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Liver· Chapter 23

Portal Hypertension and Cirrhosis Complications

Baveno VII variceal prophylaxis (carvedilol preferred over propranolol), refractory ascites and TIPS criteria, SBP with Sort albumin, HRS-AKI on terlipressin per CONFIRM, hepatic encephalopathy with rifaximin per Bass, HPS and POPH MELD-exception criteria, and the vascular liver diseases that drive non-cirrhotic portal hypertension.

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What this chapter covers

  • Section 23.1: Portal hypertension hemodynamics and Baveno VII

    Portal hypertension begins as increased intrahepatic resistance from sinusoidal architectural distortion, most commonly cirrhosis from any etiology.

  • Section 23.2: Variceal screening and primary prophylaxis

    Screening EGD is required in most cirrhotic patients except the Baveno VI exception (liver stiffness under 20 kPa AND platelets over 150,000), where yearly transient elastography and platelet trending substitute for endoscopy until either parameter crosses the threshold.

  • Section 23.3: Acute variceal hemorrhage and secondary prophylaxis

    Any GI bleeding in cirrhosis is variceal until proven otherwise.

  • Section 23.4: Gastric varices, portal hypertensive gastropathy, and GAVE

    Gastric varices are classified by Sarin: GOV1 (along the lesser curve, extension of esophageal varices, approximately 75 percent of all gastric varices, and behave most like esophageal varices, often controllable with band ligation); GOV2 (cardiofundal extension into the fundus); IGV1 (isolated fundal, often with gastrorenal shunt); IGV2 (isolated ectopic gastric sites).

  • Section 23.5: Ascites pathophysiology and diuretic management

    Ascites pathophysiology begins with portal hypertension driving splanchnic vasodilation through nitric oxide and other vasodilator excess.

  • Section 23.6: Refractory ascites, TIPS, and hyponatremia

    Refractory ascites is treated with serial large-volume paracentesis plus albumin or with TIPS in carefully selected patients.

  • Section 23.7: Spontaneous bacterial peritonitis

    SBP is diagnosed on diagnostic paracentesis with PMN over 250 per mm3 in a patient with cirrhotic ascites, regardless of symptoms or culture result.

  • Section 23.8: Hepatorenal syndrome

    HRS terminology has been updated: type 1 HRS is now called HRS-AKI, and type 2 is now HRS-CKD or HRS-NAKI.

  • Section 23.9: Hepatic encephalopathy

    Hepatic encephalopathy spans minimal (covert) HE detected only on psychometric testing through grade 4 coma per the West Haven classification.

  • Section 23.10: Pulmonary vascular complications: HPS, POPH, hepatic hydrothorax

    Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are clinically and physiologically opposite and require very different management.

  • Section 23.11: Coagulopathy and periprocedural management

    Cirrhosis produces a state of rebalanced hemostasis: parallel reductions in pro-coagulant factors (II, V, VII, IX, X, XI) and anti-coagulant factors (protein C, protein S, antithrombin) and parallel changes in pro- and anti-fibrinolytic proteins.

  • Section 23.12: Vascular liver disease

    Budd-Chiari syndrome (hepatic vein outflow obstruction) presents with abdominal pain, hepatomegaly, ascites, and elevated transaminases.

Podcast episodes

  1. 01

    Portal Hypertension and Varices

    The hemodynamic gold standard and noninvasive thresholds for clinically significant portal hypertension, screening and primary prophylaxis, the acute variceal hemorrhage bundle with early TIPS, and the gastric varices, portal hypertensive gastropathy, and GAVE distinctions.

  2. 02

    The Splanchnic Vasodilation Cluster

    Ascites with diuretic management and the TIPS-versus-serial-paracentesis decision, hyponatremia, spontaneous bacterial peritonitis with the antibiotic-plus-albumin bundle, hepatorenal syndrome with terlipressin and albumin, and hepatic encephalopathy with lactulose plus rifaximin.

  3. 03

    Pulmonary, Coagulopathy, and Vascular Complications

    The remaining decompensated complications: hepatopulmonary syndrome, portopulmonary hypertension, hepatic hydrothorax, the coagulopathy where the INR misleads about bleeding risk, and the vascular liver diseases.