Updated: 6/29/2019

Portal Hypertension

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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
    • etiologies can be divided into the following:
      • 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
  • Hyperdynamic circulation ↑ portal blood flow → portal hypertension
    • mainly due to arterial splanchnic vasodilation
      • leads to increased blood flow to the portal venous system
Presentation
  • Manifestations
    • jaundice
    • ascites
      • excess fluid accumilation in peritoneal cavity
    • portosystemic shunting
      • due to portal blood flow reversal
        • complications where capillary beds are shared between the systemic and portal circulation
          • hemorrhoids
            • superior rectal - middle and
              inferior rectal
          • esophageal varices
            • left gastric vein -  tributaries of the azygous vein
            • can cause massive hematemesis → risk of death
          • caput medusae at the umbilicus
            • parapumbilical veins - anterior abdominal wall veins
    • splenomegaly
      • secondary to congestions
      • can lead to hypersplenism thrombocytopenia
    • hyperestrinism
      • impairment in estrogen metabolism → sex hormone imbalance
        • gynecomastia
        • palmar erythema
        • spider angiomata
        • testicular atrophy
Evaluation
  • Upper endoscopy
  • Doppler ultrasonography
    • can identify collateral vessels, alterations in portal blood flow
  • 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)  
        • β1 blockade - decreased cardiac output
        • β2 blockade - splanchnic vasoconstriction
      • endoscopic variceal ligation
    • ascites
      • want to decrease ascitic fluid and peripheral edema
        • stop alcohol intake
        • sodium restriction
        • diuretics
          • spironolactone and furosemide
            • before using furosemide, check for hypokalemia
              • add when hypokalemia is adequately corrected
              • hypokalemia → renal ammonia production
        • large-volume therapeutic paracentesis
          • in those with tense ascites
    • spotaneous bacterial peritonitis
      • ascitic fluid infection
        • positive bacterial culture and ≥ 250 cells/mm3 absolute polymorphonuclear leukocyte count in the ascitic fluid
          • ascitic fluid culture first, and then broad spectrum antibiotics (e.g., cefotaxime)
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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Topic COMMENTS (6)
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