1. TREATMENT OF PORTAL
HYPERTENSION
SANTOSH K
RAGIV GANGHI UNIVERSITY OF HEALTH
SCIENCES
KARNATAKA , INDIA

2. TREATMENT OF PORTAL
HYPERTENSION INCLUDES
TREATMENT OF VARICEAL BLEEDING
TREATMENT OF ASCITES
TREATMENT OF SPLEENOMEGALY

3. VARICES AND VARICEAL HEMORRHAGE
Cirrhosis
Resistance
to portal flow
Portal
pressure
Variceal
Varices Growth

4. VARICES INCREASE IN DIAMETER PROGRESSIVELY
VARICES INCREASE IN DIAMETER
PROGRESSIVELY
No varices Small varices Large varices

5. PREVENTION OF VARICEAL DEVELOPMENT
TREATMENT OF VARICES / VARICEAL
HEMORRHAGE
No varices Prevention of
variceal
development
Varices
No hemorrhage
Variceal
hemorrhage
Recurrent
hemorrhage

6. NON-SELECTIVE BETA BLOCKERS DO NOT PREVENT DEVELOPMENT OF VARICES
PRE-PRIMARY PROPHYLAXIS
MULTICENTER, RANDOMIZED, PLACEBO-
CONTROLLED TRIAL OF TIMOLOL (NON-SELECTIVE
BETA-BLOCKER) VS. PLACEBO IN PATIENTS
BETA-BLOCKERS DID NOT PREVENT THE
DEVELOPMENT OF VARICES AND WERE ASSOCIATED
WITH A HIGHER RATE OF SERIOUS ADVERSE EVENTS
HEPATIC VENOUS PRESSURE GRADIENT WAS THE
STRONGEST PREDICTOR OF THE DEVELOPMENT OF
VARICES

7. MANAGEMENT OF PATIENTS WITHOUT VARICES
Treatment of Varices / Variceal
Hemorrhage
No specific therapy
No varices
Repeat endoscopy in every
2-3 yrs
Varices
No hemorrhage
Variceal
hemorrhage
Recurrent
hemorrhage

8. PREVENTION OF FIRST VARICEAL HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Varices Prevention of first
No hemorrhage variceal
hemorrhage
Variceal
hemorrhage
Recurrent
hemorrhage

9. MANAGEMENT OF PATIENTS WITH VARICES WHO HAVE NEVER BLED
Treatment of Varices / Variceal
Hemorrhage
No varices
Varices Management depends on
No hemorrhage the size of varices
Variceal
hemorrhage
Recurrent
hemorrhage

10. MANAGEMENT OF PATIENTS WITH MEDIUM/LARGE VARICES WITHOUT PRIOR HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Small varices
No hemorrhage
1) -blockers (propranolol 1-2
mg/kg/day) indefinitely
Medium/ large varices
No hemorrhage 2) Endoscopic variceal
ligation/Sclerotherapy in
patients intolerant to -
Variceal blockers
hemorrhage
Recurrent
hemorrhage

11. PROPRANOLOL
DECREASES CARDIAC OUTPUT
REDUCES THE INTRAHEPATIC
RESULTING IN DECREASED
PORTAL VASCULAR
PORTAL PRESSURE AND
RESISTANCE.
VARICEAL SIZE.
MOST WIDELY
USED β
BLOCKER.
USED ALONG WITH
PRODUCES SPLANCHNIC SCLEROTHERAPY.
VASOCONSTRICTION WHICH BENIFICIAL RESULTS IN TERMS
LEASD TO DECREASE IN OF LOWER REBLEEDING RATES
PORTAL BLOOD FLOW. & LOWER VARICEAL
RECURRENCE.

12. ENDOSCOPIC LIGATION OF VARICES
RECENT DEVELOPMENT IN THE TREATMENT OF VARICES
BASED ON PRINCIPLES OF BAND LIGATION TECHNIQUE FOR
HEMORRHOIDS.
OESOPHAGEAL VARICES ARE MECHANICALLY ENSNARED
WITH SMALL ELASTIC RINGS CAUSING NECROSIS WITHIN 4-7
DAYS FOLLOWED BY RE-EPITHELIALIZATION AND SCAR
FORMATION.
ENDOSCOPIC THERAPY IS A LOCAL THERAPY THAT HAS NO
EFFECT ON THE PATHOPHYSIOLOGIC MECHANISMS THAT
LEAD TO PORTAL HYPERTENSION AND VARICEAL RUPTURE.

