Understanding Portal hypertension

1. Portal Hypertension:
Learn from the start
Pratap Sagar Tiwari, Lecturer, NGMC

2. What does Portal HTN mean ?
• In simpler terms. It means Hypertension or
increased blood pressure in the Hepatic portal
system.
•
Note: this isnt an standard definition
What is hepatic portal System ????

3. Hepatic portal system
• The hepatic portal system is the system of
veins that consists of the hepatic portal vein
and its tributaries.
• It is also called the portal venous system.
Pic taken from : http://imageradiology.
blogspot.com/2010/10/hepatic-portal-vein.html
It is one of the two portal system in the body and the other
being is the Hypophyseal portal system is a blood system of
vessels in the brain that connects the hypothalamus with the
anterior pituitary.

4. Portal circulation
Hepatic vein
IVC
25
%
Hepatic Artery
Proper
75
%
Hepatic portal
vein
SMV
GI tract
Splenic vein
Spleen
IMV
Gastric vein
Cystic vein

5. Portal circulation
• The liver receives about 75% of its blood through the
hepatic portal vein, with the remainder coming from
the hepatic artery proper.
• The hepatic portal vein is a blood vessel that conducts
blood from the gastrointestinal tract and spleen to the
liver.
• The blood leaves the liver to the heart in the hepatic
veins.
• The hepatic portal vein is usually formed by the
confluence of the superior mesenteric and splenic
veins and also receives blood from the inferior
mesenteric, gastric, and cystic veins.

6. Portal triad
Pic taken from : https://cms.webstudy.com/WebstudyFileSystem/testovaci/GetFile/293875/Ch%2022/Ch22b/index.html

7. Portal triad
A portal triad (a component of the hepatic
lobule)
It consists of the following five structures:
1. proper hepatic artery
2. hepatic portal vein
3. common bile duct
4. lymphatic vessels
5. branch of the vagus nerve

8. PostHepatic
Portal vein &
tributaries
PreHepatic
Bile canaliculi &
sinusoids
Hepatic vein
IntraHepatic
IVC
Occulsion↑ resistance↑ pressure hypertension
Systemic cirulation
HEART

9. Portal HTN :causes
Ref: HEMODYNAMIC PRINCIPLES OF PORTAL HYPERTENSION. Sleisenger-2010. http://www.uptomed.ir

10. Portal HTN : manifestations

11. Understanding HVPG
Ref: http://www.ias.ac.in/meetings/annmeet/71am_talks/sksarin/img46.html

12. Portal hypertension
• PHTN is hypertension (high BP) in the portal vein
system, which is composed by the portal vein,
and its branches.
• Portal venous pressure is the blood pressure in
the hepatic portal vein, and is normally between
5-10 mmHg.
•
•
•
NOTE: Wedged hepatic venous pressure (WHVP)= hepatic sinusoidal pressure
hepatic venous pressure gradient HVPG= WHVP- FHVP
Normal HVPG = < 5 mmhg
• Portal hypertension is defined as elevation of
hepatic venous pressure gradient to >5mmHg.

13. Summary
• Normal portal venous pressure is generally
considered to be between 5 -10 mm Hg.
• Once the portal venous pressure rises to 12
mm Hg or greater, complications can arise,
such as varices ,ascites etc.
• Portal hypertension is defined as elevation of
hepatic venous pressure gradient to
>5mmHg.

14. Prognostic value of HPVG in CLD
Measurement(mmhg)
Significance
1-5
normal
6-10
Preclinical sinusoidal portal htn
≥10
Clinically significant phtn
≥12
Increase risk of rupture of varices
≥16
Increase risk of mortality
≥20
Treatment failure and mortality in acute variceal bleeding
An HPVG of ≥10 mmHg defines clinically significant portal hypertension
Ref: Iris W. Liou, MD. Screening for Varices and Prevention of Bleeding http://hepatitisc.uw.edu/
Portal hypertension is defined as elevation of hepatic
venous pressure gradient to >5mmHg.

15. Differentiating Sinusoidal from
preSinusoidal portal HTN
Intrahepatic
PVP
WHVP
FHVP
HVPG
Presinusoidal
↑
N
N
N
SInusoidal
↑
↑↑
↑
↑
WHVP = sinusoidal pressure
HVPG = WHVP – FHVP
Portal venous pressure is increased ,so portal hypertension
But WHVP increases in Sinusoidal ,so Ascites is common in Sinusoidal causes of portal htn
(increased Sinusoidal pressure= transudation of fluid )

16. Schematic dig showing blood flow
Normal
Source: emedicine
Portal HTN

17. Overall Manifestations: PHTN
•
•
•
•
Ascites
Varices
Hepatic encephalopathy
Splenomegaly

18. Next Part :
• Investigation & Management of portal
hypertension

19. • Thankyou