Portal hypertension

Portal hypertension is an increase in the pressure within the portal vein, which is the main vein that carries nutrient-rich blood from your bowel, pancreas and spleen to the liver. 

The increase in pressure in the vein is caused by a blockage in the blood flow through the liver. As a result of portal hypertension, tiny, naturally occurring blood vessels become swollen and form abnormally large vessels called varices.

Varices that run along the lining of the stomach and in the lower end of the oesophagus (gullet) can become fragile and easily bleed. 

However, not all varices will bleed. The risk of them bleeding depends on how big they are. In general, small varices rarely bleed but varices may grow in size over time.

The most common cause of portal hypertension is scarring (fibrosis) or cirrhosis (late-stage liver disease).

Cirrhosis is scar tissue that has built up over time because your liver has been healing itself due to constantly being injured. A liver injury can be caused by a hepatitis virus (such as hepatitis B or hepatitis C), drinking too much alcohol, smoking or eating too much fat.

Regular blood clots that block the portal vein can also cause portal hypertension.

The main symptoms and complications of portal hypertension are:

Gastrointestinal bleeding 

You may bleed or vomit blood. You may also pass a large amount of blood through your bowels, which you may see in your poo (stools), or your poo may turn black and tarry.

Gathering of fluid 

Fluid may start to build-up in your abdomen, which is a condition called ascites. You may also accumulate fluid in other areas, such as your lower legs.

Anaemia 

if the bleeding in your body is slow and goes unnoticed, you may experience anaemia before you’re diagnosed with portal hypertension.

Anaemia is caused by a lack of healthy red blood cells in your body and symptoms include tiredness, dizziness and cold hands and feet.

Portal hypertension is usually diagnosed through an endoscopic examination of your oesophagus and stomach. 

This involves a long, thin, flexible tube being passed through your mouth, down your oesophagus and into your stomach. At the end of the tube are a light and a camera.

The camera sends images back to a computer that are looked at by your consultant. X-rays and laboratory tests may also be used to confirm you have bleeding from varices.

If you’ve been newly diagnosed with cirrhosis, it’s important you have an endoscopic examination to check for varices. People with established cirrhosis should have an endoscopic examination every one to two years.

If you have varices that are not actively bleeding, you may be given medication called beta-blockers to reduce the risk of them bleeding in the future. 

Commonly used beta-blockers include propranolol and carvedilol. Varices may also be treated at the time of an endoscopy to reduce the risk of future bleeding.

If you have varices that are actively bleeding, this is a medical emergency and you’ll need to go into hospital. After the bleeding is made stable, you’ll usually undergo an endoscopy to locate and treat the source of the bleeding. 

You’ll normally be given medication to relax you and stop any pain while the endoscopy takes place. Treatment may involve your gastroenterologist using tiny rubber bands to block the blood supply to the bleeding varices. This is called banding. 

You may also be injected with a type of biological ‘glue’ that causes the blood in the varices to clot and stop the bleeding.

It’s also likely that you’ll be required to have further endoscopies over the following weeks to reduce the risk of further bleeding.

You may need further treatment to stop the bleeding from your varices, and your consultant may recommend a treatment called TIPSS (trans-jugular intrahepatic portal systemic shunt).

TIPSS is a procedure that involves a metal stent (mesh tube) being inserted into your liver to allow blood to flow directly from the portal vein to the hepatic vein. 

This redirects blood flow through the liver and helps to reduce portal hypertension. TIPSS is performed under general anaesthesia, which means you’ll be asleep during it.

Access to the liver is obtained via the main vein in the neck, the jugular vein, without the need for any surgical cuts on your skin. TIPSS can also be used to help manage fluid build-up in your belly (ascites) that’s difficult to control with diet and medication. 

TIPSS is also occasionally performed as an emergency procedure to stop bleeding from varices after an endoscopy. Your doctor will need to assess the severity of your portal hypertension and the risk of potential complications to decide whether TIPSS is the best treatment option for you.

How is fluid retention treated?

The fluid retention in your belly (ascites) or other parts of your body is the most common complication of cirrhosis. 

You’ll be advised on what to eat to help reduce fluid retention. This will mainly focus on you cutting down on your salt intake. Medication may also be given to reduce fluid retention. These medicines are called diuretics.

Commonly used diuretics are spironolactone and furosemide. Diuretics encourage the body to get rid of extra salt and fluid through the kidneys. 

If you’re given diuretic medication, you may need to have regular blood tests to see how you are getting on with them. In some people, the fluid may need to be drained directly through the skin to allow the fluid to come out. 

This is a straightforward procedure performed under local anaesthetic, and it usually takes four to six hours for the fluid to drain out.