Diagnostic Considerations

When evaluating a patient with portal hypertension, also consider the following conditions:

Cirrhosis of any etiology (viral hepatitis, autoimmune cirrhosis, alcohol-related cirrhosis, primary biliary cirrhosis, etc)
Hepatic infiltrative diseases (eg, Wilson disease, hemochromatosis, sarcoidosis)
Hepatoportal arteriovenous fistula
Portal vein obstruction
Portal vein occlusion (eg, portal vein thrombosis)
Primary sclerosing cholangitis
Severe congestive heart failure (cardiac cirrhosis)
Splenic vein thrombosis
Veno-occlusive disease
Budd-Chiari syndrome
Schistosomiasis
Chronic pancreatitis

Patients who present with upper gastrointestinal (GI) bleeding can be approached as whether the bleeding is variceal or nonvariceal. Not all upper GI bleeding in cirrhotic patients are from variceal hemorrhage. It should also be noted that peptic ulcer disease is present more frequently in cirrhotic patients than noncirrhotic patients.^[12]The differential diagnosis of variceal hemorrhage includes the following:

Acute gastric erosions
Duodenal ulcers
Gastric cancer
Gastric ulcers
Mallory-Weiss tear
Nasogastric tube trauma
Portal hypertensive gastropathy - It is a relatively uncommon cause of significant bleeding

Gastric varices are the source of bleeding in 5-10% of patients with variceal hemorrhage. Higher rates are reported in patients with left-sided portal hypertension due to thrombosis of the splenic vein.

