Here are the revisions to the document: 1. Normal portal venous pressure is less than 5 mm Hg. 2. Oesophageal balloon used to achieve temporary haemostasis is Sengstaken-Blakemore tube. 3. TIPSS stands for transjugular intrahepatic portosystemic shunt. 4. Median GCS score in hepatic coma is below 8. 5. Diet recommended for hepatic coma is low in protein and sodium.

1. PORTAL
HYPERTENSION
Mrs. Daisy Kuruvilla

2. PORTAL HYPERTENSION
• Portal hypertension refers to elevated pressures in the portal
venous system. Venous pressure more than 5 mm Hg greater
than the inferior vena cava pressure is defined as portal
hypertension.
• Clinically significant portal hypertension is present when
gradient exceeds 10 mmHg. •
• Risk of variceal bleeding increases beyond a gradient of 12
mmHg

4. CAUSES
•PRE HEPATIC
•HEPATIC
•POST HEPATIC

5. PRE HEPATIC
• Portal vein Thrombosis
• Splenic vein thrombosis
• Massive spleenomegaly
• Congenital portal atresia
• Phlebitis of portal vein
• Pancreatitis
• Trauma
• Hypercoaguable states

6. HEPATIC
1. Presinusoidal:
• schistosomiasis ( parasitic flatworm infection)
• Congenital hepatic fibrosis
2. Sinusoidal:
• Cirrhosis of liver
• alcoholic hepatitis
3. Postsinusoidal:
• Hepatic sinusoidal obstruction (veno-occlusive syndrome)

7. POST HEPATIC
• Budd-Chiari Syndrome – hepatic venous thrombosis
• Inferior vena cava obstruction
• cardiac causes:
• Restrictive cardiomyopathy
• Constrictive pericarditis
• Severe congestive cardiac failure

8. PATHOPHYSIOLOGY
• Increased resistance to portal blood flow.
• Gradual reduction in the flow of portal blood to the liver
• Development of collateral vessels, allowing portal blood
to bypass the liver and enter the systemic circulation
directly.
• Portal flow increases in the splanchnic bed due to
splanchnic vasodilatation and increased cardiac output
• Portal hypertension

9. CLINICAL FEATURES

10. Diagnostic measures
1. Blood count
2. Liver function tests
3. Indirect measurement of portal pressure
4. Oesophagogastroduodenoscopy
5. USG
6. MRI
7. Liver angiography
8. Arteriography

11. COMPLICATIONS
• Variceal bleeding
• Congestive gastropathy
• Hypersplenism
• Ascites
• Iron deficiency anaemia
• Renal failure
• Hepatic encephalopathy

12. Management
•General measures
•Specific measures
A.Treatment of oesophageal varices
B.Treatment of ascites

13. 1. General measures
•Anti coagulation for budd chiari
syndrome
•Treatment of hepatic cause

14. 2. Management of bleeding
varices
1.ADMIT PATIENT TO ICU
2.SECURE 2 LARGE BORE I.V LINES- ADMINISTER RINGER LACTATE
3.MONITOR VITALSIGNS AND URINE OUTPUT
4.BLOOD TRANSFUSION
5.CORRECT COAGULOPATHY
6.PREVENT HEPATIC ENCEPHALOPATHY
• Bowel wash – to decrease ammonia from gut
• Lactulose-acidifies colon
• Oral neomycin-1gm 6 hrly-it suppresses urease containing bacteria

15. 2. Management of bleeding varices
7. ENDOSCOPIC EXAMINATION IF BLEEDING IS SEVERE.
• Oesophageal balloon tamponade (sengstakenblakemore tube) to achieve
temporary haemostasis
• Sclerotherapy
• Banding( varix banding)
8. DRUGS
• VASOPRESSIN: 20-40 Units IV in 200 ml of 5 % dextrose IV over 10
minutes and may be repeated at 2-4 hrs intervalsuntil bleeding stops
• OCTREOTIDE: 50 microgram bolus followed by 50 microgram/hr
infusion for 5 days

16. 2. Management of bleeding
varices
9. SURGICAL
• TRANS JUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT
SHUNTS
• Splenectomy
• Gastroesophageal devascularization
• Oesophageal transection
• Liver transplantation

17. 3. MANAGEMENT OF ASCITES
• SALT RESTRICTION
• STOP ALCOHOL
• CORRECT ELECTROLYTE IMBALANCE
• DIURETICS-SPIRINOLACTONE
• IV ALBUMIN THERAPY
• ABDOMINAL PARACENTESIS
• SHUNT SURGREY( PEROTONEOVENOUS SHUNTING)
• TIPSS- transjugular intrahepatic portosystemic shunt
• LIVER TRANSPLANTATION

18. NURSING CARE PLAN
• Excess fluid volume ralated to compromised regulatory
mechanisms as evidenced by ascites, jugular vein distension,
anasarca
• Measure I/O
• Weigh daily
• Assess respiratory status and cardiac dysrhythmias
• Measure abdominal girth
• Monitor serum albumin and electrolytes
• Restrict sodium and fluids

19. NURSING CARE PLAN
• Ineffective breathing pattern related to ascites and fatigue
• Monitor respiratory status
• Check level of consciousness
• Monitor ABG
• Supplemental oxygen
• Paracentesis
• Shunting procedures

20. NURSING CARE PLAN
• Risk for injury related to abnormal blood profile, portal
hypertension and varices
• Check signs of bleeding
• Monitor vital signs
• Encourage use of soft toothbrush, electric razor, avoiding
straining for stool, vigorous nose blowing, and so forth.
• Use small needles for injections.
• Supplemental vitamins: vitamin K, D, and C.
• Assist with insertion and maintenance of GI tube.

21. Revision
1. Normal portal venous pressure is ……………….
2. Oesophageal balloon used to achieve temporary
haemostasis is …………….
3. Expand TIPSS
4. Median GCS score in hepatic coma
is…………………
5. Diet recommended for hepatic coma
is……………….