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Digestive Diseases

Portal Hypertension

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• About Portal Hypertension
• Symptoms of Portal Hypertension
• Diagnosis of Portal Hypertension
• Treatment for Portal Hypertension
• Research for Portal Hypertension
• Contact Information

Portal hypertension is increased blood pressure in the liver's portal vein, a major vein that transports blood from the stomach to the liver, large and small intestines, spleen, gallbladder, and pancreas. High blood pressure or hypertension in this vein is most often caused by cirrhosis. Other causes include blood clots in this vein, and schistosomiasis, a parasitic infection common in Africa, sub-Saharan Africa, southern China, the Middle East, Southeast Asia, South America, and a few countries in the Caribbean.

Portal hypertension can cause a life-threatening condition known as varices where blood vessels in the esophagus, stomach or rectum become enlarged and can rupture, causing internal bleeding. Patients with varices often have black, tarry or bloody stools. They also may vomit blood.

Portal hypertension can also cause a condition known as encephalopathy. Encephalopathy occurs because the damaged liver can no longer successfully screen toxins from the blood. These toxins travel to the brain and impair the function of brain cells. Patients with encephalopathy generally become forgetful or easily confused.

A third condition caused by portal hypertension is ascites. With ascites, fluid leaks from the portal artery (due to the high pressure) and accumulates in the abdomen. Patients with ascites may have abdominal swelling and pain, loss of appetite from the swollen abdomen pressing on the stomach, and shortness of breath from the swollen abdomen pressing on the lungs. In some cases, patients with ascites experience swelling in their ankles.

If our liver experts suspect portal hypertension, they will perform the following diagnostic tests:

• Upper endoscopy: a procedure in which an endoscope, a narrow, flexible tube equipped with a tiny light and camera, is inserted into the mouth, through the esophagus, and into the stomach, after the patient is given a local anesthetic. The physician can see images of the digestive tract, and also may take a tissue biopsy.
• Ultrasound: a procedure in which sound waves are used to produce an image of blood vessels and internal organs, to assess blood flow through veins.

Portal hypertension is often treated with a surgical procedure knows as transjugular intrahepatic portosystemic shunt, or TIPS. With TIPS, the physician, guided by x-rays and ultrasound imaging, creates a small hole in the portal vein and inserts a shunt (a small tube) into it. He or she then connects the shunt to one of the hepatic veins, creating another pathway which blood can flow through and reducing pressure in the portal vein. This also reduces pressure in other abdominal veins, including those in the stomach, liver, esophagus and bowel.

Before TIPS, patients will have a number of tests to pinpoint the severity of the condition. These tests check the heart's function and help determine the extent and severity of portal hypertension. Pre-procedure tests include:

• Cardiac echography
• Endoscopy
• Blood tests
• Ultrasound or angiogram

Physicians may also use TIPS to treat other conditions such as recurrent bleeding of the varices, refractory ascites, hepatorenal syndrome, and Budd-Chiari syndrome, a clotting in the hepatic vein.

Other procedures used to treat portal hypertension include banding or sclerotherapy. With banding, a surgeon uses rubber bands to tie off blood vessels feeding the portal vein. This reduces blood flow and pressure in the portal vein and the likelihood that the vein will rupture or leak fluid.

With sclerotherapy, physicians inject a liquid into the portal artery which creates scar tissue. This doesn't reduce pressure in the portal vein, but creates a stronger "covering" to contain blood and fluid. Sclerotherapy is only done if banding cannot be performed.

Medication may also be used to treat portal hypertension. Physicians may prescribe nonselective beta blockers, medication for hypertension, which reduces blood pressure, with or instead of TIPS. They may also prescribe Lactulose, a drug which helps reduce confusion and other mental changes caused by encephalopathy.

NewYork-Presbyterian physicians were principal investigators in a large clinical trial demonstrating that a new stent device significantly improves outcomes in patients with portal hypertension. This clinical trial led to the device's approval in the US. Our researchers are also testing new drug combinations to treat portal hypertension.