Cirrhosis and portan hypertension

Question 1

Complications of cirrhosis

Answer 1

Portal hypertension
Variceal haemorrhage
Primary Biliary Cirrhosis

Question 2

What veins join to form portal vein

Answer 2

Superior mesenteric vein

Splenic veins

Question 3

Normal pressure of portal vein

Answer 3

5-8mmHg (small gradient across the liver)

Question 4

What vein transports blood from liver to inferior vena cava

Answer 4

Hepatic vein

Question 5

Pre-hepatic causes of portal hypertension

Answer 5

Portal vein thrombosis

Question 6

Intra-hepatic causes of portal hypertension

Answer 6

Cirrhosis (80% UK)
Schistosomiasis (commonest worldwide)
Sarcoidosis

Question 7

Post-hepatic causes of portal hypertension

Answer 7

Right HF (rare)
Constrictive pericarditis
IVC obstruction

Question 8

What is most common cause of hepatic portal hypertension worldwide

Answer 8

Schistosomiasis

Question 9

Pathophysiology of portal hypertension

What causes 1st increase in BP, then decrease in BP, then 2nd increase in BP

Answer 9

1st INCREASE:
Liver injury and fibrogenesis (e.g. due to cirrhosis)
Contraction of activated myofibroblasts (mediated by endothelin, nitric oxide and prostaglandins) contributes to increased resistance to blood flow (vasoconstriction)
Causes portal hypertension
DECREASE:
→ splanchnic vasodilation
→ drop in BP
2nd INCREASE:
→ increased cardiac output to compensate for BP
→ salt and water retention to increase blood volume and compensate
→ hyperdynamic circulation (high circulatory volume) /increased portal flow
→ Formation of collaterals between the portal and systemic systems e.g. in the lower oesophagus and gastric cardia

Microvasculature of gut becomes congested and gives rise to portal hypertensive gastropathies and colopathies

Question 10

Sites of collaterals/varices as a result of portal hypertension

Answer 10

• Gastro-oesophageal junction - superficial and tend to rupture
• Rectum (30%)
• Left renal vein
• Diaphragm
• Retroperitoneum

Question 11

Portal hypertension clinical presentation

Answer 11

Often asymptomatic

Only clinical sign = splenomegaly (unspecific)

Question 12

Portal hypertension clinical presentation if chronic liver disease present

Answer 12

• Haematemesis and melaena from ruptured gastro-oesophageal varice or portal hypertensive gastropathy
• Clubbing
• Palmar erythema
• Dupuytren’s contracture (one or more fingers bending into palm of hand)
• Spider naevi