Imaging Course of Lung Transplantation: From Patient Selection to Postoperative Complications | RadioGraphics

Portal Hypertensive Gastropathy (PHG) Treatment

Portal hypertensive gastropathy (PHG) is a condition in which the gastric mucosal area is subjected to friability. This condition leads to changes in gastric mucosa, which normally occurs due to portal hypertension. Treatment for PHG is usually done using endoscopy, where fiber-optic camera can be used to view the gastric mucosal area.

Complications of Portal Hypertension: Management DilemmasPlay

Medications are usually prescribed to stop the bleeding because of PHG. Medications are also suggested to treat PHG that occurs as a result of varices treatment. Treatment for PHG is suggested based on various factors such as symptoms, bleeding rate, and severity of the disease. Some of the medications and treatment for PHG are discussed below.

Argon Plasma Coagulation Technique

Argon plasma coagulation is a technique by which bleeding and abnormalities in gastric mucosa are treated through electro surgery approach. In this technique, hemostasis and coagulation are created in the bleeding lesion location of gastric mucosa through a jet of argon plasma, when a current of high frequency is applied to the bleeding tissue. Tissue penetration depth due to argon plasma jet is much limited (in the order of millimeter). It has been observed that the argon plasma coagulation technique had improved the hemoglobin levels and decreased the need for transfusion in patients affected with PHG.

Argon Plasma Coagulation Procedure

The whole argon plasma coagulation arrangement consists of a source of argon gas, high-frequency generator, and a probe. Optimum parameters to avoid the local perforation risks are 2.5 l/min of argon gas flow and electrical power output in the range of 60–90 W. Argon plasma coagulation procedure is carried out in all the lesions that are visible in the gastric mucosal area. Argon plasma jet is applied on the bleeding location for about 1–3 s. The time taken to complete the whole procedure is about 15–30 min. Formation of white coagulum in gastric mucosal bleeding site indicates the successful completion of the procedure.  All the patients are subjected to pump inhibitor therapy to enhance the mucosal healing after the argon plasma coagulation. Improvement in hemoglobin levels, initial symptoms cessation, and decrease in the need for blood transfusions are the possible outcomes of argon plasma coagulation procedure.

Transjugular Intrahepatic Pportosystemic Shunt Technique

Transjugular intrahepatic portosystemic shunt technique (TIPS) is used to treat PHG by creating an artificial channel between portal vein and systemic vessels to cure portal hypertension. Generally, TIPS technique is performed using fluoroscopy to treat postal hypertensive gastropathy.

It has been observed that there is a drop in portal vein pressure after the TIPS procedure. The TIPS procedure significantly increases the blood flow to 55.6 ml/min/100 g in gastric mucosa. TIPS procedure for treating PHG does not have any impact on the function of liver. Improvement in PHG after TIPS procedure can be observed by the improvement in damaged gastrointestinal perfusion in patients affected with PHG. TIPS procedure led to complete recovery of hemorrhage due to severe PHG in patients with massive hematemesis.

Salvage Cryotherapy

In this method, PHG is treated by freezing and destroying the gastric mucosal tissue in the bleeding region using pressurized carbon dioxide. Initially, cryotherapy technique identifies vascular ecstasias all over the gastric mucosa, especially in antrum. Then, liquid nitrogen or pressurized carbon dioxide is used for ablating the lesions in gastric mucosal antrum. Successful cryotherapy is indicated by ablation in frozen and hyperemic tissues. This technique can be performed as a salvage procedure when compared to all other treatment methods for PHG.

Medications Nonselective β-blockers (propranolol and nadolol)

Nonselective β-blockers are suggested for people with mild PHG. Nevertheless, prescription of nonselective β-blockers as a primary prophylaxis is still disputable for patients suffering from gastro mucosal bleeding due to PHG. Nonselective β-blockers are found to decrease long-term bleeding secondary to PHG.

The risk of occurrence of PHG post-esophageal variceal eradication is reduced when treated with propranolol. Generally, propranolol is suggested to control bleeding in gastro mucosa due to severe PHG. Occurrence of PHG is found to be less when propranolol is preferred over band ligation. Typically, 240-480 mg/d of propranolol will be prescribed to control acute bleeding due to PHG. The need for blood transfusion is comparatively less when propranolol is used to treat PHG.

Octreotide and Somatostatin

It has been observed that the portal blood flow, portal pressure, and gastric perfusion have been reduced, when PHG patients are treated with octreotide and somatostatin. The use of octreotide can remarkably reduce gastric mucosal vein cross-sectional area. Initial stage treatment for acute bleeding due to PHG is octreotide. Octreotide can remarkably control the bleeding rate when compared to omeprazole. Both somatostatin and octreotide can decrease portal pressure only for a short period of time.

