CAUSES :
β’ Cirrhosis accounts for > 90% of cases. Alcoholic and hepatitis C most common causes of cirrhosis, but hemochromatosis, hepatitis B, nonalcoholic steatonecrosis, biliary cirrhosis, autoimmune cirrhosis account for some.
β’ Extrahepatic portal vein occlusion from umbilical vein infection, trauma, chronic pancreatitis, thrombotic conditions, polycythemia cause a few
β’ Noncirrhotic portal hypertension common in patients from Asian continents
β’ Malignant invasion of liver sinusoids or portal vein. Seen in lymphoma, leukemia, hepatocellular carcinoma, pancreatic carcinoma.
β’ Metabolic diseases altering liver sinusoids - amyloid, Gaucher disease, fatty liver
β’ Budd-Chiari syndrome, veno-occlusive disease due to senecio, thrombotic conditions
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DIFFERENTIAL DIAGNOSIS
. Upper GI bleeding
. Pulmonary bleeding; hemoptysis
. Peptic ulcer disease
. Gastric malignancy
. Lower GI bleeding
. Hemorrhoids
. Colon malignancy
. Colonic polyp
. Diverticulitis
IMAGING
β’ Esophagram following barium swallow with adherent barium demonstrates very advanced varices, but is insensitive to small ones. Is not used when bleeding present for it precludes possible urgent angiography.
β’ MRI demonstrates large vascular channels intraabdominally, and in the mediastinum. Demonstrates patency of the intrahepatic portal vein and splenic vein if this is required.
β’ Doppler sonography demonstrates patency, diameter, and flow in portal vein, and splenic vein, and large collaterals intra-abdominally
β’ Venous phase celiac arteriography demonstrates portal vein and its collaterals
DIAGNOSTIC PROCEDURES :
β’ Esophagoscopy as part of EGD endoscopy can identify and treat. Large, protruding, lumenal veins in the distal 1/3 of the esophagus are diagnostic. If recent bleeding, they may be seen to be bleeding in 5%. Useful when active bleeding is present, to identify early varices, and to follow course of treatment.
Doppler sonography to demonstrate patency of:
. Portal and splenic veins
. Porta-caval shunts
Venous phase angiography
. Diagnose hepatic vein occlusion
Endoscopic ultrasound particularly sensitive to gastric varices
Portal pressure measure
. Radiologist introduces a catheter retrograde into the hepatic veins in a wedged position to occlude flow
. Catheter is withdrawn to a free position and pressure again measured. Difference between wedged and free is portal pressure. If under 12 mm Hg, bleeding is extremely unlikely. Progressive increases above 12 correlate with likelihood of hemorrhage.
. This is sometimes used to monitor successful treatment with beta adrenergic blocking agents