From the Guidelines
Portal hypertension management should prioritize the use of non-selective beta-blockers, such as propranolol or nadolol, as first-line therapy for primary prevention of variceal bleeding in patients with medium to large varices, as recommended by the most recent guidelines 1.
Pathogenesis and Complications
Portal hypertension is a condition characterized by increased blood pressure in the portal venous system, typically resulting from cirrhosis of the liver. It occurs when resistance to blood flow through the liver increases, causing blood to back up in the portal vein and seek alternative pathways through collateral vessels. The most concerning complication is the development of esophageal and gastric varices, which can rupture and cause life-threatening bleeding.
Management Strategies
Management includes both prevention and treatment of acute bleeding episodes.
- Non-selective beta-blockers like propranolol (20-40mg twice daily) or nadolol (20-40mg daily) are first-line medications for primary prevention in patients with medium to large varices.
- Endoscopic variceal ligation is recommended every 2-4 weeks until varices are obliterated for patients who cannot tolerate beta-blockers or have contraindications.
- For acute variceal bleeding, immediate resuscitation with blood products, vasopressors like octreotide (50mcg IV bolus followed by 50mcg/hour infusion for 3-5 days), and antibiotics such as ceftriaxone (1g IV daily for 5-7 days) are essential.
- Endoscopic therapy should be performed within 12 hours.
- TIPS (transjugular intrahepatic portosystemic shunt) may be considered for refractory bleeding or in patients with recurrent bleeding despite medical and endoscopic therapy, as per the latest practice-based recommendations 1.
Long-term Management
Long-term management focuses on treating the underlying liver disease, as portal hypertension will persist until the primary condition improves. The use of statins, which have antifibrotic properties and can improve endothelial dysfunction, may also be beneficial in reducing portal pressure, as suggested by recent studies 1.
Key Considerations
- The decision to perform TIPS should be determined by specialists in gastroenterology and hepatology, with the procedure being performed by interventional radiology (IR) 1.
- TIPS creation is effective for management of complications of portal hypertension but is associated with several risks, including deterioration in liver function, new onset or worsening hepatic encephalopathy, and changes in cardiopulmonary and renal hemodynamics.
From the Research
Definition and Causes of Portal Hypertension
- Portal hypertension is defined as increased pressure in the portal venous system, with the most common cause being cirrhosis, leading to an increase in intrahepatic resistance and portal pressure 2.
- Splanchnic vasodilation can further aggravate portal hypertension by increasing portal blood flow 2.
Diagnosis of Portal Hypertension
- The presence of varices at endoscopy and/or other abdominal portosystemic collaterals confirms the diagnosis of portal hypertension 2.
- Non-invasive tests, such as liver stiffness measurement in combination with platelet count, may be accurate in identifying clinically significant portal hypertension 3.
Treatment of Portal Hypertension
- Non-selective beta blockers, such as propranolol and nadolol, are effective in reducing the risk of variceal bleeding and hepatic decompensation 2, 4, 5, 6.
- Carvedilol is a more potent agent than propranolol in reducing portal pressure and is better tolerated 3, 4.
- Terlipressin, somatostatin, or octreotide, in combination with early endoscopic therapy, are recommended for the treatment of acute variceal hemorrhage 2.
- Early Transjugular intrahepatic portosystemic shunt (TIPS) is effective as salvage therapy in acute variceal bleeding in selected patients and prevents rebleeding more effectively than endoscopic and medical therapy 2.
Pharmacological Therapies for Portal Hypertension
- Non-selective beta blockers remain the pharmacotherapy of choice for primary and secondary prophylaxis of variceal bleeding 3.
- The combination of beta blockers and nitrates may be more effective than one drug alone in reducing portal pressure 4, 6.
- Carvedilol has been shown to reduce the risk of hepatic decompensation and improve patient survival among patients with clinically significant portal hypertension 3.