Portal Hypertension Panel, Part 1: Medical ManagementPlay

Further Reading

What Is A TIPS Procedure On The Liver?

A transjugular intrahepatic portosystemic shunt (TIPS) procedure is a treatment method used to lower portal hypertension, or excessive pressure in your portal vein.

This vein is responsible for carrying blood from your abdomen to your liver. Excess pressure can lead to significant bleeding and fluid buildup in your abdomen, which is known as ascites.

Keep reading to find out more about the TIPS procedure, including why you might need it, how doctors perform it, and potential side effects that could result from this procedure.

A TIPS procedure involves creating a shunt between your portal vein and your hepatic vein by placing a stent. Here are each of the three parts of the procedure:

Shunt: Something that re-routes or re-directs flow from its normal pathway.

Portal vein: The vein that transports blood from your gastrointestinal system, gallbladder, pancreas, and spleen on the way to your liver.

Hepatic vein: The veins (usually three) that return blood that doesn't have oxygen from your liver back to your heart.

A specialist known as an interventional radiologist will perform the procedure, typically in a specialized operating suite known as an interventional radiology suite. During this time, an interventional radiologist will use X-ray guidance to place the shunt.

Those who need a TIPS procedure are usually moderately to severely ill.

Examples of conditions and acute occurrences that may warrant a TIPS procedure include:

Budd-Chiari syndrome: A rare disorder that affects the ability of blood to leave the liver, which causes significant portal hypertension.

Hepatopulmonary syndrome: A syndrome that occurs in people with significant liver disease that affects the abilities of their lungs to work well.

Hepatorenal syndrome: A condition where a person experiences significant liver failure that also affects the way their kidneys work.

Portal hypertensive gastropathy: Bleeding in the stomach and stomach lining due to portal hypertension.

Refractory ascites: Ascites (severe swelling in the abdomen) that won't respond to traditional treatments.

Refractory hepatic hydrothorax: Severe pleural effusion (fluid buildup outside the lungs) that's a result of significant liver disease.

Variceal hemorrhage: A condition that causes veins in the esophagus or stomach to bleed profusely.

As you can likely tell from these indications, the liver is an important receiver and transporter of blood in your body. When your liver doesn't work well, its poor function can impact multiple organ systems and cause symptoms that can become indicators for the TIPS procedure.

Doctors will usually perform a TIPS procedure after other first-line treatments have failed. For example, doctors may try to lower ascites by draining the excess fluid or variceal fluid by banding or stopping bleeding in your esophagus. If these fail, a doctor may recommend a TIPS procedure.

As with any procedure, the TIPS procedure isn't without side effects. Those who need the procedure are often very sick, which can increase the risk for side effects. A doctor should thoroughly explain the pros, cons, and risks of the procedure.

Pros

It quickly and effectively lowers portal venous pressure.

It improves renal perfusion, lowers ascites, and can help to reverse hepatorenal syndrome.

It has a low incidence of postprocedure side effects and 30-day mortality rates.

Cons

People who undergo a TIPS procedure have a 10% higher rate of encephalopathy (brain disturbances that can cause confusion and affected memory) compared with those who don't undergo the procedure.

People who undergo a TIPS procedure are at increased risk of right heart failure due to excessive pressures that can back up to the right heart.

Doctors perform the TIPS procedure under general anesthesia (where you're completely asleep and unaware) or under conscious sedation. While the approaches may vary based on the person, the following are some of the basic steps for a TIPS procedure:

An interventional radiologist will cannulate (access) your right internal jugular vein.

The radiologist will advance the catheter down to your right hepatic vein.

A doctor will use ultrasound guidance to identify your portal veins.

After identifying the portal veins, the surgeon will place a stent that extends to where your hepatic vein and inferior vena cava meet.

A doctor may also have to embolize (destroy with heat) other bleeding areas in your body.

The doctor will measure pressures in the portal veins as well as the right atrium of your heart to ensure the shunt is working appropriately. They'll also measure the velocity of blood flow via ultrasound to ensure the blood is flowing through the shunt appropriately.

Your doctor will remove the catheters, and you'll be taken to the postanesthesia recovery unit, where healthcare professionals will closely observe you.

However, if your case is very complicated, the procedure may take longer.

