What is the normal intra duodenal pressure
The pressure in the portal vein can be pathologically increased due to various causes, e.g. due to pre- (e.g. portal vein thrombosis), intra- (e.g. liver cirrhosis) or posthepatic flow obstruction (e.g. right heart failure). This situation, known as “portal hypertension”, leads to the formation of collaterals in periumbilical, rectal and gastric / esophageal veins as well as splenomegaly and ascites via a backwater. Diagnostic imaging methods (e.g. sonography) are particularly helpful: This reveals an expansion of the portal vein and the consequences it has mentioned. Therapy includes both treating the underlying disease and lowering pressure with non-selective beta blockers such as propranolol.
A dangerous complication of portal hypertension is esophageal variceal bleeding, which can acutely lead to life-threatening blood loss. Therapeutically, the portal vein pressure should be reduced with medication (e.g. with terlipressin by reducing the blood flow to the splanchnic nerve) and endoscopic hemostasis should be carried out. For (relapse) prophylaxis, in addition to ligation of esophageal varices, the transjugular application of an intrahepatic, portosystemic shunt (TIPS) can also be used.
Classification of portal hypertension using the "hepatic venous pressure gradient" (HVPG)
The portal vein pressure can be measured invasively and consequently the response to a pressure-lowering therapy can be checked.
|Classification and risk stratification of portal hypertension|
|HVPG in mmHg||clinic|
Consequences / Risks
|2–5||Normal portal pressure||No|
|6–9||Portal hypertension||Hardly any clinical manifestations|
|≥ 10||Clinically significant portal hypertension||Ascites, esophageal varices, hepatic encephalopathy, opening of portocaval anastomoses|
|≥ 12||Clinically risky portal hypertension||The risk of bleeding from esophageal varices increases significantly|
|≥ 20||High risk portal hypertension||Frequent bleeding that is difficult to control → check TIPS indication|
|According to Reiberger T, Pathophysiology of portal hypertension as a prerequisite for innovative therapies, Journal for Gastroenterological and Hepatological Diseases 2012; 10 (2), 28–33, Krause & Pachternegg|
Paquet classification of esophageal varices
|Esophageal varices classification, modified from Paquet|
|Grade I.||Varices protrude above the level of the mucous membrane, but disappear with air insufflation|
|Grade II||Varices that barely protrude into the lumen (≤ 1/3 of the esophageal lumen) can no longer be compressed by air insufflation, usually sufficient mucosal cover|
|Grade III||Varices clearly bulging into the lumen (≤ 1/2 of the esophageal lumen), some of which touch each other; So-called “cherry red spots” as an expression of a tendency to bleed and damage to the mucous membrane possible|
|Grade IV||Varices fill the esophageal lumen and often protrude into the upper third of the esophagus; endoscopic view is usually only possible after copious air insufflation; "Whale sign" possible|
Symptoms / clinic
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