Portal Hypertension with Dr. Alex Bondoc

Portal hypertension is defined as a hepatic venous portal wedge pressure of greater than 5 millimeters of mercury.

Portal hypertension develops when resistance to portal blood flow increases.

In prehepatic portal vein thrombosis, the vast majority of pediatric patients have no predisposition to clotting despite hematology workup.

Biliary atresia is the number one cause worldwide of pediatric liver transplantation.

The most common clinical manifestation of portal hypertension is GI bleeding due to esophageal varices.

After the first episode of GI bleeding, the risk of complications including rebleeding, ascites, spontaneous bacterial peritonitis, and conditions associated with end-stage liver disease continues to occur.

Higher incidence of bleeding occurs with a wedge pressure of greater than 12 mmHg.

Portal vein velocity decreases in severe portal hypertension as intrahepatic resistance increases.

In transient elastography, a pressure greater than 15 kilopascals is highly suggestive of portal hypertension.

At Cincinnati Children's, varices are graded 1 through 4, where grade 4 means the entire esophagus is essentially collapsed, grade 3 is 2/3 collapsed, grade 2 is 1/3 collapsed, and grade 1 is just ridges under the mucosa.

Primary prophylaxis is not performed in pediatric patients with portal hypertension at Cincinnati Children's.

Octreotide can work well for esophageal varices but not as well for gastric varices or portal hypertensive gastropathy.

Data suggests that carvedilol might be a better option than propranolol for non-selective beta blockade in portal hypertension.

All patients with acute variceal bleeding should be started on IV antibiotics because of the high risk for bacterial translocation.

Patients with end-stage liver disease should not be shunted and should go to liver transplant instead.

The mesoportal (Rex) shunt provides physiologic flow and is by far the number one preferred shunt option when possible.

For prehepatic disease, a messorex shunt is the preferred option.

For hepatic disease, options include distal splenorenal shunt, central splenorenal shunt, or mesocaval H-type shunt.

For posthepatic disease, options include H-type mesocaval shunt, TIPS, or atrial caval shunt.

If platelet count starts dropping during follow-up, there is probably something wrong with the shunt.