Management of Portal Hypertension

Abstract

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

Keywords: ACLF, acute-on-chronic liver failure; AKI, acute kidney injury; APRI, AST to platelet ratio; AST, aspartate transaminase; BB, Beta blocker; BRTO, balloon occluded retrograde transvenous obliteration; CKD, chronic kidney disease; CSPH, clinically significant portal hypertension; CT, computed tomography; GFR, glomerular filtration rate; GOV, gastrpoesopahegal varices; HE, hepatic encephalopathy; HRS, hepatorenal syndrome; HVPG, hepatic venous pressure gradient; ICG, indocyanine green; LOLA, l-ornithine l-aspartate; NAFLD, Non-alcoholic fatty liver disease; SBP, spontaneous bacterial peritonitis; SGLT2I, sodium glucose co-transporter 2 inhibitors; SSM, splenic stiffness measurement; TE, transient elastography; TIPS, transjugular intrahepatic portosystemic shunt; VITRO, von Willebrand factor to platelet counts; acute kidney injury; ascites; hemodynamics; history; vasoconstrictors.

Figure 1

Non-invasive methods for diagnosis of portal hypertension. HVPG, hepatic venous pressure gradient; APRI, AST to platelet ratio; ICGr, indocyanine green retention test; TE, transient elastography; SWE, shear wave elastography; MRE, magnetic resonance elastography; SSM, splenic stiffness measurement; CSPH, clinically significant portal hypertension; vWF, Von Willebrand factor.

Figure 2

Management of acute variceal bleed. Patients with HVPG >20 mmHg or patients with a Child-Pugh score of 10–13 (Child class C) or Child-Pugh score of 7–9 (Class B) with active bleeding at endoscopy are high risk patients who may benefit from pTIPS. PRBC, packed red blood cells; EV, esophageal varices; GOV, gastrpoesopahegal varices; BRTO, balloon occluded retrograde transvenous obliteration; pTIPS, pre-emptive TIPS; TIPS, transjugular intrahepatic portosystemic shunt.

Figure 3

Management of hepatic encephalopathy. ¶ A bolus intravenous indomethacin (0.5 mg/kg) may be considered for raised intracranial hypertension and cerebral hyperemia, which does not respond to mannitol and hypertonic saline. ǁ For patients with increased intracranial pressures and progressive encephalopathy, an electroencephalogram is suggested to evaluate seizure activity and start antiepileptics accordingly. MV, mechanical ventilation; HE, hepatic encephalopathy; Na, sodium; NG, nasogastric; PEG, polyethylene glycol; LOLA, l-ornithine l-Aspartate.

Figure 4

Secondary prophylaxis to prevent rebleeds. AVB, acute variceal bleed; EV, esophageal varices; GOV, gastroesophageal varices; HVPG, hepatic venous pressure gradient; TIPS, transjugular intrahepatic portosystemic shunt; LT, liver transplantation; NSBB, non-selective beta-blocker; EVL, endoscopic variceal ligation; GVB, gastric variceal bleed; PPG, portal pressure gradient; BRTO, balloon occluded retrograde transvenous oblit- eration; HE, hepatic encephalopathy; EUS, endoscopic ultrasonography.

Figure 5

Management of ascites and its complications. LVP, large volume paracentesis; SGLT2I, sodium glucose co-transporter 2 inhibitors; TIPS, transjugular intrahepatic portosystemic shunt; PCD, percutaneous drainage; CPAP, continuous positive airway pressure; HRS, hepatorenal syn- drome; CKD, chronic kidney disease.