PORTAL
HYPERTENSION AND
VARICEAL BLEEDING
DR UMAIR HASSAN
PGR GASTROENTEROLOGY
GUJRANWALA TEACHING HOSPITAL
Normal Portal Circulation
Total length P.V is approximately
7.5cm,Diameter is 7-13mm.
Liver received 30% of total C.O and 75% of
which through portal vein and 25% through
hepatic artery.
Portal Hypertension
Defined as increase in hepatic sinusoidal pressure
to 6mmHg or greater.
Portosystemic collaterals decompress the
hypertensive hepatic sinusoids and give rise the
varices.
P.H result from the changes in portal resistance and
portal inflow.
∆P=F×R
Increase Intrahepatic Resistance
Intrahepatic Resistance
Drugs that can decrease Intrahepatic
Resistance
Carvedilol
Nitrates
Statins
Somatostatin(inhibit ET-1dependant HSC
contraction)
Hyper dynamic Circulation
Increased NO production causes splanchnic
vasodilation that leads to increase portal inflow.
Drugs limiting portal inflow are
Octreotide, Somatostatin
Terlipressin,Vasopressin
NSBB
Collateral Circulation and Varices
Increased portal pressure leads to Portosystemic
collateral formation.
Most common site for Varices are distal esophagus,
proximal stomach, umbilicus and rectum.
P.H greater than 10mmHg result in variceal
development
P.H> 12 leads to variceal Bleeding
Measurement of portal pressure
HVPG is the difference between WHVP & FHVP.
Splenic pulp pressure
Portal vein pressure
Esophageal Varices
E.V are the dilated submucosal veins that connect
the portal and systemic circulation.
Accounts for 1/3rd of all death due to cirrhosis.
Mortality due to variceal bleeding is 5-8% In 1 week
and 20-30% in 6 week after 1st episode.
50% bleeding stop spontaneously and 30% rebleed
40% of rebleeding occur within 5 day.
Most Common sites are distal esophagus, proximal
stomach, rectum and Umbilicus.
E.V present in 40% of cirrhotics and 60% of cirrhotics
with ascites.
Classification of Varices
On the Basis of Size:
Small <5mm (Risk of bleeding 7% by 2 years)
Large>5mm (Risk of bleeding 30% by 2 years)
On the Basis of Colour
White or Blue.
Detection of Varices
Endoscopy
USG Abdomen
CT Scan
MRI
EUS
Investigations
Baselines
PT,INR
Blood Grouping & Cross matching
Viral Serology
Primary Prophylaxis
Indication of Screening EGD:
Cirrhosis with platelet count less than 110,000
and Liver stiffness by transient elastography
more than 25kPa.
Prevention of Rebleeding
Risk of rebleeding is 80% in 2 years.
Combined therapy with EVBL & NSBB reduce the
risk.
Drug therapy target is to reduce HVPG greater
than 20% or less than 12mmHg and HR by 25% or 55-
60bpm.
Endoscopy session after 7-14 days to ligate all
Varices. Then 1st EGD after 3-6 after eradication
and then annually.
Other Options for Esophageal Varices
Sclerotherapy
Esophageal Stents
Balloon Temponade. (Sengstaken blackemore
tube & Minnesota tube & Linton-Nachlas tube)
TIPS
Clips
Detachable Snares
Gastric Varices
Gastric Varices
Approximately 25% of of cirrhotics develop GV.
Bleeding mostly associated with GOV-2 and IGV-1.
Primary Prevention:
MELD score>17 and Size>20mm needs primary
prophylaxis with NSBB.
TIPS and Sclerotherapy not recommended for
primary prophylaxis.
Gastric Varices
Sclerosing agents:
Cyanoacrylate, sodium morrhuate, sodium
tetradecyl sulfate,ethanolamine oleate and
absolute alcohol.
Complications:
Rebleeding, infection, sepsis, ulcers, thrombolic
event, stricture and perforation and scope
damage.
Ectopic Varices
Varices that occur at the site other than esophagus
and stomach.
Accounts for less than 5% of Varices related
Bleeding.
Can present with UGIB, hematuria,
hemoperitoneum and retroperitoneal bleeding.
Most commonly in duodenum, anorectal and
stomal Varices.
Portal Hypertensive Gastropathy
Gastric mucosal changes associated with PTH.
Types:
Mild: when only mosaic pattern seen.
Severe: when superimposed discrete red spots
are also seen.
PHG accounts for 1/4th of UGIB in patients with
PTH.
Gastric Antral Vascular Ectasia
Aggregates of Ectatic vessels as red spots without
mosaic pattern in patients with PTH.
When limited to Antrum called as GAVE.
When distributed to proximal and distal stomach
known as Diffuse gastric vascular ectasias.
Histology: Biopsy shows fibrin thrombi, proliferation of
spindle cells and Ectatic vessels.
