Diagnosis of Portal Hypertension 1

DIAGNOSIS OF PORTAL HYPERTENSION

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 Diagnosis of Portal Hypertension 2

Portal hypertension

Introduction

Portal hypertension is characterised by an abnormal increase of the blood pressure in a

network of veins referred as the portal venous system. Veins emerging in the stomach, spleen,

pancreas as well as intestine diverge in the portal vein, which then branches into reduced vessels

and passes through the liver (WebMD, 2018). When these vessels are blocked due to some

damaged of the liver, the blood will cease to flow normally through the liver (Sauerbruch,

Schierwagen and Trebicka, 2018). Consequently, this will cause a change in the flow gradient

that leads to an elevation of the blood pressure in the portal system. Sauerbruch, Schierwagen

and Trebicka(2018) further explain that the increased obstruction of the venous flow will result

to a development of large varices (swollen veins) in various parts of the middle section of the

human anatomy including the oesophagus, umbilical area, rectum or the stomach.

Specifically, portal hypertension is expressed when portal blood pressure is set above the

normal values of between 1 and 5 mm HG. Samonakis et al. (2004) explain that for the condition

to be considered clinically significant the pressure surpasses the 12mm HG threshold since at this

point the rate of mortality and morbidity are quite high. The mechanism that leads to portal

hypertension can explain by a duo hemodynamic process (Al-Busafi et al., 2012). The first part

of the process is the amplified intrahepatic impediment of the blood flow passage across the liver

as a result of cirrhosis. Secondly, the augmented splanchnic flow of blood tributary to the

vasodilatation occurrence in the splanchnic vascular area. Portal hypertension occurs from

possibly various causes in the prehepatic, intrahepatic, and posthepatic regions (Samonakis et al,

2004). In the western countries, the liver cirrhosis has been identified as the major cause

contributing to about ninety percent of the cases. The purpose of compiling this paper is to
 Diagnosis of Portal Hypertension 3

explore the causes, diagnosis, and manifestation, the prognosis as well as the treatment of portal

hypertension.

Background

A 38 years old Briton male was admitted with complaints of occasional bloodstains in the

bowel. In addition, he reported to experience increased abdominal pains over the last couple of

months and have lost approximately 8 kilograms over the eight weeks despite having a proper

diet. There is no significant medical history but the information during a recent visit to a private

clinic, the medical practitioner noted some of the levels of confusion. This signs indicated

possible infection of the liver, which could have developed into portal hypertension.

Portal Hypertension

Aetiology

The primary cause of PH is the presence of liver cirrhosis, a scar that is left healing from

an injury caused by alcohol, hepatitis or other causes of liver damages. It causes inflammation of

the cytokines intrinsic in the immune system (Iwakiri and Groszmann, 2014). The factors that

may contribute to elevated intrahepatic blood flow impediment for a patient suffering from liver

cirrhosis include dysfunctional endothelial cells, stimulation of hepatic stellate cells (HSCs), and

a notable level of liver angiogenesis (Bosch, 2007). In cirrhotic patients, the liver fails to make

an adequate synthesis of the NO and therefore, this will worsen the case of portal hypertension.

The intrahepatic vascular resistance can occur when the HSCs are activated. An injury on the

liver triggers the activation of the HSCs and then transformation process takes places whether

they become myofibroblas

 Diagnosis of Portal Hypertension 4

Diagnosis

Health practitioners have a variety of tools and procedures at their disposal to diagnose

portal hypertension. Portal hypertension among patients suffering from liver cirrhosis can be

detected by checking for varices, ascites, or both. Doctors need to be certain of the symptoms

leading to portal hypertension and thus they need to use available imaging procedures such

ultrasonography, computed tomography, and magnetic resonance imaging (MRI) that will aid in

highlighting portal venous system anatomical features. With the application of these methods,

some of the most observation findings that suggest the presence of portal hypertension can

include occlusion and dilation of the portal vein, splenomegaly, decreasing blood cells counts,

ascites, and formation of collateral vessels. Procopet and Berzigotti (2017) explain that

substantial hepatic venous pressure gradient (HVPG) (≥ 5 mmHg), defines the advent of major

portal intravenous clinical implications. Endoscopy is one of the most popular approaches used

to diagnose portal hypertension in cirrhotic patients. In this case, the paper will focus on two

common imaging procedures that are clinically used to diagnose the cirrhosis and consequently,

portal hypertension in patients.