Some people shouldn't undergo a TIPS procedure. People who absolutely shouldn't undergo a TIPS procedure include those with:

bile duct obstruction

liver cysts that impair the ability to advance or place a stent

right heart failure

sepsis or severe systemic infection

severe pulmonary hypertension

The fatality rate for a TIPS procedure is less than 1%, and the 30-day mortality rate is less than 3%. This means that after 30 days, 97% of people who underwent the procedure are alive.

You'll likely remain in a hospital for at least 24 hours after a TIPS procedure. This allows medical staff to monitor your blood pressure, heart rate, circulation, and urine output. Your doctor will monitor other blood tests that indicate how well your heart and liver are working and make sure you aren't experiencing any internal bleeding.

Before you're allowed to go home, your doctor will perform an ultrasound of your abdomen to identify how well blood is flowing in the portal vein and ensure the stent is working appropriately.

A TIPS procedure doesn't cure the underlying disorders that lead to ascites and bleeding. As a result, doctors don't consider it 100% effective.

Often, those undergoing a TIPS procedure may be on the list for a liver transplant, which could correct the underlying disorder(s).

The outcome for people with portal hypertension is poor. Survival rates and outlook for people after undergoing the TIPS procedure depend upon why they needed the TIPS procedure and their overall health. People who undergo the TIPS procedure due to ascites usually have a better outlook than those who have bleeding varices.

The following are some commonly asked questions after a TIPS procedure.

Is there a special diet after a TIPS procedure?

Your doctor may advise you as to a healthy post-TIPS procedure diet. Examples of interventions include a low-protein diet and low-sodium diet. Immediately following the procedure, your doctor may recommend eating no more than 20 grams of protein a day for 3 days to lower the risks for postoperative side effects.

Will I need a liver transplant after a TIPS procedure?

Over time, the TIPS procedure can lower your liver's functioning. The effect is likely due to less blood flow to your liver. The underlying reasons you needed a TIPS procedure and undergoing the TIPS procedure itself may be indications for a liver transplant. However, there are many factors that impact if you need a liver transplant. You should discuss if you're a candidate given your age and overall health.

What is the life expectancy after a TIPS procedure in the liver?

A TIPS procedure can lower a person's mortality compared with no intervention. Those who don't undergo TIPS procedures but may be candidates have a mortality rate of 40% compared with those who undergo TIPS procedures, whose mortality rate is between 20% and 35%.

A TIPS procedure can lower portal hypertension without requiring significant, open surgery. Because the procedure doesn't correct the underlying issues of liver dysfunction, you may require further treatments to improve your liver health following the procedure. A doctor should carefully explain the risks and benefits of the procedure to you before undergoing it.

Portal Hypertension Symptoms & Their Most Common Complications

Portal Hypertension Symptoms and Their ComplicationsPortal hypertension is a condition in which increased pressure within the portal vein—an important vessel that carries blood from the stomach and intestines to the liver—rises beyond normal levels. This rise in pressure often occurs due to advanced liver disease, particularly cirrhosis. Cirrhosis causes the liver to develop scars that replace healthy liver tissue, which makes it difficult for blood to flow freely through the organ. When that primary route of blood flow becomes blocked or narrowed, pressure in the portal vein begins to climb, forcing blood to divert into smaller blood vessels. Over time, these smaller vessels can swell under the added load, eventually leading to various complications [1].

Table of Contents

Causes of Portal Hypertension

Portal hypertension can be caused by various factors, including liver disease, blood clots in the portal vein, blockages of the veins that carry blood from the liver to the heart, schistosomiasis, and focal nodular hyperplasia. The most common cause of portal hypertension is cirrhosis of the liver, which is scarring that accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage.

How the Portal Vein Works

Esophageal varices and and illustration of a portal vein.

(Alila Medical Media)

The portal vein plays a central role in transporting nutrient-rich blood from the digestive organs straight to the liver. There, the liver filters out toxins and processes nutrients. Increased portal blood flow, driven by vasodilators and shear stress, contributes to the buildup of pressure in the portal vein. When it is scarred by cirrhosis, it is no longer an open highway for blood flow. This buildup of pressure is often first noticed by signs such as fluid accumulation, swelling of veins in the digestive tract, or changes in organ function.

Risk Factors

Risk factors for developing portal hypertension include chronic liver disease, family history of liver disease, viral hepatitis, and alcohol abuse. Regular monitoring and follow-up with a healthcare provider can help detect portal hypertension early and improve outcomes.