Differential Diagnoses

Workup

Hou W, Sanyal AJ. Ascites: diagnosis and management. Med Clin North Am. 2009 Jul. 93(4):801-17, vii. [QxMD MEDLINE Link].
Khurana I. Essentials of Medical Physiology. Noida, Uttar Pradesh, India: Elsevier; 2008. 215.
Lubel JS, Angus PW. Modern management of portal hypertension. Intern Med J. 2005 Jan. 35(1):45-9. [QxMD MEDLINE Link].
Obara K. Hemodynamic mechanism of esophageal varices. Dig Endosc. 2006 Jan. 18(1):6-9.
Ravindra KV, Eng M, Marvin M. Current management of sinusoidal portal hypertension. Am Surg. 2008 Jan. 74(1):4-10. [QxMD MEDLINE Link].
Theodorakis NG, Wang YN, Wu JM, Maluccio MA, Sitzmann JV, Skill NJ. Role of endothelial nitric oxide synthase in the development of portal hypertension in the carbon tetrachloride-induced liver fibrosis model. Am J Physiol Gastrointest Liver Physiol. 2009 Oct. 297(4):G792-9. [QxMD MEDLINE Link].
Gupta TK, Toruner M, Chung MK, Groszmann RJ. Endothelial dysfunction and decreased production of nitric oxide in the intrahepatic microcirculation of cirrhotic rats. Hepatology. 1998 Oct. 28(4):926-31. [QxMD MEDLINE Link].
[Guideline] Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, and the Practice Guidelines Committee of the American Association for the Study of Liver Diseases, the Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007 Sep. 102(9):2086-102. [QxMD MEDLINE Link].
Bhathal PS, Grossman HJ. Reduction of the increased portal vascular resistance of the isolated perfused cirrhotic rat liver by vasodilators. J Hepatol. 1985. 1(4):325-37. [QxMD MEDLINE Link].
Chawla Y, Duseja A, Dhiman RK. Review article: the modern management of portal vein thrombosis. Aliment Pharmacol Ther. 2009 Nov 1. 30(9):881-94. [QxMD MEDLINE Link].
Seijo S, Reverter E, Miquel R, et al. Role of hepatic vein catheterisation and transient elastography in the diagnosis of idiopathic portal hypertension. Dig Liver Dis. 2012 Oct. 44(10):855-60. [QxMD MEDLINE Link].
[Guideline] Dite P, Labrecque D, Fried M, et al, for the World Gastroenterology Organisation (WGO). World Gastroenterology Organisation practice guideline: esophageal varices. Munich, Germany: World Gastroenterology Organisation; 2008. Available at http://guideline.gov/content.aspx?id=13000. Accessed: August 6, 2012.
Thalheimer U, Leandro G, Samonakis DN, Triantos CK, Patch D, Burroughs AK. Assessment of the agreement between wedge hepatic vein pressure and portal vein pressure in cirrhotic patients. Dig Liver Dis. 2005 Aug. 37(8):601-8. [QxMD MEDLINE Link].
Sanyal AJ, Bosch J, Blei A, Arroyo V. Portal hypertension and its complications. Gastroenterology. 2008 May. 134(6):1715-28. [QxMD MEDLINE Link].
[Guideline] Qureshi W, Adler DG, Davila R, et al, for the Standards of Practice Committee. ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005. Gastrointest Endosc. 2005 Nov. 62(5):651-5. [QxMD MEDLINE Link].
Heil T, Mattes P, Loeprecht H. Gastro-oesophageal reflux: an aetiological factor for bleeding in oesophageal varices?. Br J Surg. 1980 Jul. 67(7):467-8. [QxMD MEDLINE Link].
Eckardt VF, Grace ND. Gastroesophageal reflux and bleeding esophageal varices. Gastroenterology. 1979 Jan. 76(1):39-42. [QxMD MEDLINE Link].
Yoon Y, Yi H. Surveillance report no. 88: liver cirrhosis mortality in the United States, 1970-2007. National Institute on Alcohol Abuse and Alcoholism. Available at http://pubs.niaaa.nih.gov/publications/surveillance88/Cirr07.htm. Accessed: Jul 17 2012.
Kim WR, Brown RS Jr, Terrault NA, El-Serag H. Burden of liver disease in the United States: summary of a workshop. Hepatology. 2002 Jul. 36(1):227-42. [QxMD MEDLINE Link].
D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology. 2006 Nov. 131(5):1611-24. [QxMD MEDLINE Link].
Fussner LA, Iyer VN, Cartin-Ceba R, Lin G, Watt KD, Krowka MJ. Intrapulmonary vascular dilatations are common in portopulmonary hypertension and may be associated with decreased survival. Liver Transpl. 2015 Nov. 21(11):1355-64. [QxMD MEDLINE Link].
Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am. 1996 Sep. 80(5):1035-68. [QxMD MEDLINE Link].
