Symptoms of portal hypertension

The clinic. Symptoms of portal hypertension is very diverse and depend on the shape. They could be categorized as typical for out (up) hepatic, intrahepatic and over (over)the hepatic portal hypertension.
Out (up)hepatic portal hypertension. Clinic of this form of portal hypertension are less diverse, despite the large number of causing her illness.
The main symptom of extrahepatic portal hypertension is splenomegaly. It can be without ascites and bleeding from esophageal varices. Most often, splenomegaly is accompanied by hypersplenism, but without bleeding and without ascites, rarely with hypersplenism and with bleeding from the veins of the esophagus and even more rarely - with all the triad: the hypersplenism, bleeding and always follow them ascites.
Extrahepatic form of portal hypertension appears most often in the age of 20-25 years, and after 40 years is very rare. This age diseases caused by etiology: transferred umbilical sepsis, congenital anomalies portal system, childhood infections, FilePlanet appendicular, intestinal origin. Liver with extrahepatic portal hypertension is usually no palpable and externally is usually unchanged. Caput Medusa on the abdominal wall usually not the case.
The development of extrahepatic portal hypertension is usually slow, smooth, with many times recurrent esophagogastrectomy bleeding. After one another bleeding case may rapidly change for the worse. Appear ascites, hepatic failure. Stable until now for hypertension becomes progressive. For the Clinician, it is important to note, as a signal for more activity.
Cause of death in this type of portal hypertension are bleeding, venous thrombosis of the portal system, pulmonary embolism, rarely, hepatic failure.
Intrahepatic portal hypertension. The syndrome of this form of hypertension is more complex and diverse. Here the most prominent symptoms are: splenomegaly, varicose veins with possible bleeding and ascites. But they expressed more "malignant" and, most importantly, they are in fact signs of neglect of the process. Their presence in the aggregate, severely limits the possibility of surgical treatment of the patient. For successful treatment is important for early diagnosis. It should be noted that the earlier signs of intrahepatic portal hypertension exist, but not all of them can remember. These include: a) valproatami but persistent diarrhoeal phenomenon, especially after eating, in the absence of changes in the stomach; b) often occur after taking any kind of food swelling and feeling of fullness in the stomach; the feeling of constant overcrowding guts without expressed constipation; d) the constant growth of weight loss and weight when saved appetite and actually obtaining sufficient calories and rich in vitamins power without the availability of data in favor of cancer; d) periodic painless and astemperature diarrhea, bring temporary relief. There are complaints about fatigue, malaise, sharp decrease of working ability, recurrent pain in the epigastrium or podreberie without clear localization; often the only manifestation are bleeding from the nose and gums, and sometimes the first manifestation of increase of portal hypertension is abundant gastroezofagealna bleeding, appearing as if among full health.
History in patients detected epidemic hepatitis (Botkin's disease), dysentery, colitis, malaria, etc., Men suffer more often women. The spleen is usually increased. The size of the liver can be different: it is unmodified, then sharply increased; then the liver is palpated with uniformly dense pitted surface. Sometimes the size of the liver is so reduced that it does not palpated, but even not percuteret.
Cirrhosis often noticeable expansion of the lower thoracic aperture with vastanie mud arches rib. Often long before the appearance of jaundice appear resistant skin itch. The skin are dry and sparse vegetation; on the skin are visible "vascular asterisks", the Palmar surface of brushes giperemiei; men suffer from gynecomastia and impotence in women - amenorrhea, mammary glands atrophy. If the disease began in childhood, it can be observed infantilism.
Very often there are changes in the blood. They are characterized by giperstenichesky triad: anemia, leukopenia, thrombocytopenia. The latter is not always correspond to the changes of coagulation. It in full, and also data of thromboelastography need to know that before the operation to prevent the possibility of formation of thrombosis and bleeding during the operation and after it.
Unlike extrahepatic forms of portal hypertension when intrahepatic esophagogastroscopy bleeding is fatal, because behind it there is a sharp deterioration in liver function.
Along with varicose veins of the esophagus in patients with intrahepatic portal hypertension is often observed dilatation of the abdominal wall - caput Medusa. Less frequently observed and expansion pryamokishechnye veins; bleeding from them not so abundant and less formidable.
Liver damage when intrahepatic form of portal hypertension are much stronger than other forms of this disease. It is based on a complex disorganization hepatic lobules, due to necrosis and alignment with cirrhosis, which is poorly expressed without cirrhosis. In the future itself portal hypertension, lowering the oxygenation of the liver, increases the disorder liver.
Finally, one of the major clinical manifestations of intrahepatic portal hypertension (especially cirrhosis) is ascites. Usually it is not transient, and more formidable - stable and progressive. As a rule, it is a sign of decompensation and impaired liver function and disorders of the portal blood flow. Daily quantity of urine does not exceed 300-400 ml Diuretics cease to act, that is a poor prognostic sign.
Hypertension in intrahepatic block portal system always total, but can prevail in the gastro-lenalee, in intestinal-mesenteric zone portal system. The clinical picture with the predominance of one or the other they have some special features. So, when the gastro-lenalina the prevalence of hypertension localized pain in epigastria, and particularly in the left hypochondrium, while intestinal-mesenteric the prevalence of pain are fickle and around the navel, iliac regions or in the liver and less often in the left hypochondrium. For gastro-litelnogo of more characteristic epigastric-dyspeptic symptoms are, for the prevalence of intestinal - kolitnym syndrome. Weight loss, despite the safety of appetite, more pronounced in the intestinal-mesenteric prevalence. Swelling in epigastralna area and the feeling of fullness in the stomach after eating, even poor, more commonly found in the gastro-lenalina prevalence, whereas intestinal-mesenteric - more pronounced hipogastrica swellings and spilled flatulence.
Splenomegaly and hypersplenism, as well as esophagogastrectomy of variceal hemorrhage, more commonly found in the gastro-lenalina prevalence.


