Portal hypertension is among the serious complications of advanced liver disease. Scar tissue formed by damaged liver cells leads to the development of liver cirrhosis. This tissue compresses the blood vessels within it, causing blood flow to decrease. This problem in the area may also affect other organs and tissues in the body, causing serious internal bleeding and some other problems in the later stages. Therefore, it is important for your health to understand the type and effects of any disease that develops in the liver and to start the treatment process without wasting time.
What is Portal Hypertension?
Higher than normal blood pressure in the vein called portal vein is called portal hypertension . This vein, also called the hepatic portal vein, is responsible for carrying blood with reduced oxygen content from the small intestine, stomach, large intestine, pancreas, gallbladder and spleen to the liver. Therefore, it has a key role in the gastrointestinal system (digestive system). Liver; It filters the blood, purifies it from harmful components, and then sends it back to the heart and general circulation in the body. When any condition blocks or slows blood flow in the portal vein, the pressure in the portal system directly increases. To manage this situation, the human body directs blood flow to other vessels and thus tries to balance intravascular pressure. However, higher than normal intravascular pressure and blood flow rate cause these other vessels to expand. As a result, the vascular walls become stretched and weakened, thinning and fluid leakage into the abdomen may occur in the damaged wall areas. There may even be ruptures and bleeding in the vessels. Because of this severe effect on the vessels, portal hypertension is a serious disease that can be life-threatening. However, if diagnosed in time, it is possible to successfully treat portal hypertension when portal venous system blood pressure is controlled. Diagnosing the disease is not always easy. Since it is usually diagnosed after symptoms appear, the opportunity for early treatment may be missed. For this reason, it is important to have regular health screenings, especially for people with liver diseases .
Portal Hypertension Symptoms
Any symptoms may not appear until complications of portal hypertension develop. Research conducted; found that up to ninety percent of cirrhosis patients develop portal hypertension before symptoms appear. Large varicose veins (enlarged veins) were observed in approximately forty percent of the patients (4). The first and most obvious symptoms of portal hypertension usually involve dilated, bleeding, and leaky veins. The following symptoms may be observed during this process:
• Vomiting blood or seeing blood in the vomit,
• Presence of blood in the stool (black colored stool),
• Ascites caused by fluid leaking into the abdomen and rapid weight gain and abdominal swelling due to this ascites,
• Swelling caused by edema in the feet or legs,
• Mental confusion and difficulty making decisions, changes in consciousness and mood, tremors in hands.
The patient’s weight gain is not related to overeating. Fluid leaking into the abdomen causes edema. This causes the patient to lose their appetite. In severe cases, edema extends into the chest cavity and makes it difficult for the patient to breathe. In addition, this fluid that accumulates in the peritoneal cavity, which is the space between the peritoneal membrane covering the abdominal wall and the peritoneal membrane covering the internal organs, can also cause infections. Reduced blood flow in the spleen can cause the spleen to swell with heavy blood and form new vessels called shunts. The spleen, which grows in size, works harder than it should and retains too many blood cells from the circulation. This may lead to blood clotting disorders and weakening of immunity due to the decrease in the number of responsible cells in circulation. Again, as a reaction to the expansion of blood vessels in the spleen, narrowing of the vessels in other parts of the body may occur. Narrowing of the vessels in the kidneys triggers kidney failure. These are among the most common symptoms seen; However, it is possible to experience different symptoms due to the patient’s condition and changes in the affected vessels.
Causes of Portal Hypertension
Although there are multiple causes of portal hypertension, the most common cause is liver cirrhosis. Cirrhosis is the end stage of chronic liver disease and often occurs as a result of viral hepatitis C, alcoholic hepatitis, and nonalcoholic fatty liver disease. The liver is an organ that can repair itself; However, when damaged, it starts working harder than it should to heal itself. This leads to scar (scar tissue) formation in the liver over time. As the amount of these tissues increases, the function of the liver begins to decrease over time. Additionally, due to cirrhosis, the normally smooth inner walls of the portal vein become irregular and a resistance to blood flow occurs on the inner surface of the vein. As a result, blood pressure in the portal vein increases. Blood clots may even occur in the portal vein due to this rough inner surface. Clot formation can also play a role in increasing pressure. Every individual at risk for cirrhosis should be considered as a potential candidate for portal hypertension. Some conditions that are among the risk factors for portal hypertension include:
- Long-term alcohol use,
- Drug use through intravenous injection,
- Getting tattoos or piercings in unsanitary conditions
- Contact with infected needles or infected blood
- Unprotected sexual intercourse with more than one partner,
- Family history of hepatitis
- Familial-hereditary predisposition to clot formation.
