What is the normal intra duodenal pressure

Portal hypertension


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 mmHgclinic

Consequences / Risks

2–5Normal portal pressureNo
6–9Portal hypertensionHardly any clinical manifestations
≥ 10Clinically significant portal hypertensionAscites, esophageal varices, hepatic encephalopathy, opening of portocaval anastomoses
≥ 12Clinically risky portal hypertensionThe risk of bleeding from esophageal varices increases significantly
≥ 20High risk portal hypertensionFrequent 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 IIVarices 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 IIIVarices 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 IVVarices 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