Portal Hypertension Clinical Presentation
- Author: Jesus Carale, MD; Chief Editor: BS Anand, MD more...
In obtaining the medical history of a patient with portal hypertension, attention should be directed toward determining the cause of the condition and, secondarily, to which complications are present.
Determining the cause of portal hypertension involves obtaining information on the following:
History of jaundice - Previous jaundice suggests the possibility of a previous acute hepatitis, hepatobiliary disorder, or drug-induced liver disease; recurrence of jaundice suggests the possibility of reactivation, infection with another virus, or the onset of hepatic decompensation
History of blood transfusions, administration of various blood products, or intravenous drug use - These raise the possibility of infection with hepatitis B and C viruses
Family history of hereditary liver disease (eg, hemochromatosis, Wilson disease)
History of alcohol abuse
History of high-risk sexual behavior
History of schistosomiasis in childhood may be obtained from patients who resided in areas where the infection is endemic
History of other hepatic-related diseases (eg, nonalcoholic steatohepatitis [NASH], autoimmune hepatitis, diabetes mellitus, and hyperlipidemia) - Research suggests that esophageal varices occur in approximately 50% of patients with NASH with severe fibrosis (like patients with other chronic liver disorders, NASH patients with esophagogastric varices need to be followed up carefully)
Despite conflicting studies, the most common causes of gastrointestinal (GI) bleeding are peptic ulcer disease, of which gastric ulcers are usually more common than duodenal ulcers, and a nonspecific mucosal abnormality (21-55%).[22, 23, 24] Bleeding from esophageal varices is responsible for 12-14% of upper GI bleeding; acute gastric erosions/hemorrhagic gastritis, Mallory-Weiss tears, gastric carcinoma, and Dieulafoy lesion, account for less than 10% of cases.[22, 23, 24]
Patient history of risk factors for upper GI bleeding, including the following, should also be assessed:
Use of alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs)
Documented episodes of GI bleeding
History of recent vigorous retching or emesis before an attack of hematemesis or melena
Symptoms of liver disease include the following:
Weakness, tiredness, and malaise
Sudden and massive bleeding, with or without shock on presentation
Nausea and vomiting
Weight loss - This symptom is common with acute and chronic liver disease; it is mainly due to anorexia and reduced food intake and regularly accompanies end-stage liver disease, when a loss of muscle mass and adipose tissue is often a striking feature
Abdominal discomfort and pain - Usually felt in the right hypochondrium or under the right lower ribs (front, side, or back) and in the epigastrium or the left hypochondrium
Jaundice or dark urine
Edema and abdominal swelling
Pruritus - Usually associated with cholestatic conditions, such as extrahepatic biliary obstruction, primary biliary cirrhosis, sclerosing cholangitis, cholestasis of pregnancy, and benign, recurrent cholestasis
Spontaneous bleeding and easy bruising
Symptoms of encephalopathy - These include disturbance of the sleep-wake cycle; deterioration in intellectual function, memory loss, and, finally, an inability to communicate effectively at any level; personality changes; and, possibly, displays of inappropriate or bizarre behavior
Impotence and sexual dysfunction
Muscle cramps - Common in patients with cirrhosis
The presence of complications of portal hypertension can be ascertained by determining whether the following are present:
Hematemesis or melena - May indicate gastroesophageal variceal bleeding or bleeding from portal gastropathy
Mental status changes - Such as lethargy, increased irritability, and altered sleep patterns; these may indicate the presence of portosystemic encephalopathy
Increasing abdominal girth - May indicate ascites formation
Abdominal pain and fever - May indicate spontaneous bacterial peritonitis, although this disease also presents without symptoms
Hematochezia - May indicate bleeding from portal colopathy
Check the patient's blood pressure and pulse with the patient in the supine and seated positions.
Signs of portosystemic collateral formation include the following:
Dilated veins in the anterior abdominal wall - May indicate umbilical epigastric vein shunts
Venous pattern on the flanks - May indicate portal-parietal peritoneal shunting
Caput medusae (tortuous paraumbilical collateral veins)
Ascites - Shifting dullness and fluid wave (if a significant amount of ascitic fluid is present) 
Signs of liver disease include the following:
Ascites  - Abdominal distention due to accumulation of fluid; may be associated with peripheral edema and may involve the abdominal wall and genitalia
Gynecomastia in males from failure of liver to metabolize estrogen, resulting in a sex hormone imbalance; loss of pubic hair and axillary hair may also be observed
Palmar erythema and leukonychia - May be present in patients with cirrhosis
Asterixis ("flapping tremor," "liver flap")
Testicular atrophy - Common in males with cirrhosis, particularly those with alcoholic liver disease or hemochromatosis
Signs of a hyperdynamic circulatory state include the following:
Warm, well-perfused extremities
Flow murmur over the pericardium
Other signs of portal hypertension and esophageal varices include the following:
Pallor - May suggest active internal bleeding
Parotid enlargement - May be related to alcohol abuse and/or malnutrition
Cyanosis of the tongue, lips, and peripheries - Due to low oxygen saturation
Dyspnea and tachypnea
Telangiectasis of the skin, lips, and digits
Gynecomastia - Results from failure of the liver to metabolize estrogen, resulting in a sex hormone imbalance; loss of pubic and axillary hair may also be observed
Fetor hepaticus - Occurs in portosystemic encephalopathy of any cause (eg, cirrhosis)
Venous hums - Continuous noises audible in patients with portal hypertension; may be present as a result of rapid, turbulent flow in collateral veins
Tarry stool - During the rectal examination, obtain a stool sample for visual inspection; a black, soft, tarry stool on the gloved examining finger suggests upper gastrointestinal bleeding
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|Etiology of Portal Hypertension||WHVP||FHVP||HVPG|
|Posthepatic||Budd-Chiari syndrome||N/A||Hepatic vein cannot be cannulated||N/A|
|Other posthepatic causes||Increased||Increased||Normal|
|FHVP = free hepatic venous pressure; HVPG = hepatic venous pressure gradient; N/A = not applicable; WHVP = wedged hepatic venous pressure.|