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Questions and Answers
What is considered portal hypertension (PHT) in terms of portal vein pressure?
Splenomegaly is one of the least common manifestations of portal hypertension.
False
What is the main differential diagnosis (DDx) tool used for narrowing the causes of ascites?
abdominal paracentesis and ascitic fluid analysis
Portal vein is formed by the union of the _____ and _____ veins.
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Match the following signs of ascites with their descriptions:
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Which of the following conditions is considered a prehepatic cause of ascites?
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High Serum-Ascitic Albumin Gradient (SAAG) indicates the presence of post-hepatic causes of ascites.
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What does a low SAAG value suggest in the context of ascites?
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The presence of _____ is highly suggestive of abdominal tuberculosis when SAAG is less than 33 u/l.
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Match the following conditions with their respective categories:
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What is the primary clinical sign associated with oesophageal varices?
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Caput medusae is characterized by dilated periumbilical veins.
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What complication occurs in 90% of patients with portal hypertension over 10 years?
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In portal hypertension, the direction of blood flow below the umbilicus will drain __________.
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Match the clinical signs with their corresponding description:
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What is the primary difference between blood flow in portal hypertension and IVC obstruction?
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What is the importance of identifying 'red signs' on endoscopy for varices?
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Bleeding from varices is a non-urgent medical condition.
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Study Notes
Portal Hypertension
- Normal portal vein pressure: 5-8mmHg
- Portal hypertension is a condition where the pressure in the portal vein is greater than 10-12mmHg
- The portal vein is formed by the union of the superior mesenteric vein and splenic vein
Clinical Manifestations of Portal Hypertension
- Patients are often asymptomatic
- Splenomegaly is the most common manifestation
- Ascites is a key sign
Ascites
- Ascites is a pathological fluid collection within the peritoneal cavity
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Inspection
- Distended abdomen with bulging flanks
- Everted/shallow, downward pointing umbilicus
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Palpation
- May feel tense depending on the volume
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Percussion
- Shifting dullness
- Fluid thrill (in large, tense ascites)
- Puddle sign (in small volume ascites)
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Differential Diagnosis
- Can be quickly narrowed down by abdominal paracentesis and ascitic fluid analysis, especially by comparing fluid albumin to serum albumin
- Serum albumin – Ascites albumin = Serum albumin ascites gradient (SAAG)
- The SAAG is a better indicator of the cause of ascites than classifying ascitic fluid as transudate or exudate
- All high SAAG patients have portal hypertension
Causes of Ascites and SAAG
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High SAAG (≥11.1mmol/L) indicates portal hypertension, and can be caused by:
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Prehepatic
- Portal vein obstruction (due to thrombosis, tumor, etc.)
- Presinusoidal (before the sinusoids)
- Schistosomiasis
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Hepatic
- Cirrhosis (most common cause)
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Post-sinusoidal (after the sinusoids)
- Veno-occlusive disease
- Right-sided heart failure
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Post-hepatic
- Budd-Chiari syndrome (thrombosis of the hepatic veins)
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Prehepatic
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Low SAAG indicates non-portal hypertension-related ascites:
- Decreased intake/malnutrition
- Decreased production
- Chronic Liver Disease (CLD)
- Hypoalbuminemia (low albumin in blood)
- Nephrotic syndrome
- Increased losses
- Peritonitis
- Low SAAG with ascites albumin <33 u/L suggests tuberculosis
Portosystemic Anastomosis
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In healthy individuals, the portosystemic anastomosis (connections between portal and systemic circulation) do not exchange a significant amount of blood due to similar pressures.
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In portal hypertension, blood is shunted from the portal veins to the caval (systemic) veins
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Regions and Manifestations
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Oesophagus: Oesophageal varices (dilated veins in the esophagus)
- Oesophageal branch of left gastric vein (portal circulation)
- Oesophageal branches of azygous vein (caval circulation)
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Rectum: Anal varices (painless hemorrhoids)
- Superior rectal vein (portal circulation)
- Middle and inferior rectal veins (caval circulation)
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Paraumbilical: Caput Medusae (dilated veins around the umbilicus)
- Paraumbilical veins (portal circulation)
- Superficial epigastric vein (caval circulation)
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Assessing Caput Medusae
- Direction of blood flow can differentiate inferior vena cava obstruction from portal hypertension
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Steps
- Occlude the vein with a finger.
- Empty the vein below the occluding finger using a second finger.
- Remove the second finger.
- If the vein refills, flow is occurring towards the occluding finger.
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Important Note:
- Veins below the umbilicus are most informative.
- In portal hypertension, blood will flow away from the umbilicus, draining inferiorly.
- In inferior vena cava obstruction, veins drain up towards the IVC, draining superiorly.
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Oesophageal Varices
- May occur in 90% of patients with portal hypertension over 10 years
- Only 1/3 will bleed.
- Bleeding varices are an emergency.
- Increased chance of bleeding with large varices and the presence of red signs on endoscopy.
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Red Signs
- Red wale marks: longitudinal red streaks
- Cherry-red spots: red, discreet, flat spots
- Haematocystic spots: red, discreet, raised spots
- Diffuse erythema
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Description
This quiz covers the basics of portal hypertension, its clinical manifestations, and the diagnostic approach to ascites. It includes key signs, symptoms, and differences in diagnosis using fluid analysis. Test your knowledge on this important clinical topic.
