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The portal hypertension syndrome: etiology, classification, relevance, and animal models

  • Special Issue - Portal Hypertension
  • Published:
Hepatology International Aims and scope Submit manuscript

Abstract

Background

Portal hypertension is a key complication of portal hypertension, which is responsible for the development of varices, ascites, bleeding, and hepatic encephalopathy, which, in turn, cause a high mortality and requirement for liver transplantation.

Aim

This review deals with the present day state-of-the-art preventative treatments of portal hypertension in cirrhosis according to disease stage. Two main disease stages are considered, compensated and decompensated cirrhosis, the first having good prognosis and being mostly asymptomatic, and the second being heralded by the appearance of bleeding or non-bleeding complications of portal hypertension.

Results

The aim of treatment in compensated cirrhosis is preventing clinical decompensation, the more frequent event being ascites, followed by variceal bleeding and hepatic encephalopathy. Complications are mainly driven by an increase of hepatic vein pressure gradient (HVPG) to values ≥10 mmHg (defining the presence of Clinically Significant Portal Hypertension, CSPH). Before CSPH, the treatment is limited to etiologic treatment of cirrhosis and healthy life style (abstain from alcohol, avoid/correct obesity…). When CSPH is present, association of a non-selective beta-blocker (NSBB), including carvedilol should be considered. NSBBs are mandatory if moderate/large varices are present. Patients should also enter a screening program for hepatocellular carcinoma. In decompensated patients, the goal is to prevent further bleeding if the only manifestation of decompensation was a bleeding episode, but to prevent liver transplantation and death in the common scenario where patients have manifested first non-bleeding complications. Treatment is based on the same principles (healthy life style..) associated with administration of NSBBs in combination if possible with endoscopic band ligation if there has been variceal bleeding, and complemented with simvastatin administration (20-40 mg per day in Child–Pugh A/B, 10–20 mg in Child C). Recurrence shall be treated with TIPS. TIPS might be indicated earlier in patients with: 1) Difficult/refractory ascites, who are not the best candidates for NSBBs, 2) patients having bleed under NSBBs or showing no HVPG response (decrease in HVPG of at least 20% of baseline or to values equal or below 12 mmHg). Decompensated patients shall all be considered as potential candidates for liver transplantation.

Conclusion

Treatment of portal hypertension has markedly improved in recent years. The present day therapy is based on accurate risk stratification according to disease stage.

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Acknowledgements

J.B.: supported in part by grants from the Instituto de Salud Carlos III (PI 13/00341, and PI14/00182) in a program cofunded by FEDER, EU, and by EU (CLEVER- IAPP-GA-2013-612273). The CIBERehd is funded by the Instituto de Salud Carlos III. Y.I.: supported by NIH Grant R21AA023599 and Connecticut DPH Grant #2015-0901.

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Authors and Affiliations

  1. Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, C.Villarroel 170, 08036, Barcelona, Spain

    Jaime Bosch

  2. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Barcelona, Spain

    Jaime Bosch

  3. Swiss Liver Center, Hepatology, UVCM, Inselspital, University of Bern, Bern, Switzerland

    Jaime Bosch

  4. Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA

    Yasuko Iwakiri

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Correspondence to Jaime Bosch.

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This work was supported in part by grants from the Instituto de Salud Carlos III (PI 13/00341, and PI14/00182) in a program cofunded by FEDER, EU, and by EU (CLEVER- IAPP-GA-2013-612273) (J.B.). The CIBERehd is funded by the Instituto de Salud Carlos III. Also, this work was supported by NIH Grant R21AA023599 and Connecticut DPH Grant #2015-0901 (Y.I.).

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J.B. declares that he has no conflicts of interest with regards to the contents of this article. Y.I. declares that she has no conflicts of interest.

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Bosch, J., Iwakiri, Y. The portal hypertension syndrome: etiology, classification, relevance, and animal models. Hepatol Int 12 (Suppl 1), 1–10 (2018). https://doi.org/10.1007/s12072-017-9827-9

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