Clinical Review ABC of diseases of liver, pancreas, and biliary system

Portal hypertension—1: varices

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7282.348 (Published 10 February 2001) Cite this as: BMJ 2001;322:348
  1. J E J Krige,
  2. I J Beckingham

    The portal vein carries about 1500 ml/min of blood from the small and large bowel, spleen, and stomach to the liver at a pressure of 5-10 mm Hg. Any obstruction or increased resistance to flow or, rarely, pathological increases in portal blood flow may lead to portal hypertension with portal pressures over 12 mm Hg. Although the differential diagnosis is extensive, alcoholic and viral cirrhosis are the leading causes of portal hypertension in Western countries, whereas liver disease due to schistosomiasis is the main cause in other areas of the world. Portal vein thrombosis is the commonest cause in children.

    Anatomical relations of portal vein and branches

    Increases in portal pressure cause development of a portosystemic collateral circulation with resultant compensatory portosystemic shunting and disturbed intrahepatic circulation. These factors are partly responsible for the important complications of chronic liver disease, including variceal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome, recurrent infection, and abnormalities in coagulation. Variceal bleeding is the most serious complication and is an important cause of death in patients with cirrhotic liver disease.

    Causes of portal hypertension

    Increased resistance to flow
    Prehepatic (portal vein obstruction)
    • Congenital atresia or stenosis

    • Thrombosis of portal vein

    • Thrombosis of splenic vein

    • Extrinsic compression (for example, tumours)

    Hepatic
    • Cirrhosis

    • Acute alcoholic liver disease

    • Congenital hepatic fibrosis

    • Idiopathic portal hypertension (hepatoportal sclerosis)

    • Schistosomiasis

    Posthepatic
    • Budd-Chiari syndrome

    • Constrictive pericarditis

    Increased portal blood flow
    • Arterial-portal venous fistula

    • Increased splenic flow

    Varices

    In Western countries variceal bleeding accounts for about 7% of episodes of gastrointestinal bleeding, although this varies according to the prevalence of alcohol related liver disease (11% in the United States, 5% in the United Kingdom). Patients with varices have a 30% lifetime risk of bleeding, and a third of those who bleed will die. Patients who have bled once from oesophageal varices have a 70% chance of bleeding again, and about a third of further bleeding episodes are fatal.

    Several important considerations influence choice …

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