Portal hypertension is defined as a hepatic venous pressure gradient (HVPG) >5 mmHg. Hepatic venous pressure gradient is a surrogate for the portosystemic pressure gradient. Clinically significant portal hypertension is defined as a gradient >10 mmHg and variceal bleeding may occur at a gradient >12 mmHg.
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Pathology
Causes can be split by their relation to the hepatic sinusoids 7:
Prehepatic causes
extrinsic compression of portal vein
arteriovenous fistula
SVC obstruction (downhill varices)
Hepatic / sinusoidal causes
schistosomiasis (S. mansoni or S. japonicum)
Posthepatic causes
Subtypes
Radiographic features
Ultrasound
dilated portal vein (>13 mm): non-specific
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decreased portal vein velocity 9
if recanalized paraumbilical vein, velocity may be increased 9
pulsatile portal waveform as pressure increases 9
biphasic or reverse flow in the portal vein (late stage): pathognomonic
enlarged paraumbilical veins 8: pathognomonic
portal-systemic collateral pathways (collateral vessels/varices)
cause of portal hypertension often identified, most commonly cirrhosis
CT and MRI
dilated portal vein +/- mesenteric veins
contrast enhancement of the paraumbilical vein: pathognomonic ref
cause of portal hypertension can often be identified
Treatment and prognosis
Management ultimately depends on the underlying etiology and the associated complications. Generally, management options include:
lifestyle modifications: dietary sodium restriction (e.g. for ascites)
medications: propranolol (e.g. for varices), diuretics (e.g. for ascites)
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interventional procedures
creation of shunts: transjugular intrahepatic portosystemic shunt (TIPS), surgical portosystemic shunt, surgical splenorenal shunt
balloon dilatation of hepatic vein (e.g. for thrombosis/web in hepatic vein)
transhepatic clot thrombolysis (e.g. for portal vein thrombosis)
liver transplantation
Complications
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esophageal varices and gastric varices
variceal bleeding (30-50% mortality with each bleed)
congestive splenomegaly and hypersplenism
Differential diagnosis
Dilatation of splenic veins at the splenic hilum without splenomegaly may occur in situations such as a state of increased perfusion of splenic tissue associated with an immune response 6.
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