Boonpongmanee S, Fleischer DE, Pezzullo JC, et al. The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated. Gastrointest Endosc. 2004 Jun. 59(7):788-94. [QxMD MEDLINE Link].
Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen G. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc. 2008 Mar. 67(3):422-9. [QxMD MEDLINE Link].
Singal AK, Ahmad M, Soloway RD. Duplex Doppler ultrasound examination of the portal venous system: an emerging novel technique for the estimation of portal vein pressure. Dig Dis Sci. 2010 May. 55(5):1230-40. [QxMD MEDLINE Link].
Wereszczynka-Siemiatkowska U, Swidnicka-Siergiejko A, Siemiatkowski A, et al. Endothelin 1 and transforming growth factor-β1 correlate with liver function and portal pressure in cirrhotic patients. Cytokine. 2015 Dec. 76(2):144-51. [QxMD MEDLINE Link].
Beppu K, Inokuchi K, Koyanagi N, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc. 1981 Nov. 27(4):213-8. [QxMD MEDLINE Link].
Khan NM, Shapiro AB. The white nipple sign: please do not disturb. Case Rep Gastroenterol. 2011 May. 5(2):386-90. [QxMD MEDLINE Link]. [Full Text].
de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015 Sep. 63(3):743-52. [QxMD MEDLINE Link].
Castera L, Pinzani M, Bosch J. Non invasive evaluation of portal hypertension using transient elastography. J Hepatol. 2012 Mar. 56(3):696-703. [QxMD MEDLINE Link].
Kim TY, Jeong WK, Sohn JH, Kim J, Kim MY, Kim Y. Evaluation of portal hypertension by real-time shear wave elastography in cirrhotic patients. Liver Int. 2015 Nov. 35(11):2416-24. [QxMD MEDLINE Link].
Salzl P, Reiberger T, Ferlitsch M, et al. Evaluation of portal hypertension and varices by acoustic radiation force impulse imaging of the liver compared to transient elastography and AST to platelet ratio index. Ultraschall Med. 2014 Dec. 35(6):528-33. [QxMD MEDLINE Link].
Elkrief L, Rautou PE, Ronot M, et al. Prospective comparison of spleen and liver stiffness by using shear-wave and transient elastography for detection of portal hypertension in cirrhosis. Radiology. 2015 May. 275(2):589-98. [QxMD MEDLINE Link].
Pollo-Flores P, Soldan M, Santos UC, et al. Three months of simvastatin therapy vs. placebo for severe portal hypertension in cirrhosis: A randomized controlled trial. Dig Liver Dis. 2015 Nov. 47(11):957-63. [QxMD MEDLINE Link].
de Franchis R. Updating consensus in portal hypertension: report of the Baveno III Consensus Workshop on definitions, methodology and therapeutic strategies in portal hypertension. J Hepatol. 2000 Nov. 33(5):846-52. [QxMD MEDLINE Link].
Ferreira FG, Ribeiro MA, de Fatima Santos M, Assef JC, Szutan LA. Doppler ultrasound could predict varices progression and rebleeding after portal hypertension surgery: lessons from 146 EGDS and 10 years of follow-up. World J Surg. 2009 Oct. 33(10):2136-43. [QxMD MEDLINE Link].
Burger-Klepp U, Karatosic R, Thum M, et al. Transesophageal echocardiography during orthotopic liver transplantation in patients with esophagoastric varices. Transplantation. 2012 Jul 27. 94(2):192-6. [QxMD MEDLINE Link].
Bonnet S, Sauvanet A, Bruno O, et al. Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation. Gastroenterol Clin Biol. 2010 Jan. 34(1):23-8. [QxMD MEDLINE Link].
Lo GH, Lai KH, Cheng JS, et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial. Hepatology. 2000 Sep. 32(3):461-5. [QxMD MEDLINE Link].
Lo GH, Chen WC, Chan HH, et al. A randomized, controlled trial of banding ligation plus drug therapy versus drug therapy alone in the prevention of esophageal variceal rebleeding. J Gastroenterol Hepatol. 2009 Jun. 24(6):982-7. [QxMD MEDLINE Link].
Kumar A, Jha SK, Sharma P, et al. Addition of propranolol and isosorbide mononitrate to endoscopic variceal ligation does not reduce variceal rebleeding incidence. Gastroenterology. 2009 Sep. 137(3):892-901, 901.e1. [QxMD MEDLINE Link].
de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005 Jul. 43(1):167-76. [QxMD MEDLINE Link].