Portal hypertension in infants or portal hypertension in children is mostly caused by catheters or medications administered through the umbilical cord in neonatal units, damaging the veins. In addition, some genetic factors and conditions that prevent clotting may also trigger portal hypertension.
How is Portal Hypertension Diagnosed?
Portal hypertension is a disease that is difficult to diagnose if the symptoms are not obvious enough. Scans such as Doppler ultrasound provide insight into the disease. Doppler can provide information on issues such as the status of the portal vein and the course of blood within the vein. In cases where this imaging method is not sufficient, a CT (computed tomography) scan may be useful. Another method that has become widely used recently is measuring the elasticity of the liver and surrounding tissue. This technique, called elastography, measures how tissue responds to stimuli when it is pushed or moved. Poor elasticity may be suggestive of the presence of disease. Certain complications may also occur in the patient secondary to portal hypertension. One of these is bleeding in the digestive system. This condition, called gastrointestinal bleeding, usually requires endoscopy . This examination is an application that allows the specialist to see the internal organs and is performed using a thin, flexible device with a camera at one end. Portal vein blood pressure can be determined by inserting a catheter fitted with a blood pressure monitor into a vein in the liver and taking the measurement. However, this method is usually used as a last resort. In most cases, diagnosis of the disease may be possible by evaluating blood tests and other tests together with the symptoms. Observation of most of the common symptoms in portal hypertension will be sufficient to diagnose the disease. These common symptoms, which play a key role in diagnosis, can be listed as follows:
- Varicose veins caused by enlarged blood vessels,
- enlargement of the spleen ,
- Gastrointestinal bleeding,
- Fluid accumulation in the abdomen,
- cognitive impairment,
- Decrease in the number of blood cells,
- Easy bruising and bleeding.
In very rare cases, portal hypertension may develop in a way that does not originate from the liver. For this reason, the disease is basically grouped in two different ways as portal hypertension caused by cirrhosis (cirrhotic) or not caused by cirrhosis (non-cirrhotic). However, non-cirrhotic portal hypertension that does not originate from the liver is rare. During diagnosis, the doctor can easily diagnose which type of portal hypertension is present in the patient, taking into account other findings.
Portal Hypertension Treatment
Portal hypertension is a disease that is difficult to treat if it progresses and becomes severe. Therefore, taking timely precautions against complications seen in the patient and applying treatments without delay have a direct impact on the success of the treatment. The main goal of treatment is to reduce the pressure in the portal vein as soon as possible. The main complication of portal hypertension is bleeding from varicose veins. Therefore, the aim of treatments is to manage bleeding. Applications such as drug therapy, endoscopic treatment, shunt procedures and liver transplantation may be among the treatment methods. Some procedures that may be included in the treatment practices can be listed as follows:
- If there are enlarged vessels in the esophagus or stomach due to disease, various pharmacological agents can be used to reduce the pressure in these vessels and prevent bleeding.
- The patient has cirrhosis; However , if there is no varicose vein formation, treatment can be started by applying beta blocker group drugs. However, beta blockers are not recommended to prevent the development of varicose veins; because it is known that the side effects of the drug outweigh its possible benefits for this patient group.
- Endoscopic methods can be used to treat gastrointestinal bleeding. An approach called endoscopic banding therapy can be used to manage bleeding from varicose veins, especially in the digestive system. During endoscopy, small elastic rings are placed on the vein. The rings block blood flow to each varicose vein. Thus, the growth of varicose veins can be prevented.
- Balloon tamponade is applied to control severe varicose bleeding that compresses the veins. A small balloon is inflated in the stomach or esophagus to apply pressure to bleeding vessels, which compresses and stops bleeding.
- Another method is the shunt procedure. The shunt method can be used to prevent recurrent bleeding despite medical or endoscopic treatment.
- The last method is liver transplantation. It is the most effective treatment of cirrhosis and portal hypertension. It may be possible for a patient with a liver transplant to fully recover.
If you suspect portal hypertension, you should be examined immediately. In this way, you can regain your health and live a quality life with preventive treatment methods.
