Portal Hypertension

Overview

Portal hypertension is a condition involving elevated blood pressure within the portal venous system, which carries blood to the liver from the intestines, spleen, pancreas and stomach. This increase in pressure is usually caused by a blockage in blood flow through the liver.

Though portal hypertension can develop due to issues like a blood clot in the portal vein, the condition is most often caused by cirrhosis, which is advanced scarring (A.K.A. fibrosis) of the liver due to tissue damage. This damage can be due to different causes, including alcohol abuse, chronic hepatitis, misuse or overdose of certain medicines (including over-the-counter pain relievers like acetaminophen), type 2 diabetes or nonalcoholic fatty liver disease.

In response to portal hypertension, the body often attempts to divert blood flow through other veins. The extreme pressure can make those veins dangerously expand, which thins, stretches and weakens their walls. If left untreated, these veins can leak blood or even rupture, potentially causing life-threatening internal bleeding.

Advanced Treatment for Portal Hypertension at Hoag

According to the National Institutes of Health, portal hypertension is the most frequent cause of hospitalization and death in patients with cirrhosis of the liver. Early detection of cirrhosis is difficult because the condition usually causes few noticeable symptoms until advanced scarring of the liver has developed.

That’s why you need a team with the experience to recognize subtle or rare symptoms and the tools and techniques to meet serious liver issues head on. The Hoag Digestive Health Institute’s Liver Program sets the gold standard in caring for these challenging conditions. It’s the most comprehensive program in Orange County, offering next-generation diagnosis and treatment options that can make all the difference for those facing advanced liver disease. Meet Hoag’s Liver Program Team.

Symptoms and Causes of Portal Hypertension

Portal hypertension can be caused by blood clots or tumors in the liver, but is usually caused by cirrhosis, a condition in which extensive scar tissue has built up inside the liver due to tissue damage. If not discovered and halted before too much damage has taken place, this scarring can potentially cause blockage of blood flow through the liver, which can lead to portal hypertension.

Most people don’t know they have portal hypertension or cirrhosis until they develop serious symptoms. The most common symptoms of portal hypertension are due to enlarged or leaking veins inside the abdomen related to the body’s attempts to route blood around blockages in the liver. Symptoms and complications related to portal hypertension can include:

Bleeding in the gastrointestinal tract due to the rupture of enlarged veins in the esophagus and stomach, which may cause:

• Vomiting blood
• Blood in the stool
• Black or tarry stools
• Abdominal pain
• Bloating in the abdomen due to fluid retention (AKA ascites)
• Caput medusa, which are veins, visible through the skin, that can develop around your navel
• Edema, which is swelling of the legs and feet
• Hypersplenism caused by reduced blood flow to the spleen, causing it to become enlarged
• Kidney failure (AKA Hepatorenal Syndrome), a rare complication caused by restricted blood supply
• Peritonitis, which is an infection of the abdomen

Risk Factors

Portal hypertension is most often caused by cirrhosis, which is scarring of the liver tissue. There are a number of factors that can increase your risk of cirrhosis and — by extension — portal hypertension. These include:

• Alcohol abuse
• Nonalcoholic Fatty Liver Disease (NAFLD), which is a condition that causes fat to build up in the liver, damaging the tissue in a way similar to long-term alcoholism, even in those who drink little to no alcohol. Usually, only those with a type of NAFLD called Nonalcoholic Steatohepatitis (NASH), suffer liver damage that can lead to cirrhosis. Read more about NAFLD.
• Chronic hepatitis C
• Chronic hepatitis B
• Autoimmune hepatitis, in which the body’s immune system attacks the liver and causes tissue damage
• Having certain inherited conditions, including Wilson disease, hemochromatosis and alpha-1-antitrypsin deficiency
• Heavy use or abuse of certain medications, including anabolic steroids, erythromycin, sulfa drugs, over-the-counter painkillers containing acetaminophen and others

Diagnosis and Tests

If you visit a physician with symptoms that suggest you might have portal hypertension due to cirrhosis of the liver, your doctor will likely talk to you about your symptoms, followed by a thorough physical exam. Your doctor will also likely talk to you about your alcohol use, conditions you may have, certain medicines or supplements you might take and other factors that can damage the liver.