Ultrasound

Ultrasound is conducted as the first-line of graphic examination on the patients suspected

to be suffering from liver cirrhosis and portal hypertension. The procedure has minimal safety

concerns, its repeatability is quite easy and cheap procedure compared to most of procedures

used in this line of clinical investigation. Margini and Berzigotti (2017) clarify that ultrasound

imaging can help identify thrombosis within the portal venous system as well as the hepatic

systems, thus permitting for high accuracy levels in the analysis of any emerging portal

hypertensive cases. Criss, Ralls and Jarboe (2017) explain that as part of the procedure a
 Diagnosis of Portal Hypertension 5

micropuncture needle should be inserted in the lower quadrant carefully to avoid vessels and the

dilator after setting up the patient in a supine angle. In addition, the study argues that using the

procedure to access the peritoneum will aid in conducting a safe laparoscopic surgery for a

patient suffering from portal hypertension. Jeong et al. (2015) explain that contrast-enhanced

ultrasound imaging acute cases of portal hypertension and liver damage.

The signs of cirrhosis that are observed during the imaging process provide significant

specificity that will confirm cirrhosis presence in a patient. However, the level of sensitivity from

the signs is quite low, which implies that a negative value does not mean the absence of liver

cirrhosis (Propocet andBerzigotti, 2017). When conducting an ultrasound it is important to

capture the images when the liver is still, that is, patients should hold their breath during the

ultrasound to enhance the demonstration of the hepatic waveforms and blood flow. During the

ultrasound procedure some of the common signs that the doctors are looking out for in cirrhotic

patients include presence of lesion on liver surface (see Figure 2), contracting and abnormal

plasticity of flow, echogenicity differences along the hepatic vein wall, enlarge radius of hepatic

artery and portal vein (see Figure 2 and 3), dilatation of the most parts of the portal venous

system, and enlarge spleen (Al-busafi et al, 2012). According to Berzigotti et al. (2010),

nodularity exterior of the liver is one of the sign that every diagnosis should be examining during

early stages. High-frequency transduction will enhance the performance when conducting an

abdominal ultrasound diagnosis hence it is quite preferable in cirrhotic probing (Simonovský,

1999). Clinically, detecting nodules on the liver surface provides an effective non-invasive tool

to conclude cirrhosis even in presence of confounders.

Sequentially, the investigation continues to portal hypertension, where the ultrasound

signs are specific but abstemiously sensitive; therefore, the fact a sign or array of signs allows
 Diagnosis of Portal Hypertension 6

confirmation of portal hypertension, it will not be appropriate to exclude the diagnosis in

absentia of ultrasound signs (Berzigotti et al., 2012). According to Wu (2008), some of the portal

hypertension signs are pathognomonic (100% specific); they include reserved flow in the portal

venous system and portosystemic collaterals. In addition, Wu (2008) highlighted that

splenomegaly is a common less specific but sensitive sign of portal hypertension. Other signs

that linked with portal hypertension include dilatation of various vessels in portal system,

reduced velocity of the blood movement inside the portal vein, contraction of the splenic

diameter causing reduced or no respiration, and a congestive portal vein (Berzigotti et al., 2013).

The ultrasound imaging will look for an increase of the diameter that falls below 20% during

adeep inspiration to conclude that portal hypertension is the diagnosed problem. The lesions on

the surface and dilation of portal vein as signs of advanced cirrhosis that causes portal

hypertension (see figure 2).Note as the portal venous flow pressure upsurges, the course of the

flow becomes biphasic (see figure 4) and subsequently triggering a reversal to occur. Berzigotti

and Piscaglia (2011) assert that most signs mentioned early are associated with HVPG and

cannot be used after embarking on non-discriminatory beta-blocker treatment; however, they

provide valuable prognostic information that aids in malignant portal hypertension follow-up.
 Diagnosis of Portal Hypertension 7

Figure 1 Oblique ultrasound imaging of a liver with nodular surface and dilated portal

vein. (Koslin, Mulligan and Berland, 1992)

Figure 2 Oblique ultrasound scan of dilated portal vein (Millener et al., 1993)
 Diagnosis of Portal Hypertension 8

Figure 3: Ultrasound scan shows biphasic flow related to portal hypertension

(Criss,Rallsand Jarboe, 2017)

Computed tomography

In the recent time, computed tomography has become an invaluable tool in diagnosing

liver problems. When the liver does not have any common abnormalities in terms of shape and

size, it will quite normal under the computed tomography scan; however, splenomegaly (see the

image in figure 5) and ascites can easily be detected. With zero enhancement, computed

tomography has the ability to detect confluent fibrosis in a cirrhotic liver (Smith et al., 2016).

