Snapshot A 46-year-old male presents to his primary care physician for a health maintenance examination. The patient talks about how he is struggling to cut back on his alcohol intake. The patient currently has no complaints, but feels as though he is gaining weight despite early satiety. On physical exam, the patient has mild scleral icterus. Gynecomastia is noted. Abdomen is distended, with a fluid wave. Introduction ↑ portal blood flow resistance at the level of the sinusoids → portal hypertension Hyperdynamic circulation → ↑ portal blood flow → portal hypertension mainly due to arterial splanchnic vasodilation leads to increased blood flow to the portal venous system ETIOLOGY Prehepatic portal vein thrombosis malignancy compression e.g., pancreatic cancer Intrahepatic cirrhosis (most common) schistosomiasis Wilson disease Posthepatic Budd-Chiari syndrome right-sided heart failure constrictive pericarditis Presentation Manifestations jaundice ascites excess fluid accumilation in peritoneal cavity portosystemic shunting due to portal blood flow reversal login to view 8 more bullets splenomegaly secondary to congestions can lead to hypersplenism → thrombocytopenia hyperestrinism impairment in estrogen metabolism → sex hormone imbalance login to view 4 more bullets IMAGING Upper endoscopy Doppler ultrasonography can identify collateral vessels, alterations in portal blood flow STUDIES Serum-ascites albumin gradient (SAAG) ≥ 1.1 g/dL can suggest portal hypertension Treatment Treatment aimed at ameliorating the complications of portal hypertension, examples include: varices but no bleeding primary prophylaxis with nonselective beta blocker (e.g., propranolol and nadolol preferred) login to view 2 more bullets endoscopic variceal ligation ascites want to decrease ascitic fluid and peripheral edema login to view 9 more bullets spotaneous bacterial peritonitis ascitic fluid infection login to view 2 more bullets