Portal Hypertension and Cirrhosis Complications

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• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
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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: Varices and Bleeding

   Portal hypertension begins as resistance inside the liver, then splanchnic vasodilation drives the hyperdynamic circulation behind most cirrhosis complications. The episode first measures and estimates portal pressure and starts carvedilol for compensated cirrhosis with clinically significant portal hypertension, then separates presinusoidal and postsinusoidal causes and recognizes acute-on-chronic liver failure. It next decides who can skip screening endoscopy and how to treat each size of varix, including when to hold the beta-blocker. Acute bleeding follows, with the transfusion target, ceftriaxone, octreotide, banding, preemptive TIPS, and secondary prophylaxis. It closes with gastric varices, splenic vein thrombosis, portal hypertensive gastropathy, and GAVE.

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2. 02

   Portal Hypertension: Ascites and Complications

   Ascites in cirrhosis grows out of splanchnic vasodilation and hormonal sodium retention, so treatment targets sodium rather than water. The episode starts with the diagnostic tap, the SAAG, and diuretic dosing, then covers albumin after large taps and refractory ascites with TIPS. It moves to hyponatremia and its correction limits, then spontaneous bacterial peritonitis with antibiotics, albumin, and prophylaxis, and the secondary peritonitis that needs surgery. Hepatorenal syndrome follows, diagnosed only after an albumin challenge and treated with terlipressin or norepinephrine. The episode ends with hepatic encephalopathy: find the precipitant, titrate lactulose, add rifaximin, and keep protein in the diet.

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3. 03

   Cirrhosis Complications: Lungs and Vessels

   This episode is organized around one idea: in cirrhosis, the vessels of the lungs, the clotting system, and the liver's own blood supply each fail in a way that changes management. It starts with the two opposite pulmonary vascular syndromes, hepatopulmonary syndrome and portopulmonary hypertension, and their effects on transplant, then hepatic hydrothorax and why a chest tube is never placed. It then explains why the INR misleads, which procedures need no correction, and when to anticoagulate. It closes with vascular liver disease by level of obstruction: Budd-Chiari syndrome, sinusoidal obstruction syndrome, portal vein thrombosis, and porto-sinusoidal vascular disease.

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Key topics

• ·How portal hypertension develops
• ·Hepatic venous pressure gradient thresholds
• ·Baveno seven estimation of CSPH
• ·Carvedilol to prevent decompensation
• ·Presinusoidal and postsinusoidal causes
• ·Acute-on-chronic liver failure
• ·Screening endoscopy and primary prophylaxis
• ·Holding the beta-blocker
• ·Acute variceal bleed bundle
• ·Preemptive TIPS and secondary prophylaxis
• ·Gastric varices and BRTO
• ·Splenic vein thrombosis, gastropathy, and GAVE
• ·Pathophysiology of ascites
• ·Diagnostic paracentesis and SAAG
• ·Sodium restriction and diuretics
• ·Drugs to avoid in ascites
• ·Albumin after large-volume paracentesis
• ·Refractory ascites and TIPS
• ·Hyponatremia management
• ·Spontaneous bacterial peritonitis
• ·Secondary bacterial peritonitis
• ·Hepatorenal syndrome diagnosis and treatment
• ·Hepatic encephalopathy and protein intake
• ·Hepatopulmonary syndrome
• ·Portopulmonary hypertension and transplant candidacy
• ·Hepatic hydrothorax
• ·Rebalanced hemostasis and the INR
• ·Procedure prophylaxis and viscoelastic testing
• ·Anticoagulation and cirrhotic cardiomyopathy
• ·Budd-Chiari syndrome