When a contrasting element is administered in the venous system, confluent fibrosis, which is a

naturally low attenuating, will tend to become mildly hypoattenuating; therefore, the likelihood

of missing it is quite high when using contrast-enhanced computed tomography (De Franchis,

2008). The collateral venous system is usually observed within the peritoneal cavity, the

abdominal wall, the retroperitoneal site as well as the mediastinum. With basic computed

tomography, the poor contrasts make it hard for the scans to determine a normal liver and the

presence of lesions on the liver.

The portal vein is largest supplier of the blood flowing into the liver which makes

contrast enhancement a vital during the portal venous stage of computed

 Diagnosis of Portal Hypertension 9

tomography(Khan,2017). Helical computed tomography takes only about twenty-second of

examination to completely capture the required scan in one breath hold. At this stage, the

examiner can use dual-phase or extended contrast-enhanced computed tomography scans. In the

case, the imaging is duo-fold using one bolus of the contrasting agent, the first scan is obtained

in the arterial stage and the second in the portal intravenous stage (see Figure 6 scan

image).Kulali et al. (2016) explain that computed topography identifies hepatosteatosis as an

antecedent condition for liver cirrhosis and sequentially a precursor of obtaining portal

hypertension.

Various researches have indicated that the standard measure of the increased liver as seen

from the CT images is able to show the variation between a normal liver and a hardened liver by

the presence nodules on its surface. The knowledge can also be used in determining whether a

patient has a chronic cirrhosis.

Using contrasted cross-section images of the liver improves the visibility of portal venous

enhancing better diagnostic results on the affected oesophageal varices. However, the specificity

of CT scan on very tiny injuries is not 100%; lowering the doctor’s visibility creating a necessity

of using of other more accurate scans (De Franchis, 2008).

The plain CT is considered safer as it has very low radiations hence cannot cause

irritations on the patient. The images are clear and hence useful to the specialist during

interpretation. Some of the deep veins in the fatty deposit are less visible to the CT image scan.

Moreover, CT produces some harmful radiations that can be detrimental to the health of the

patient especiall when using the contrasted mode.

 Diagnosis of Portal Hypertension 10

Figure 4: CT-scan indicating splenomegaly and dilated splenic vein (Henseler et al.,

2001)

Figure 5: Contrast-enhanced CT imaging of dilated left renal vein (Ulu et al., 2008).

Magnetic Reasoning Imaging

 Diagnosis of Portal Hypertension 11

Magnetic Reasoning imaging has almost similar function to the CT scan as both provide

images of the organ being examined. For patients with portal hypertension, the magnetic imaging

will indicate inelasticity of the liver. This shows the liver is receiving less blood leading to its

stiffness. The test removes the possibility of performing a biopsy of the liver as the evidences are

displayed with clarity. However, in some situations, the doctor may be forced by circumstances

to carry out a biopsy to ascertain the level of damage to the liver .

There are several ways of scanning in the MRI.It is used in parts that can produce echo

i.e tubular body organs.It is very sensitive to timing and the resonance (Berzigotti et al., 2012). A

small delay can lead to incorrect imaging. It uses the times series of T1,T2 to measure the

magnitude and intense of the injury. It is an important instrument in the Dignosis of HP.

Depending on the patient’s co-operation; MRI can be very efficient in imaging.

Endoscopy

Severe Portal hypertension leads to stiffening of the liver a condition called liver

cirrhosis. The major complication of this condition regardless of the effort to keep it at bay is the

massive bleeding of the varices. To curb blood loss , there is need to carry out pre-diagnosis of

the affected varices.The most important endoscopy is that of the upper body as it aid in

examining the possibility gastroesophageal varices and in detecting symptoms of any possibility

bleeding Kulali et al. (2016). It is a recommendation by the World Health Organization to

perform endoscopy screening to any patient with possibility of deloveloping liver cirrhosis.

However, endoscopy has the effect of increasing medical costs to the health facility especially

when the facility is handling a larger number of patients with liver problem. If the patient has a

blood with an average platelet percentage of between 20- 30 %; known as elastography of less

than than 25 kPa, the doctor can omit the endoscopy. Although, all the patient falling short of the
 Diagnosis of Portal Hypertension 12

recorded category have to be screened to prevent possibility of blood clots in the body and to

identify other symptoms i.e hypersensitive gastropathy that may lead to undetected blood loss in

the patient’s body..