Castaneda B, Morales J, Lionetti R, et al. Effects of blood volume restitution following a portal hypertensive-related bleeding in anesthetized cirrhotic rats. Hepatology. 2001 Apr. 33(4):821-5. [QxMD MEDLINE Link].
Sass DA, Chopra KB. Portal hypertension and variceal hemorrhage. Med Clin North Am. 2009 Jul. 93(4):837-53, vii-viii. [QxMD MEDLINE Link].
Rimola A, Garcia-Tsao G, Navasa M. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000 Jan. 32(1):142-53. [QxMD MEDLINE Link].
de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010 Oct. 53(4):762-8. [QxMD MEDLINE Link].
Chandramouli J, Jensen L. Vasopressin injection. [Updated October 16, 2012.] Alternative agents & management. Table 1. Alternatives to vasopressin in selected situations. American Society of Health-System Pharmacists. Available at https://www.ashp.org/DrugShortages/Current/bulletin.aspx?id=795. Accessed: November 20, 2012.
Imperiale TF, Teran JC, McCullough AJ. A meta-analysis of somatostatin versus vasopressin in the management of acute esophageal variceal hemorrhage. Gastroenterology. 1995 Oct. 109(4):1289-94. [QxMD MEDLINE Link].
Baik SK, Jeong PH, Ji SW. Acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis: a randomized comparison. Am J Gastroenterol. 2005 Mar. 100(3):631-5. [QxMD MEDLINE Link].
D'Amico G, Pagliaro L, Pietrosi G, Tarantino I. Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev. 2010 Mar 17. CD002233. [QxMD MEDLINE Link].
Bajaj JS, Sanyal AJ. Treatment of active variceal hemorrhage. UpToDate. Available at http://www.uptodate.com/contents/treatment-of-active-variceal-hemorrhage. Accessed: August 2, 2012.
Garcia-Pagan JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol. 2005 Nov. 2(11):526-35. [QxMD MEDLINE Link].
Avgerinos A, Armonis A, Stefanidis G, et al. Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis. Hepatology. 2004 Jun. 39(6):1623-30. [QxMD MEDLINE Link].
Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AE, Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol. 2010 Sep. 8(9):760-6. [QxMD MEDLINE Link].
Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010 Jun 24. 362(25):2370-9. [QxMD MEDLINE Link].
Danziger J, Thummalakunta L, Nelson R, Faintuch S. The risk of acute kidney injury with transjugular intrahepatic portosystemic shunts. J Nephrol. 2015 Dec. 28 (6):725-8. [QxMD MEDLINE Link].
Samonakis DN, Triantos CK, Thalheimer U. Management of portal hypertension. Postgrad Med J. 2004 Nov. 80(949):634-41. [QxMD MEDLINE Link].
D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999. 19(4):475-505. [QxMD MEDLINE Link].
Bosch J, Abraldes JG, Groszmann R. Current management of portal hypertension. J Hepatol. 2003. 38 Suppl 1:S54-68. [QxMD MEDLINE Link].
Chang YW. Indication of treatment for esophageal varices: who and when?. Dig Endosc. 2006 Jan. 18(1):10-5.
Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007 Sep. 46(3):922-38. [QxMD MEDLINE Link].
Sinagra E, Perricone G, D'Amico M, Tine F, D'Amico G. Systematic review with meta-analysis: the haemodynamic effects of carvedilol compared with propranolol for portal hypertension in cirrhosis. Aliment Pharmacol Ther. 2014 Mar. 39(6):557-68. [QxMD MEDLINE Link].
Chen S, Wang JJ, Wang QQ, et al. The effect of carvedilol and propranolol on portal hypertension in patients with cirrhosis: a meta-analysis. Patient Prefer Adherence. 2015. 9:961-70. [QxMD MEDLINE Link]. [Full Text].
Li T, Ke W, Sun P, et al. Carvedilol for portal hypertension in cirrhosis: systematic review with meta-analysis. BMJ Open. 2016 May 4. 6(5):e010902. [QxMD MEDLINE Link]. [Full Text].
Merkel C, Marin R, Enzo E, et al. Randomised trial of nadolol alone or with isosorbide mononitrate for primary prophylaxis of variceal bleeding in cirrhosis. Gruppo-Triveneto per L'ipertensione portale (GTIP). Lancet. 1996 Dec 21-28. 348(9043):1677-81. [QxMD MEDLINE Link].
Garcia-Tsao G. Portal hypertension. Curr Opin Gastroenterol. 2000 May. 16(3):282-9. [QxMD MEDLINE Link].
Gluud LL, Klingenberg S, Nikolova D, Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007 Dec. 102(12):2842-8; quiz 2841, 2849. [QxMD MEDLINE Link].