In addition to these physical differences, to differentiate the dominance of zonal intrahepatic portal hypertension even better allow some special methods of examination of patients. This is evident in the data table. 9.

TABLE 9. The data of special research
Method of research Uniform total hypertension Gastro-lenalee the prevalence of portal hypertension Enteric-mesenteric the prevalence of portal hypertension
Laparoscopy Vienna strained and twisted everywhere Congestive veins visible mainly in the area of the greater curvature of the stomach and spleen Congestive veins visible mainly in the area of the diaphragm, liver, biliary tracts, round ligament, guts
Splenomegalia Indicators increased significantly The pressure is very high The pressure increased moderately
Splenoportography Trunks v. lienalis and v. portae evenly considerably expanded. Collaterals developed everywhere Trunk v. lienalis expanded even more than the barrel v. portae. Collaterals are dominated by gastro-esophageal way Trunk v. lienalis much already trunk v. portae. Collaterals are developed by mesenteric-hemorrhoidal way
Umbilic-pornografia Especially well seen very wide trunk v. portae, almost devoid of intrahepatic branches, trunks v. lienalis and mesenteric veins filled intensively As with total, but the trunk v. portae very wide, varicose, and sharply strengthened diaphragmatic and okoloplodna collaterals Trunk v. portae is less pronounced, but like total, v. lienalis not contoured, mesenteric vein very wide
Mesenteric-pornografia The same The varicose veins splenic group prevails over the varicose veins mesenteric veins The same
Gepatomegalia The pressure in the liver almost equal to the pressure in the spleen The pressure in the liver lot below the pressure in the spleen The pressure in the liver higher pressure in the spleen
Wanasegara Zone v. hemiazygos visible groups varices Zone v. hemiazygos varices developed not sharply
Fluoroscopy (monograph) of the esophagus and stomach Vrixy visible in the lower third of the esophagus, the relief of gastric mucosal places wavy Vrixy the largest, they are distributed highly; mucous stomach just nabuhshie-wavy Vrixy esophagus poorly visible, the relief of gastric mucosal changed mainly in its part aboral
Esophagoscopy Vrixy in the lower third of the esophagus Vrixy achieve very high esophagus Vrixy in the esophagus not cutting

Intrahepatic portal hypertension is usually proceeds without increasing the temperature of the body. However, in cases, when there are complications, the temperature rises. This is usually seen with acute necrotic process in the liver or thrombosis (thrombophlebitis) veins portal system. Fever lasts very long, often accompanied by relapses of esophago-gastric bleeding. The death of patients with intrahepatic portal hypertension is most often occurs from bleeding, liver failure, or thrombosis.
Over (over) the hepatic portal hypertension is the result of: 1) decompensation splenic activities; 2) thrombosis, sclerosis, spinal stenosis, obliteration of the hepatic veins at their exit from the liver or at the confluence them into the inferior Vena cava.
The first option nadrechenskaya portal hypertension has no independent status; the second option is more often associated with either a syndrome Budd - Chiari, or with sdavlennoy hepatic veins (at their passing through venous aperture) or specific parasitic granulomas. Acute hepatic vein thrombosis occurs liver enlargement, massive ascites with little or oscillating enlargement of the spleen and significant edema. Jaundice is reasonable. Pain in the liver caused by voltage its capsule. Tortuous venous collaterals on the abdominal wall depends on the duration of the blockage of veins. Typical vomiting with some blood from usuriously esophageal varices. Laboratory data indicate some degree of liver failure. Often the patients die from hepatic coma.