13. ENDOSCOPIC VARICEAL BAND LIGATION
Endoscopic Variceal Band
Ligation
BLEEDING CONTROLLED IN 90%
REBLEEDING RATE 30%
COMPARED WITH
SCLEROTHERAPY:
 Less rebleeding
 Lower mortality
 Fewer complications
 Fewer treatment sessions

14. MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Small varices
No hemorrhage ? Prevention of variceal
growth
Medium/ large varices
No hemorrhage
Variceal
hemorrhage
Recurrent
hemorrhage

15. MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Repeat endoscopy in 1-2
Small varices years
No hemorrhage
Beta-blockers?
Medium/ large varices
No hemorrhage
Variceal
hemorrhage
Recurrent
hemorrhage

16. CONTROL OF ACUTE VARICEAL HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Small varices
No hemorrhage
Medium/ large varices
No hemorrhage
Variceal Control of
hemorrhage hemorrhage
Recurrent
hemorrhage

17. TREATMENT OF ACUTE VARICEAL
HEMORRHAGE
GENERAL MANAGEMENT:
IV ACCESS AND FLUID RESUSCITATION
DO NOT OVERTRANSFUSE (HEMOGLOBIN
~ 8 G/DL)
ANTIBIOTIC PROPHYLAXIS (IV
CEFTRIAXONE 50-100 MG/KG/DAY)
SPECIFIC THERAPY:
PHARMACOLOGICAL THERAPY:
TERLIPRESSIN, SOMATOSTATIN AND
ANALOGUES, VASOPRESSIN +
NITROGLYCERIN
ENDOSCOPIC THERAPY: BAND LIGATION,
SCLEROTHERAPY
SHUNT THERAPY: TIPS, SURGICAL SHUNT

18. PHARMACOLOGIC
THERAPY
SOMATOSTATIN-DECREASES PORTAL
FLOW, SPLANCHNIC VASOCONSTRICTION.
OCTREOTIDE- 50MCG/H SHOWN TO REDUCE
COMPLICATIONS OF BLEEDING AFTER
SCLEROTHERAPY.
VASOPRESSIN- REDUCES BLOOD FLOW TO
ALL SPLANCHNIC ORGANS, DECREASES
PORTAL PRESSURE, VENOUS BLOOD FLOW.
USE NITROGLYCERIN WITH IT! IT’S THE MOST
POTENT SPLANCHNIC VASOCONSTRICTOR.
ANTIBIOTICS TO PREVENT INFECTION.

19. BALLONON TAMPONADE
BALLOON TAMPONADE ONLY IN MASSIVE
BLEEDING AS A TEMPORARY MEASURE.
SENGSTAKEN TUBE
HAS 3 LUMENS, 1 FOR GASTRIC
ASPIRATION, 2TO INFLATE THE
GASTRIC BALLOON AND THE
OESOPHAGEAL BALLOON.

20. TIPS IN THE TREATMENT OF VARICEAL HEMORRHAGE
TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT
TIPS IS RESCUE THERAPY FOR RECURRENT
VARICEAL HEMORRHAGE
IT IS ONLY USEFUL IN PORTAL HYPERTENSION OF
HEPATIC ORIGIN.
TIPS IS INDICATED IN PATIENTS WHO REBLEED ON
COMBINATION ENDOSCOPIC PLUS PHARMACOLOGIC
THERAPY
IN PATIENTS WITH CIRRHOSIS, THE DISTAL SPLENO-
RENAL SHUNT IS AS EFFECTIVE AS TIPS.

21. ACCEPTED INDICATIONS
ACTIVE BLEEDING DESPITE ENDOSCOPIC OR
PHARMACOLOGIC TREATMENT
RECURRENT VARICEAL BLEEDING DESPITE
ADEQUATE ENDOSCOPIC TREATMENT.
POTENTIAL INDICATIONS INCLUDE BLEEDING
GASTRIC FUNDIC VARICES, REFRACTORY
ASCITES.
A BRIDGE TO TRANSPLANTATION.

22. PROCEDURE
INSERTION OF AN EXPANDABLE METALLIC
STENT FROM THE HEPATIC TO THE PORTAL
VEIN THROUGH THE PERCUTANEOUS
TRANSJUGULAR ROUTE UNDER RADIOLOGICAL
GUIDANCE.
UNDER FLUOROSCOPIC CONTROL, A
GUIDEWIRE IS PASSED INTO A HEPATIC VEIN. A
NEEDLE IS THEN ADVANCED OVER A
GUIDEWIRE INTO THE HEPATIC VEIN AND THEN
TO THE PORTAL VEIN.
A BALLOON CATHETER IS SUBSEQUENTLY USED
TO DILATE THE INTRAHEPATIC TRACT AND THE
STENT IS DEPLOYED

24. PORTOSYSTEMIC SHUNTS
SHUNT OPERATIONS ARE THE ONLY
MODALITIES THAT EFFECTIVELY REDUCE
PORTAL PRESSURE AND THUS
DEFINATIVELY TREAT THE UNDERLYING
CAUSE OF VARICEAL BLEEDING.
TYPES OF SHUNT OPERATIONS
NON SELECTIVE SHUNTS
PORTOCAVAL SHUNTS
MESOCAVAL SHUNTS
SPLENORENAL SHUNTS
• SELECTIVE SHUNTS
DISTAL SPLENORENAL SHUNT

25. DISTAL SPLEENORENAL SHUNT

26. MANAGEMENT OF PATIENTS WITH ACUTE VARICEAL HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Small varices
No hemorrhage
Medium/ large varices
No hemorrhage
1) Safe vasoactive drug +
Variceal endoscopic therapy + balloon
tamponade+antibiotic
hemorrhage prophylaxis
2) TIPS / Shunt (rescue therapy)
Recurrent
hemorrhage

