Portal Hypertension Surgery
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Direct answer
Portal hypertension is a pathologically raised pressure in the portal venous system, defined by a hepatic venous pressure gradient of 10 mmHg or more, and classified into pre-hepatic, intra-hepatic and post-hepatic causes. In India, cirrhosis, extrahepatic portal vein obstruction and non-cirrhotic portal fibrosis are all important causes of variceal bleeding. Acute variceal haemorrhage is treated by resuscitation, a vasoactive drug such as terlipressin, prophylactic antibiotics and endoscopic band ligation within about 12 hours, with balloon tamponade or TIPS as rescue measures.
What you must remember
- The hepatic venous pressure gradient is normal at 1 to 5 mmHg; clinically significant portal hypertension begins at 10 mmHg and bleeding risk rises steeply above 12 mmHg.
- Classification: pre-hepatic (portal vein thrombosis — a leading cause of variceal bleeding in Indian children and young adults), intra-hepatic (cirrhosis of any cause, and non-cirrhotic portal fibrosis, distinctly common in India) and post-hepatic (Budd-Chiari syndrome).
- Acute variceal bleed protocol: protect the airway, restore volume cautiously, start a vasoactive drug — terlipressin is standard in India, with octreotide or somatostatin as alternatives — and give short-course antibiotic prophylaxis such as ceftriaxone.
- Endoscopy within about 12 hours with band ligation is the definitive control measure; cyanoacrylate glue is used for gastric fundal varices.
- A balloon tamponade tube is only a temporary bridge in uncontrolled bleeding; TIPS is the rescue for refractory bleeding.
- Secondary prophylaxis combines non-selective beta blockers such as propranolol or carvedilol with scheduled repeat band ligation until varices are eradicated.
- The Child-Turcotte-Pugh score — bilirubin, albumin, prothrombin time, ascites and encephalopathy — grades operative risk, class C contraindicating elective surgery; splenectomy with devascularisation remains an option for selected extrahepatic portal vein obstruction with preserved liver function.
Common confusion
Candidates mix up the gradients — 10 mmHg defines clinically significant portal hypertension and 12 mmHg the bleeding-risk zone — and forget that non-cirrhotic causes matter in India: a young adult with massive variceal bleeding and normal liver function should raise extrahepatic portal vein obstruction or non-cirrhotic portal fibrosis, not occult cirrhosis. Also, vasoactive drugs and antibiotics are started before endoscopy, not after it, and balloon tamponade is a bridge, never a treatment endpoint.
Exam-focused takeaway
FMGE stems on this topic are protocol questions: the cirrhotic with haematemesis gets terlipressin plus antibiotics immediately, then endoscopy within about 12 hours for band ligation; fundal varices get glue; the refractory bleeder gets balloon tamponade as a bridge to TIPS; the survivor gets a beta blocker plus a banding schedule. A second type uses the Child-Turcotte-Pugh score to grade surgical risk — learn its five components — and a third asks which Indian cause gives varices with a normal liver: extrahepatic portal vein obstruction and non-cirrhotic portal fibrosis.
Frequently asked questions
At what hepatic venous pressure gradient is portal hypertension clinically significant?
From 10 mmHg onwards, with variceal bleeding risk rising steeply above 12 mmHg; the normal gradient is 1 to 5 mmHg.
What is the first drug in acute variceal bleeding?
A vasoactive drug — terlipressin in Indian practice, or somatostatin or octreotide — started at once with prophylactic antibiotics, before endoscopy.
What is the definitive treatment of bleeding oesophageal varices?
Endoscopic band ligation, performed within about 12 hours of presentation, with cyanoacrylate glue for gastric fundal varices.
What are the components of the Child-Turcotte-Pugh score?
Bilirubin, serum albumin, prothrombin time or INR, ascites and encephalopathy, graded to give classes A, B and C.
Which non-cirrhotic causes of portal hypertension matter in India?
Extrahepatic portal vein obstruction and non-cirrhotic portal fibrosis, both important causes of variceal bleeding with preserved liver function.
What is the role of shunt surgery now?
Largely replaced by endoscopy and TIPS; splenectomy with gastro-oesophageal devascularisation is still chosen for selected patients with extrahepatic portal vein obstruction.