Lay CS, Tsai YT, Lee FY, et al. Endoscopic variceal ligation versus propranolol in prophylaxis of first variceal bleeding in patients with cirrhosis. J Gastroenterol Hepatol. 2006 Feb. 21(2):413-9. [QxMD MEDLINE Link].
Abraczinskas DR, Ookubo R, Grace ND. Propranolol for the prevention of first esophageal variceal hemorrhage: a lifetime commitment?. Hepatology. 2001 Dec. 34(6):1096-102. [QxMD MEDLINE Link].
Augustin S, Millan L, Gonzalez A, et al. Detection of early portal hypertension with routine data and liver stiffness in patients with asymptomatic liver disease: a prospective study. J Hepatol. 2014 Mar. 60(3):561-9. [QxMD MEDLINE Link].
Bhasin DK, Siyad I. Variceal bleeding and portal hypertension: new lights on old horizon. Endoscopy. 2004 Feb. 36(2):120-9. [QxMD MEDLINE Link].
Boggs W. Simple strategy detects early portal hypertension in asymptomatic patients. Reuters Health Information. November 28, 2013. Available at http://www.medscape.com/viewarticle/815191. Accessed: December 10, 2013.
Chalasani N, Imperiale TF, Ismail A. Predictors of large esophageal varices in patients with cirrhosis. Am J Gastroenterol. 1999 Nov. 94(11):3285-91. [QxMD MEDLINE Link].
Conn HO. Portal hypertension, varices, and transjugular intrahepatic portosystemic shunts. Clin Liver Dis. 2000 Feb. 4(1):133-50, vii. [QxMD MEDLINE Link].
de Franchis R, Primignani M. Why do varices bleed?. Gastroenterol Clin North Am. 1992 Mar. 21(1):85-101. [QxMD MEDLINE Link].
Feldman M, Scharschmidt B, Zorab R, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 6th ed. Philadelphia, PA: WB Saunders; 1998.
Garcia-Pagan JC, Bosch J. Medical treatment of portal hypertension. Baillieres Best Pract Res Clin Gastroenterol. 2000 Dec. 14(6):895-909. [QxMD MEDLINE Link].
Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology. 2001 Feb. 120(3):726-48. [QxMD MEDLINE Link].
Goh SH, Tan WP, Lee SW. Clinical predictors of bleeding esophageal varices in the ED. Am J Emerg Med. 2005 Jul. 23(4):531-5. [QxMD MEDLINE Link].
Henderson JM. Surgical treatment of portal hypertension. Baillieres Best Pract Res Clin Gastroenterol. 2000 Dec. 14(6):911-25. [QxMD MEDLINE Link].
Krige JE, Beckingham IJ. ABC of diseases of liver, pancreas, and biliary system. Portal hypertension-1: varices. BMJ. 2001 Feb 10. 322(7282):348-51. [QxMD MEDLINE Link].
Krige JE, Shaw JM, Bornman PC. The evolving role of endoscopic treatment for bleeding esophageal varices. World J Surg. 2005. 29:966-73. [QxMD MEDLINE Link].
Lowe RC, Grace ND. Pharmacologic therapy for portal hypertension. Curr Gastroenterol Rep. 2001 Feb. 3(1):24-9. [QxMD MEDLINE Link].
Merkel C, Zoli M, Siringo S. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol. 2000 Oct. 95(10):2915-20. [QxMD MEDLINE Link].
Pruvot FR, Quandalle P, Paris JC. [What's left for surgical treatment of portal hypertension in cirrhosis patients?]. Gastroenterol Clin Biol. 2003 Nov. 27(11):1013-20. [QxMD MEDLINE Link].
Russo MW, Brown RS Jr. Endoscopic treatment of patients with portal hypertension. Gastrointest Endosc Clin N Am. 2001 Jan. 11(1):1-14. [QxMD MEDLINE Link].
Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992 Dec. 16(6):1343-9. [QxMD MEDLINE Link].
Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff's Diseases of the Liver. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
Sherlock S, Dooley J, eds. Diseases of the Liver and Biliary System. 10th ed. Oxford, UK: Wiley-Blackwell; 1997.
Soares-Weiser K, Brezis M, Tur-Kaspa R. Antibiotic prophylaxis of bacterial infections in cirrhotic inpatients: a meta-analysis of randomized controlled trials. Scand J Gastroenterol. 2003 Feb. 38(2):193-200. [QxMD MEDLINE Link].
Sterling RK, Sanyal AJ. Are TIPS tops in the treatment of portal hypertension? A review on the use and misuse of transjugular intrahepatic portosystemic shunts. Can J Gastroenterol. 2000 Nov. 14 Suppl D:122D-128D. [QxMD MEDLINE Link].
Wongcharatrawee S, Groszmann RJ. Diagnosing portal hypertension. Baillieres Best Pract Res Clin Gastroenterol. 2000 Dec. 14(6):881-94. [QxMD MEDLINE Link].

