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Portal hypertension

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High Yield Notes

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Portal hypertension

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Questions

USMLE® Step 1 style questions USMLE

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A 54-year-old woman is brought to the emergency department by her partner due to altered mental status for the last 2 days. According to her husband, the patient has become increasingly lethargic, disoriented, and agitated. The patient has a history of chronic hepatitis C infection that was diagnosed 14 years ago. She refused all treatment at that time. Temperature is 37.0°C (98.6°F), pulse is 98/min, and blood pressure is 104/74 mmHg. On examination, the patient is lethargic and oriented only to self. When her hands are outstretched in front of her and extended at the wrist, they exhibit a flapping tremor. The abdomen is nontender and mildly distended; shifting dullness to percussion is present. There is no nuchal rigidity. Stool occult blood is positive. Laboratory testing reveals the following findings:



The patient is started on emergent therapy for her symptoms. Which of the following best explains the pathophysiology of this patient’s current condition?

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Budd-Chiari syndrome p. 399

portal hypertension p. 396

Cirrhosis p. 396

portal hypertension p. 396

Portal hypertension p. 396

ARPKD p. NaN

cirrhosis and p. 396

pulmonary arterial hypertension p. 697

Schistosoma spp. p. 158

serum markers for p. 397

varices and p. 372

Schistosomiasis

portal hypertension p. 396

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Transcript

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Content Reviewers

Viviana Popa, MD

Portal hypertension means increased blood pressure in the hepatic portal system - or portal venous system.

Most commonly, this happens because of hepatic cirrhosis, which is when the liver tissue is replaced by fibrotic, functionless tissue.

Now, the portal venous system comprises the portal vein and its tributaries - namely, the splenic, and mesenteric veins.

This blood contains all the nutrients absorbed in the GI tract, but it also carries toxins that the liver metabolizes so that they can be safely excreted by the kidneys.

Once the liver processes all these substances, it sends the blood to the heart, through the inferior vena cava, to enter the systemic venous system.

Now, there’s a few points in the boundaries of the hepatic portal system, where it could be connected with the systemic venous system that collects blood from the rest of the body: the inferior portion of the esophagus, the superior portion of the anal canal, and the round ligament of the liver - which used to be the umbilical vein during fetal life.

At birth, the umbilical cord is cut, and the umbilical vein collapses to form the round ligament.

Normally, the round ligament stays shut because pressures in the portal venous system and the systemic venous system are the same, between 5 and 10 Millimeters of Mercury

But in some situations, an obstruction may prevent blood flow from the portal vein towards the inferior vena cava.

When this happens, venous blood accumulates in the hepatic portal system, causing pressure to rise above 5 to 10 12 mmHg - which defines portal hypertension of mercury.

Portal hypertension leads to the formation of portosystemic shunts - which is when blood is diverted away from the portal venous system and backs up into systemic veins.

Summary

Portal hypertension is hypertension in the hepatic portal system, which is composed of the portal vein and its branches and tributaries. This can lead to serious complications, such as the development of enlarged veins in the esophagus and stomach, called varices, which can rupture and cause bleeding. It can also lead to ascites, an accumulation of fluid in the abdomen, and liver failure. Treatment involves medications to reduce pressure in the portal vein, such as beta-blockers like propranolol.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Portal hypertension: pathophysiology, diagnosis and management" Internal Medicine Journal (2015)
  6. "Pathophysiology of Portal Hypertension and Esophageal Varices" International Journal of Hepatology (2012)