is used in combination with NSBBs to prevent recurrent variceal bleeding and improve survival 2, 5.
- Transjugular intrahepatic portosystemic shunt (TIPS), which is indicated in patients with uncontrolled variceal bleeding, difficult or refractory ascites, or patients who have bled under NSBBs or shown no HVPG response 2, 5.