Portal Hypertension (portal High Pressure) Is Usually Caused By Liver Cirrhosis. It Can Cause Both Physical And Mental Discomfort

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Portal Hypertension (portal High Pressure) Is Usually Caused By Liver Cirrhosis. It Can Cause Both Physical And Mental Discomfort
Portal Hypertension (portal High Pressure) Is Usually Caused By Liver Cirrhosis. It Can Cause Both Physical And Mental Discomfort
Video: Portal Hypertension (portal High Pressure) Is Usually Caused By Liver Cirrhosis. It Can Cause Both Physical And Mental Discomfort
Video: Portal hypertension - causes, symptoms, diagnosis, treatment, pathology 2023, February
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Portal hypertension (portal hypertension)

The portal vein (Vena portae) is the vessel that carries the venous blood of the abdominal organs (stomach, small intestine, parts of the large intestine, pancreas, spleen) to the liver. There nutrients are metabolized and many substances toxic to the body are converted and excreted. Various diseases can slow or interrupt the blood flow in the portal vein and thereby increase its blood pressure. Blood backs up in front of the liver. The blood now has to flow to the heart via so-called collateral circuits via other veins, bypassing the liver. This means that substances remain in the bloodstream that should actually be broken down in the liver and then excreted or metabolized. In addition, the veins of the collateral circulation are not suitable for transporting such large amounts of blood. This can have life-threatening consequences.

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  • What are the causes of portal hypertension?
  • What are the symptoms?
  • How is the diagnosis made?
  • How is portal hypertension treated?
  • How can portal hypertension be prevented?
  • Whom can I ask?
  • How will the costs be reimbursed?

What are the causes of portal hypertension?

The blood pressure in the portal vein is usually higher than in the inferior vena cava, into which the blood from the hepatic veins flows. Differences in pressure of up to five mmHg are normal. Portal hypertension (portal vein high pressure) is understood to mean higher pressure differences. In the case of mild portal hypertension, the difference is six to nine mmHg. Values ​​above this indicate pronounced portal hypertension. Even if the pressure in the portal vein is above twelve mmHg, this corresponds to pronounced (clinical) portal hypertension. Above this limit, secondary diseases develop.

Portal hypertension is usually the result of cirrhosis of the liver. In Austria, this is often due to alcohol abuse. A chronic virus-related inflammation of the liver (hepatitis B or C) is also a typical cause of liver cirrhosis.

Occasionally it is due to abnormal changes in the hepatic vessels or to a blockage in the portal vein (e.g. thrombosis). An obstacle to drainage to the liver, for example due to a thrombosis in the inferior vena cava or a congestion of blood in the case of heart failure (cardiac insufficiency), can also cause portal hypertension. Very rare causes include sarcoidosis of the liver or liver metastases.

What are the symptoms?

The portal hypertension itself usually does not cause any symptoms, but does cause subsequent complications.

Since the blood can no longer flow sufficiently to the liver via the portal vein, new blood paths form from veins in the abdomen to the heart, bypassing the liver (collateralization). The veins in these collateral circuits are not suitable for carrying large amounts of blood and tend to develop into varicose veins. These vein widenings can be found on the abdominal wall around the navel (caput medusae), along the stomach and esophagus (esophagus) and in the anal area (hemorrhoids).

The most dangerous complication is the bursting of such a varicose vein. Veins in the esophagus are often affected. So-called acute esophageal variceal bleeding develops. This can lead to massive, life-threatening bleeding from the enlarged veins of the esophageal mucosa without pain. Bursting veins in the stomach can also cause severe bleeding. There may be vomiting of blood. The vomit can be red or black. Black blood in the stool (tarry stool) can also be observed when veins in the esophagus or stomach bleed. When hemorrhoids bleed, fresh, red deposits of blood appear on the stool.

Symptoms of other possible consequences of portal hypertension:

  • Ascites (ascites) leads to an increase in the size of the abdomen and possibly abdominal pain;
  • Complaints due to a restriction of detoxification functions as well as the metabolism of hormones, foreign substances and drugs in the liver (e.g. complaints from drug overdoses or from hepatic encephalopathy);
  • Complaints due to backflow of blood in the spleen: increased breakdown and thus deficiency of blood cells (anemia, leukocytopenia) and platelets (thrombocytopenia).