Acute bleeding

According to Sauerbruch, Schierwagen and Trebicka,(2018) acute bleeding increases

mortality rate of the patient when the outcome of endoscopy are below average.The bleeding

take less time stop for more than 50% of the patients, however, some emergency follow-ups have

to be conducted to improve the quality of healing. Involving the hypovolemia treatment,

disinfectants and drugs to reduce bleeding can curb the mortality rates in the hospitals. There are

cases where ligation can act as the best way to prevent acute bleeding when the physicians are

applying an emergency treatment to bleeding.

Prevention of recurrent bleeding

There are various effects of recurrent bleeding that are solved using a variety of methods.

Shunt procedure is the most preferred and efficient as it increases chances of the patient survival.

Other forms of treatment are prune to more risk of causing the patient’s death; thereby enhancing

retaining the endoscopys’s relevance in the treatment. Sclerotherapy is only less than 50% in

decreasing the rate of bleeding regardless of having prolonged negative effects of bleeding ulcers

(Sauerbruch, Schierwagen, & Trebicka, 2018).

Prognosis

The two major complications of portal hypertensiona are viriceal blood loss and hepatic

encephalopathy. More than 90% of the patients suffering from HP have a high propensity of

developing gastrointestinal bleeding visible in the patient’s stools. In additition, more than 75%
 Diagnosis of Portal Hypertension 13

of cirrhoric patients are more probable of developing ascites in their lifetime (Berzigotti et al.,

2012).

Treatment

The medical specialist should be provided with the medical guide to improve the survival

rate of the patients. The remedy for HP can be the use shunt procedure that re-routes the blood

flow away from the affected region of the artery.Beta-blockers are also recommended as they

reduce the effects of portal hypertension of the cirrhotic patients.

Clinical Pathway

A clinical application of both computed tomography and ultrasound imaging in the

assessment of the liver and portal venous system is quite informative. The imaging helps in

identifying the lesions and fibrosis on the liver surface, gastrointestinal varices, dilated splenic

and portal veins, portal vein thrombosis, biphasic blood flow, and collateral vessels Al-Busafi et

al. (2011). In addition, the imaging will play a significant function in preoperative and

postoperative intervention on patients eligible for port systemic shunts or those in need of liver

allograft. It is essential to be updated on the guidelines that will assist them in the management of

the portal hypertension. The government has an initiative to ensure campaigns on the PH

awareness to reduce the number of patients who visit the hospitals when the condition is severe

and minimal reversal can be done.

The lifestyles leading to the condition should be communicated to the public to ensure

shared burden between the specialist and the public. The physicians is the one who identifies the

symptoms through examining the patient on arrival to the health facility and has the

responsibility of directing the patient, testing, and getting involved in the management of the
 Diagnosis of Portal Hypertension 14

condition. He is also responsible for referring the patient to the health facility that deals with the

specific ailment.

All the ages should receive the required health maintenance such as immunization and

regular check-ups. The children suffering from the HP should avoid vigorous activity that can

lead to accelerated severity of their condition (Berzigotti et al., 2012). For those students in

schools, the school nurses should be availed with their health records for close monitoring on any

deviation in their health status.

The health provider is also responsible for surveillance of the patients conditions such as

ensuring the required drugs are in place; patients get regular scans to detect their healing

progress. Healthy eating for the patient should be recommended such as eating a balanced diet

and drinking the required amount of fluids Al-Busafi et al. (2011). The patient follow-up

especially those under beta-blockers is recommended and scheduled to test the rate of heart beat

and blood pressure monitoring.

More research should be conducted to evaluate the optimal healthcare for the patients and

assist them to live a normal and safe life even after being discharged from the hospital. The

doctor-patient collaboration should be encouraged to ensure effective management of HP to

ensure long term routine health administration and immunization strategy for the children.

Extended research to strengthen the HP and causes of liver cirrhosis is needed as the

current management lacks high profile health specialist to interpret the outcome in the advanced

age groups in the society Villanueva et al. (2017).

More mode of treatment should be devised to reverse the condition of the patient in the

advanced level of HP. Some pain relievers have long-term negative effects to the patients and

should be replaced with drugs with less side effects. The young patients should also be given
 Diagnosis of Portal Hypertension 15

moral support through engaging them in training of self appreciation and acceptance as they

recover from the side effects of the treatment.

In summary, portal hypertension is likely to occur when the liver suffers advanced

damage, which can be characterized by variceal bleeding. The ultrasound and computed

tomography imaging techniques are valuable in identifying sign and symptoms of a damaged

liver or blockage of the portal intravenous system. Early detection of the liver problems and

consideration of preventive dietary habits including avoid alcohol and fatty foods will help lower

mortality rate and using invasive and expensive rescue therapies such as liver transplants.
 Diagnosis of Portal Hypertension 16

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