Depending on the outcome of the initial exam, you may be referred for further diagnostic testing. These tests can include:

• Imaging tests, which may include:
  • Magnetic Resonance Imaging (MRI)
  • Ultrasound scans
  • Computerized tomography (CT) scans
• Biopsy, in which a small sample of liver tissue is removed so it can be examined in a lab
• Blood testing, including tests for:
  • Abnormal enzyme levels that can indicate liver damage
  • Increased bilirubin, which is created when your body breaks down hemoglobin and can cause jaundice if levels are too high
  • A complete blood count, which can reveal signs of infection or anemia that might indicate internal bleeding
  • Testing for hepatitis B and C

Advanced Imaging and Diagnosis at Hoag

Portal hypertension of the liver is usually caused by cirrhosis, which is extensive scarring of the liver caused by liver damage. Read more about cirrhosis here.

In most cases, cirrhosis is very advanced by the time noticeable symptoms like portal hypertension develop. Knowing how advanced the scarring is and why it’s happening is crucial for charting an effective treatment plan. That’s why you need a liver program with the next-generation tools for a pinpoint-accurate diagnosis.

At the Hoag Digestive Health Institute, advanced diagnostics for those facing portal hypertension and other chronic liver diseases include:

• FibroScan®, (AKA transient elastography), which is the first FDA-approved device in the U.S. that provides a painless, non-invasive method of testing for liver scarring without the side effects and complications of a needle biopsy. Learn more about FibroScan®
• Hepatobiliary iminodiacetic acid (HIDA) scanning, which is an advanced imaging technique which utilizes an injected radioactive tracer to diagnosis issues with the liver, gallbladder and bile ducts
• Attenuation Imaging (ATI) for Fat Quantification, which is an imaging technique used for quantifying fat deposits in the liver in real time
• Magnetic Resonance Cholangiopancreatography (MRCP), which utilizes powerful magnetic fields, radio waves and advanced computing to evaluate the gallbladder, liver, bile ducts, pancreas and pancreatic duct for disease, without the use of ionizing radiation
• Magnetic Resonance Elastography (MRE), which is used to detect stiffening of the liver caused by scarring and inflammation. This technology combines MRI imaging with low-frequency vibrations to create a visual map called an elastogram that shows the degree of stiffness of body tissues.
• Magnetic Resonance Multi-Echo Dixon Vibe Liver Iron Quantification, which is a 3D imaging technique used to simultaneously assess fatty liver disease (AKA steatosis) and abnormal iron levels in patients with chronic liver disease.
• Magnetic Resonance Proton Density Fat Fraction (MRI-PDFF), which is an emerging imaging technique that accurately measures the amount of fat in liver tissue by correcting factors that can degrade or skew magnetic resonance signal intensity

Management and Treatment for Portal Hypertension

Because liver damage due to cirrhosis is usually irreversible, many of the treatment and management strategies used against portal hypertension are about controlling internal bleeding and reducing pressure in the portal vein.

To help control bleeding, your physician may give you certain drugs known as beta-blockers that can reduce blood pressure in the portal vein. Using a long, flexible instrument called an endoscope, physicians can also potentially tie off bleeding veins. Learn more about the Hoag Endoscopy Center here.

Another treatment option is a procedure known as transjugular intrahepatic portosystemic shunting (TIPS). This procedure, performed by Interventional Radiologists, reduces pressure in the portal vein by creating a bypass called a shunt that connects the portal vein to the hepatic vein to help route blood flow.

If the scarring is too extensive, or if a patient’s portal hypertension is severe or doesn’t respond to treatment, they may be a candidate for a liver transplant. Explore liver transplant evaluation at Hoag.

Advanced Treatment for Conditions of the Liver at Hoag

Hoag’s unique, fully-integrated Liver Program is Orange County’s leader in next-generation treatment for conditions involving the liver, including advanced robotic-assisted surgeries and minimally-invasive procedures. Read more about advanced robotic surgery at Hoag.

Prevention

Ways to reduce your risk of developing portal hypertension may include:

• Use alcohol in moderation, and seek treatment for alcohol abuse
• Eat a healthy, balanced diet that’s low in fat and salt
• Maintain a healthy weight
• Get vaccinated against hepatitis B
• Get regular checkups, including blood work that can suggest changes in liver function
• Use over-the-counter medicines as directed, being particularly careful when taking non-steroidal anti-inflammatory drugs such as ibuprofen, aspirin, acetaminophen and other pain medications
• Take steps to manage chronic conditions that can impact liver function, including Type 2 diabetes, nonalcoholic fatty liver disease, high blood pressure and hepatitis B and C

Treatment for Alcoholism at Hoag

For those with alcohol addiction that may be contributing to cirrhosis or liver disease, Hoag is here for you. The longest-standing addiction treatment option in Orange County, Hoag Addiction Treatment Centers is an accredited program within the Pickup Family Neurosciences Institute that offers help, hope and healing for people facing addiction to alcohol and other drugs. For more information, visit this link, or call (949)764-6883.