Media Gallery

Large esophageal varices with red wale signs seen on endoscopy. Courtesy of Wikimedia Commons.
Uphill esophageal varices. Barium swallow demonstrates multiple serpiginous filling defects primarily involving the lower one third of the esophagus with striking prominence around the gastroesophageal junction. The patient had cirrhosis secondary to alcohol abuse.
Barium swallow demonstrating esophageal varices involving the entire length of the esophagus. This appearance may be seen in advanced uphill varices or downhill varices secondary to superior vena cava obstruction at or below the level of the azygous vein.
Computed tomography scan showing esophageal varices. Note the extensive collateralization within the abdomen adjacent to the spleen as a result of severe portal hypertension.
Normal venous flow through the portal and systemic circulation. IMC = inferior mesenteric vein; IVC = inferior vena cava; SVC = superior vena cava.
Redirection of flow through the left gastric vein secondary to portal hypertension or portal venous occlusion. Uphill varices develop in the distal one third of the esophagus. IMC = inferior mesenteric vein; IVC = inferior vena cava; SVC = superior vena cava.
Portal vein and associated anatomy.
Power Doppler sonogram through the spleen shows varices at the hilum of an enlarged spleen. The final diagnosis was hepatitis C cirrhosis, hepatocellular carcinoma of the left hepatic lobe (which had ruptured into the peritoneum), and portoarterial fistula (which had developed inside the ruptured tumor, giving rise to severe portal hypertension).
Duplex spectral Doppler sonogram of the portal vein (same patient as in the previous image) shows a bidirectional flow within the vein. The final diagnosis was hepatitis C cirrhosis, hepatocellular carcinoma of the left hepatic lobe (which had ruptured into the peritoneum), and portoarterial fistula (which had developed inside the ruptured tumor, giving rise to severe portal hypertension).
Digital subtraction selective common hepatic artery angiogram shows immediate filling of the portal venous radicles in the left lobe of the liver (straight arrow) and early filling of portal vein (curved arrow), suggestive of hepatic arterial-portal vein fistula. The final diagnosis was hepatitis C cirrhosis, hepatocellular carcinoma of the left hepatic lobe (which had ruptured into the peritoneum), and portoarterial fistula (which had developed inside the ruptured tumor, giving rise to severe portal hypertension).
Delayed venous phase of a selective common hepatic angiogram (same patient as in the previous image) shows the portal vein (P), with filling of the left gastric vein caused by retrograde flow feeding gastric and lower esophageal varices (arrows). Retrograde flow in enlarged umbilical veins also is seen. The final diagnosis was hepatitis C cirrhosis, hepatocellular carcinoma of the left hepatic lobe (which had ruptured into the peritoneum), and portoarterial fistula (which had developed inside the ruptured tumor, giving rise to severe portal hypertension).
Digital subtraction venous phase of a superior mesenteric artery angiogram (same patient as in the previous 2 images) shows retrograde flow into the left gastric vein (curved arrow) and the inferior mesenteric vein (straight arrow). Note the flow defect of the distal portal vein caused by retrograde flow (open arrowhead). The final diagnosis was hepatitis C cirrhosis, hepatocellular carcinoma of the left hepatic lobe (which had ruptured into the peritoneum), and portoarterial fistula (which had developed inside the ruptured tumor, giving rise to severe portal hypertension).
This video, captured via esophagoscopy, shows band ligation of esophageal varices. Video courtesy of Dan C Cohen, MD, and Dawn Sears, MD, Division of Gastroenterology, Scott & White Healthcare.

of 13

Author

Jesus Carale, MD Consulting Gastroenterologist, Arkansas Valley Regional Medical Center, La Junta, Colorado

Jesus Carale, MD is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Samy A Azer, MD, PhD, MPH Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia

Samy A Azer, MD, PhD, MPH is a member of the following medical societies: American College of Gastroenterology, Association for Psychological Science, Gastroenterological Society of Australia, New York Academy of Sciences, Royal Society of Medicine, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Parit Mekaroonkamol, MD Assistant Professor of Medicine, Department of Internal Medicine, Division of Digestive Diseases, Emory University School of Medicine; Advanced Endoscopist/Gastroenterologist, Emory University Hospital

Parit Mekaroonkamol, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Medical Council of Thailand

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Samy A Azer, MD, PhD, MPH Professor of Medical Education and Head of Curriculum Development Unit, King Saud University, Riyadh, Saudi Arabia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; former Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; former Consultant to the Victorian Postgraduate Medical Foundation, Melbourne, Australia; former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia

Samy A Azer, MD, PhD, MPH is a member of the following medical societies: American College of Gastroenterology, Association for Psychological Science, Gastroenterological Society of Australia, New York Academy of Sciences, Royal Society of Medicine, and Sigma Xi