What are the symptoms of portal hypertension?

Symptoms of Portal Hypertension

Portal hypertension manifests primarily through gastrointestinal bleeding (most commonly from esophageal and gastric varices), ascites, splenomegaly with reduced blood cell counts, and hepatic encephalopathy—with variceal bleeding being the most life-threatening presentation. 1, 2

Primary Clinical Manifestations

Gastrointestinal Bleeding

• Variceal bleeding is the most frequent and dreaded complication, occurring when the portal-systemic gradient exceeds 12 mmHg, affecting 30% of patients with cirrhosis and carrying a 30-day mortality of 20%. 3
• Bleeding can occur from esophageal varices, gastric varices (including fundic varices), or less commonly from rectal, duodenal, or other sites. 4
• Portal hypertensive gastropathy causes chronic bleeding with a characteristic "snake-skin appearance" or mosaic pattern on endoscopy, leading to iron-deficiency anemia and need for repeated transfusions. 4

Ascites and Fluid Accumulation

• Ascites is the most common complication of portal hypertension, dramatically reducing 5-year survival from 80% in compensated cirrhosis to 50% when it appears. 1, 2
• Refractory ascites carries a particularly grave prognosis with 1-year mortality ranging from 20% to 50%. 1
• Hepatic hydrothorax (pleural effusion) occurs in 0%-8% of cases. 2

Splenomegaly and Hematologic Changes

• Enlarged spleen is often a prominent physical finding that can be detected on examination or imaging. 2, 5
• Hypersplenism results in reduced blood cell counts, manifesting as thrombocytopenia and leukopenia. 2, 5

Hepatic Encephalopathy

• Hepatic encephalopathy occurs in more than 10% of all cirrhosis cases and critically reduces quality of life. 4
• Overt hepatic encephalopathy presents with disorientation, flapping tremor (asterixis), and various neurologic and psychiatric abnormalities. 4
• Subclinical (covert) encephalopathy is much more common than previously suspected and includes minimal hepatic encephalopathy. 4
• Ascites, bacterial infections, and overt encephalopathy are uncommon except following an episode of gastrointestinal bleeding. 4

Less Common Manifestations

Biliary Symptoms

• Portal cholangiopathy can cause biliary pain, pancreatitis, or cholecystitis due to compression and deformation of bile ducts by collateral veins. 4
• Progressive cholestatic disease or recurrent bacterial cholangitis are rare complications. 4

Abdominal Pain and Bowel Symptoms

• Some patients experience post-prandial abdominal pain or features of incomplete bowel obstruction related to ischemic stenosis. 4

Systemic Complications

• Hepatorenal syndrome is a frequent and grave complication of refractory ascites, with Type 1 showing progressive severe decline in renal function. 1
• Portosystemic collaterals can be detected on abdominal imaging. 4, 2

Important Clinical Context

The severity of portal hypertension typically contrasts with mild or absent liver dysfunction and normal levels of transaminases, alkaline phosphatase, and gamma-glutamyl transferase in non-cirrhotic portal hypertension. 4

Due to improved sensitivity of non-invasive imaging, diagnosis is increasingly made at early stages before gastrointestinal bleeding occurs, with frequent fortuitous findings of splenomegaly, reduced blood cell counts, varices, or collaterals on imaging. 4