What is the management plan for a patient with portal hypertension?

Management of Portal Hypertension

Risk Stratification and Initial Assessment

All patients with newly diagnosed cirrhosis require screening endoscopy to identify varices and assess bleeding risk, with varices classified as small (F1) or large (F2/F3) and assessment for red color signs indicating high bleeding risk. 1

• Clinically significant portal hypertension (CSPH) is defined as hepatic venous pressure gradient (HVPG) ≥10 mmHg, marking the threshold for developing varices and clinical decompensation 2, 3
• HVPG ≥12 mmHg predicts risk of variceal bleeding and ascites 3
• HVPG ≥16 mmHg independently predicts higher mortality in both compensated and decompensated cirrhosis 3
• Liver stiffness measurement (LSM) ≥20 kPa and/or platelet count <150×10⁹/L warrants upper endoscopy to screen for varices 4

Surveillance endoscopy intervals: Every 2-3 years in compensated cirrhosis without varices, every 1-2 years with small varices if liver injury is ongoing, and every 2 years if liver injury is quiescent 2, 1

Primary Prophylaxis: Preventing First Variceal Bleeding

Non-selective beta-blockers (NSBBs) are the preferred first-line therapy over endoscopic band ligation because they reduce portal pressure systemically and prevent other complications beyond variceal bleeding. 3

Patient Selection for NSBBs

• High-risk varices (large varices or small varices with red signs): Start NSBBs immediately 1, 4
• Small varices with advanced liver disease (Child-Pugh B/C): Start NSBBs 1
• Cirrhosis without varices: Do NOT start NSBBs—they do not prevent varix formation and increase adverse events without benefit 1, 4

NSBB Selection and Dosing

Carvedilol is the preferred NSBB at a target dose of 12.5 mg/day, achieving hemodynamic response in 75% of patients compared to 46-50% with traditional NSBBs (propranolol, nadolol). 1, 4

• Carvedilol works through β-1 blockade (decreases cardiac output), β-2 blockade (splanchnic vasoconstriction), and α-1 blockade (intrahepatic vasodilation) 4
• Traditional NSBBs (propranolol or nadolol) remain acceptable alternatives when carvedilol is unavailable or not tolerated 3, 1
• Hemodynamic goal: Reduce HVPG to ≤12 mmHg or achieve ≥20% reduction from baseline 3, 4

Combination Therapy

• Adding isosorbide mononitrate to NSBBs produces synergistic portal pressure reduction and increases the proportion achieving adequate hemodynamic response 4

Acute Variceal Bleeding Management

Initiate vasoactive drugs immediately as soon as variceal hemorrhage is suspected, before endoscopy. 1

Immediate Resuscitation and Medical Therapy

• Vasoactive drugs: Start octreotide or terlipressin immediately before endoscopy 2, 3, 4
  • Terlipressin: 0.5-1.0 mg IV every 4-6 hours, increase to 2 mg every 4-6 hours if creatinine hasn't decreased by >30% after fluid resuscitation 4
  • Octreotide: Continuous infusion after bolus 2
• Antibiotic prophylaxis: Administer immediately—intravenous ceftriaxone 1 g/24h for maximum 7 days reduces mortality, bacterial infections, and rebleeding 1, 4
• Blood transfusion: Start when hemoglobin reaches 7 g/dL with goal of maintaining 7-9 g/dL—excessive transfusion paradoxically increases portal pressure 1, 4

Endoscopic Management

• Perform endoscopy within 12 hours once hemodynamically stable 2, 1
• Endoscopic variceal ligation (EVL) is the procedure of choice if varices are confirmed 1
• Combination of vasoactive drugs plus endoscopy achieves 77% 5-day hemostasis versus 58% with endoscopy alone 3
• Continue vasoactive drugs for 2-5 days post-endoscopy, then transition to oral NSBBs 1

Rescue Therapy for Refractory Bleeding

TIPS is strongly indicated for variceal bleeding refractory to endoscopic and drug therapy. 2, 3

• Early/pre-emptive TIPS within 72 hours should be considered in high-risk patients: Child-Pugh class C or MELD score ≥19 2, 3
• Early TIPS reduces 1-year mortality (RR 0.68) and rebleeding (RR 0.28) compared to pharmacotherapy/band ligation 2
• TIPS hemodynamic target: Reduce portal pressure gradient to <12 mmHg or ≥20% reduction from baseline 3

Secondary Prophylaxis: Preventing Rebleeding

Combination therapy with NSBBs plus endoscopic band ligation is superior to either alone in preventing rebleeding. 3, 4

• Start NSBBs once vasoactive drugs are discontinued after acute bleeding episode 1
• Schedule repeat endoscopy for band ligation sessions until varices are eradicated 4

Management of Other Portal Hypertension Complications

Portal Hypertensive Gastropathy

• NSBBs are recommended to lower portal pressure 3, 1
• Add iron supplementation for chronic bleeding causing anemia 1
• Argon plasma coagulation for active bleeding 3
• TIPS may be considered for refractory cases 3

Refractory Ascites

• TIPS is effective in reducing fluid accumulation, though survival benefit is unclear 2, 3
• Requires appropriate screening for contraindications and experienced operator 2

Hepatic Encephalopathy

• Lactulose is first-line therapy with goal of producing 2-3 soft stools daily 3
• Post-TIPS encephalopathy: Medical therapy first, with severe cases potentially requiring TIPS diameter reduction or occlusion 3

Critical Safety Considerations and Contraindications

Temporarily suspend NSBBs in acute bleeding with hypotension (systolic BP <90 mmHg or mean arterial pressure <65 mmHg). 1, 4

• Use NSBBs with extreme caution in patients with refractory ascites who develop hypotension 1
• Do NOT routinely correct coagulation abnormalities before prophylactic band ligation in stable cirrhotic patients—this provides no benefit 1
• Do NOT use tranexamic acid in active variceal bleeding—this is contraindicated 1
• Avoid administering large volumes of blood products as this paradoxically increases portal pressure and worsens bleeding 1

Monitoring and Follow-up

• Post-TIPS surveillance: Doppler ultrasound at 1 week and 6-12 month intervals 3
• NSBB therapy monitoring: Watch for signs of hepatic decompensation; heart rate changes do not correlate with HVPG changes 3
• HVPG monitoring can identify treatment responders and guide therapy escalation when available 4

Etiological Treatment

Eliminate the etiological agent (alcohol cessation, hepatitis B/C treatment) as this decreases risk of decompensation and increases survival. 2, 1

• Correction of associated aggravating conditions (obesity, drug-induced liver injury) can decrease portal pressure and reduce decompensation risk 2