27. PREVENTION OF RECURRENT VARICEAL HEMORRHAGE
Treatment of Varices / Variceal
Hemorrhage
No varices
Varices
No hemorrhage
Variceal
hemorrhage
1) -blockers + EVL
Recurrent
2)TIPS / shunt surgery
hemorrhage

28. SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE
Evolution of Level of
Varices Intervention Management Recommendations
Cirrhosis with no
varices
Repeat endoscopy in 2-3 years
Pre-primary No specific therapy
prophylaxis

29. SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE
Evolution of Level of
Varices Intervention Management Recommendations
Cirrhosis with no
varices
Repeat endoscopy in 2-3 years
Pre-primary No specific therapy
Small varices prophylaxis
No hemorrhage Small varices
Repeat endoscopy in 1-2 years
No specific therapy
? beta-blocker to prevent
Medium / large enlargement
varices Primary
No hemorrhage prophylaxis Medium/Large varices
Non-selective beta-blockers
EVL in those who are intolerant to
drugs

30. SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE
Evolution of Level of
Varices Intervention Management Recommendations
Cirrhosis with no
varices
Repeat endoscopy in 2-3 years
Pre-primary No specific therapy
Small varices prophylaxis
No hemorrhage Small varices
Repeat endoscopy in 1-2 years
No specific therapy
? beta-blocker to prevent
Medium / large enlargement
varices Primary
No hemorrhage prophylaxis Medium/Large varices
Non-selective beta-blockers
EVL in those who are intolerant to
drugs
Variceal Endoscopic/pharmacologic therapy
hemorrhage Antibiotics in all patients
TIPS or shunt surgery as rescue
therapy

31. SUMMARY OF MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE
Evolution of Level of
Varices Intervention Management Recommendations
Cirrhosis with no
varices
Repeat endoscopy in 2-3 years
Pre-primary No specific therapy
Small varices prophylaxis
No hemorrhage Small varices
Repeat endoscopy in 1-2 years
No specific therapy
? beta-blocker to prevent
Medium / large enlargement
varices Primary
No hemorrhage prophylaxis Medium/Large varices
Non-selective beta-blockers
EVL in those intolerant to drugs
Variceal Endoscopic/pharmacologic therapy
hemorrhage Antibiotics in all patients
TIPS or shunt surgery as rescue
therapy
Beta-blockers + EVL
Recurrent Secondary TIPS or shunt surgery as rescue
variceal prophylaxis therapy
hemorrhage

32. MANAGEMENT OF ASCITES
• SODIUM RESTRICTION AND PROMOTION OF SODIUM
EXCRETION ARE THE CORNER STONES OF ASCITES
MANAGEMENT.
• SODIUM RESTRICTION TO 1 TO 2 meq/Kg/day.
• FLUID RESTRICTION.
• SPIRONOLACTONE IS THE DIURETIC OF CHOICE BECAUSE
OF ITS ADDITIONAL ANTI ALDOSTERONE ACTIVITY.
• INITIATE AT 2-3mg/kg/day IN DIVIDED DOSES. CAN BE
SAFELY DOUBLED IF NO INCREASE IN URINE OUTPUT
OCCOURS IN 3-4 DAYS.
• FUROSEMIDE CAN BE ADDED IF THERE IS NO RESPONSE TO
HIGH DOSES OF SPIRONOLACTONE.

33. • HYPONATREMIA ASSOCIATED WITH FUROSEMIDE
ADMINISTRATION SHOULD BE CORRECTED.
• INTRAVENOUS ALBUMIN 1g/kg WITH FUROSEMIDE
CAN BE GIVEN TO PREVENT RECOLLECTION OF
ASCITIC FLUID.
• IN VERY LARGE ASCITES PARACENTESIS MAY BE
DONE.

34. DENVER AND LEVEEN
SHUNTS
SUBCUTANEOUS SHUNTS THAT DRAIN
ASCITIC FLUID FROM THE ABDOMEN INTO
THE CENTRAL VENOUS SYSTEM.
DIC IS A KNOWN COMPLICATION OF
PERITONEOVENOUS SHUNTING OF ASCITIC
FLUID.

36. TREATMENT FOR
HYPER SPLEENISM
SELECTIVE SPLEENIC INFARCTION
EFFECTIVELY CONTROLS
HYPERSPLEENISM, REDUCES
INCIDENCES OF REBLEEDING &
CONSERVES SPLEENIC IMMUNE
FUNCTION.
MUST BE DONE IN CONJUNCTION WITH
PNEUMOCOCCAL VACCINATION AND
LONG TERM ANTIBIOTIC PROPHYLAXIS
TO THE AGE OF 6 YEARS.

37. LIVER TRANSPLANTATION
LIVER TRANSPLANTION IS THE LAST CHOICE
OF SURGERY FOR TREATMENT OF PORTAL
HYPERTENSION.
IT IS DONE IN REFRACTORY CASES NOT
IMPROVING WITH OTHER METHODS.