Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver. If the vessels in the liver are blocked due to liver damage, blood cannot flow properly through the liver. As a result, high pressure in the portal system develops. This increased pressure in the portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical area (belly button). Varices can rupture and bleed, resulting in potentially life-threatening complications.
The most common cause of portal hypertension is cirrhosis of the liver. Cirrhosis is scarring which accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage. In cirrhosis, the scar tissue blocks the flow of blood through the liver.
Other causes of portal hypertension include blood clots in the portal vein, blockages of the veins that carry the blood from the liver to the heart, a parasitic infection called schistosomiasis, and focal nodular hyperplasia, a disease seen in people infected with HIV, the virus that may lead to AIDS. Sometimes the cause is unknown.
The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have liver disease that leads to cirrhosis, the chance of developing portal hypertension is high.
Usually, doctors make the diagnosis of portal hypertension based on the presence of ascites or of dilated veins or varices as seen during a physical exam of the abdomen or the anus. Various lab tests, X-ray tests, and endoscopic exams may also be used.
Unfortunately, most causes of portal hypertension cannot be treated. Instead, treatment focuses on preventing or managing the complications, especially the bleeding from the varices. Diet, medications, endoscopic therapy, surgery, and radiology procedures all have a role in treating or preventing the complications. Other treatment depends on the severity of the symptoms and on how well your liver is functioning.
Maintaining good nutritional habits and keeping a healthy lifestyle may help you avoid portal hypertension. Some of the things you can do to improve the function of your liver include the following:
If endoscopic therapy, drug therapy, and/or dietary changes don't successfully control variceal bleeding, you may require one of the following procedures to reduce the pressure in these veins. Decompression procedures include:
During the TIPS procedure, a radiologist makes a tunnel through the liver with a needle, connecting the portal vein to one of the hepatic veins (veins connected to the liver). A metal stent is placed in this tunnel to keep it open.
The procedure reroutes blood flow in the liver and reduces pressure in abnormal veins, not only in the stomach and esophagus, but also in the bowel and the liver.
This is not surgery. The radiologist performs the procedure within the vessels under X-ray guidance. The process lasts one to three hours, but you should expect to stay in the hospital overnight after the procedure.
The TIPS procedure controls bleeding immediately in more than 90% of patients with portal hypertension. However, in about 20% of patients, the shunt may narrow, causing varices to re-bleed at a later time.
Shunt narrowing or blockage can occur within the first year after the TIPS procedure. Follow-up ultrasound exams are performed frequently after the TIPS procedure to detect these complications. The signs of a blockage include increased ascites (accumulation of fluid in the abdomen) and re-bleeding. This condition can be treated by a radiologist who re-expands the shunt with a balloon or repeats the procedure to place a new stent.
Encephalopathy, or abnormal functioning of the brain, can occur with severe liver disease. Hepatic encephalopathy can become worse when blood flow to the liver is reduced by TIPS, which may result in toxic substances reaching the brain without being metabolized first by the liver. This condition can be treated with medications, diet, or by making the shunt inaccessible.