How is the diagnosis made?

During the physical examination, the doctor may be able to identify veins that are shimmering through the skin (vein markings) in the abdominal area, more rarely varicose veins around the navel (caput medusae), an enlarged spleen or ascites.

If a condition is found that can cause portal hypertension, the doctor will check whether it is present:

  • A difference in blood pressure between the portal vein and the inferior vena cava can be carried out indirectly through special blood pressure measurements in a hepatic vein. These measurements are taken through a venous catheter. Ultrasound or computed tomography also provide information.
  • Varices, bleeding and changes in the gastric mucosa are detected endoscopically with the help of an esophago-gastro-duodenoscopy. This examination is usually repeated at regular intervals.

How is portal hypertension treated?

Which therapy the doctor chooses is decided individually. Primarily, the respective underlying disease (e.g. hepatitis C, alcohol-related liver cirrhosis or portal vein thrombosis) is treated.

All pathogenic changes such as nutrient deficiency, bleeding tendency and risk factors with regard to liver performance, but also the cardiovascular system, must be taken into account.

The prevention of secondary diseases is also very important in the care of patients with portal hypertension.

Endoscopic or drug treatment for gastric or esophageal varices can reduce the risk of (renewed) variceal bleeding. The doctor can prescribe a beta blocker for this. The constriction of varices (ligature) as part of an endoscopy is also possible.

If the response is inadequate, certain stent connections between the portal and venous blood circulation from the liver to the heart may be considered.

In the intrahepatic portosystemic (stent) shunt (TIPS / TIPSS), a plastic tube is inserted through the large jugular vein under ultrasound control. This is carried to the liver and through the liver tissue to the portal vein (vena portae). A metal tube (stent) (sometimes several) is inserted over the plastic tube and fixed in the liver. This keeps the connection between the portal vein and a hepatic vein open. The blood flows from the liver tissue via liver veins into the inferior vena cava (inferior vena cava). The connection between the portal vein and the liver vein allows congested blood to drain away, bypassing the liver tissue.

The creation of a peritoneovenous shunt (PVS) is also an option. This creates a connection between the abdomen and the superior vena cava (superior vena cava). This allows fluid from the abdomen to be returned to the blood system.

However, these two shunts increase the risk of developing hepatic encephalopathy. All these measures improve the long-term prognosis only slightly.

A liver transplant can be done if you have severe liver disease. Portal hypertension usually regresses after a transplant.

How can portal hypertension be prevented?

Diseases that can lead to portal hypertension are treated as quickly and consistently as possible in order to prevent the development of portal hypertension.

In the case of liver disease, it is also strongly recommended to abstain from alcohol (alcohol abstinence). Depending on the severity of the liver damage, the pathological liver changes can recede or be stopped or at least slowed down as a result of alcohol abstinence.

Whom can I ask?

The diagnosis and treatment of portal hypertension as a result of liver cirrhosis are possible in the following facilities:

  • special hospital outpatient department, e.g. hepatological outpatient department,
  • Department of Internal Medicine or Gastroenterology and Hepatology,
  • Cash outpatient clinics with special hepatology clinics,
  • In the private practice area: Specialist in internal medicine with in-depth hepatological knowledge.

How will the costs be reimbursed?

All necessary and appropriate diagnostic and therapeutic measures are taken over by the health insurance carriers. You can find more information under What does a hospital stay cost? Your resident doctor or outpatient clinic will generally settle accounts directly with your health insurance provider. With certain health insurance providers, however, you may have to pay a deductible (treatment contribution) (BVAEB, SVS, SVS, BVAEB). However, you can also use a doctor of your choice (ie doctor without a health insurance contract). For more information, see What does a hospital stay cost, a doctor's visit: Costs and deductibles.

For certain non-drug treatments (e.g. physical therapy) - in some cases only when a certain level has been reached - approval from the health insurance provider may be required.

For certain services (e.g. medical aids and medical aids) - depending on the health insurance provider - patient co-payments are provided. Most health insurance providers provide for a permit, sometimes depending on the type of medical aid. The prescription fee has to be paid for medication on a “prescription”. For more information about the respective provisions, please contact your health insurance provider, which you can find on the social security website, for example.

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