Clinical Signs and Symptoms

The main symptoms and complications of portal hypertension include ascites (fluid buildup in the abdomen), dilated veins or varices, and bleeding from varices. Doctors make the diagnosis of portal hypertension based on the presence of ascites or dilated veins or varices as seen during a physical exam of the abdomen or the anus. Various lab tests, X-ray tests, and endoscopic exams may also be used to diagnose portal hypertension. Symptoms of portal hypertension may not always be present, but when they do occur, they can include abdominal swelling, vomiting of blood, and lab abnormalities such as elevated liver enzymes or low platelet counts.

Major Complications of Portal Hypertension

Vector medical illustration of normal liver and cirrhosis with portal hypertension.

(FuHonra)

Portal hypertension can affect many parts of the body. Bleeding varices are one of the significant complications of portal hypertension. Below are the most significant complications that arise when the portal vein remains under high pressure over extended periods.

Varices (Enlarged Veins in the Digestive Tract)

What Happens? When blood cannot pass smoothly through the scarred liver, it flows into smaller veins near the esophagus and stomach, causing these veins to grow larger than normal [1]. This is somewhat similar to having a clogged pipe in a plumbing system: the backup of pressure forces fluid into adjacent, more fragile channels. These swollen veins are called varices, and complications such as bleeding varices can arise from them.

Symptoms

Vomiting of blood (hematemesis)

Black or tar-like stools (melena)

Dizziness, lightheadedness, or fainting due to blood loss

An episode of variceal bleeding is considered an emergency because it can lead to rapid blood loss.

Treatment and Prevention

Beta-blockers (Propranolol): These lower heart rate and reduce blood pressure in the portal system, decreasing the likelihood of a varicose rupture.

Endoscopic Band Ligation: A procedure in which a small, flexible camera (endoscope) is used to place tiny rubber bands around the enlarged veins, cutting off their blood supply.

Controlling Active Bleeding:

Medications (Somatostatin or Terlipressin): Reduce blood flow to the varices and help stop the bleeding.

Endoscopic Therapy: Doctors can use banding or injections to seal off the veins.

TIPS Procedure (Transjugular Intrahepatic Portosystemic Shunt): A tunnel or shunt is created inside the liver to divert blood and lower portal pressure [2].

Regular checkups, including periodic endoscopy, are often recommended to monitor for new or recurring varices.

Ascites (Fluid Buildup in the Abdomen)

What Happens? Ascites refers to the accumulation of fluid in the abdominal cavity. As increased pressure in the portal venous system rises, it disturbs fluid balance in the body. The liver can no longer regulate the flow of salt and water properly, causing fluid to leak from blood vessels into the belly [1].

Symptoms

Noticeable swelling or bloating of the midsection

Shortness of breath if the fluid presses against the lungs

Rapid weight gain that is not linked to food intake

Treatment

Low-Sodium Diet: Reducing salt intake limits fluid retention.

Diuretics (Spironolactone, Furosemide): "Water pills" help the kidneys remove excess sodium and water.

Paracentesis (Fluid Removal): In severe cases, a doctor may insert a needle into the abdomen to drain large volumes of fluid, providing quick relief.

TIPS Procedure: Can help reduce portal pressure when lifestyle changes and diuretics are insufficient.

Liver Transplant: For many with irreversible liver damage, a transplant is often the ultimate solution [1].

Ascites is a strong indicator of advanced liver disease and should not be ignored. Frequent medical monitoring can help avoid complications such as infection of the ascitic fluid.

Hepatic Encephalopathy (Brain Dysfunction Due to Toxins)

What Happens? A key function of the liver is to eliminate toxins such as ammonia from the blood. When it is damaged, these toxins linger, eventually traveling to the brain and disrupting its normal activities. This condition is called hepatic encephalopathy [3].

Portal hypertension can also lead to an enlarged spleen, which decreases the count of white blood cells, increasing the risk of infections.

Symptoms

Confusion or difficulty focusing on tasks

Sudden mood changes or personality shifts

Tremors (unsteady hands)

Slurred speech or slower thinking patterns

More severe cases may lead to unresponsiveness or coma

Treatment

Lactulose: A laxative that traps toxins in the intestines and expels them through bowel movements.

Rifaximin: An antibiotic that reduces the number of bacteria in the gut that produce ammonia.

Dietary and Medication Adjustments: Lowering protein intake, controlling infections, and changing certain medicines can improve symptoms.

Early detection of hepatic encephalopathy is vital because therapy can often reverse the mental changes and improve overall well-being.

Hepatopulmonary Syndrome (Lung Problems Due to Liver Disease)

What Happens? In advanced liver disease, blood vessels inside the lungs may expand, affecting how oxygen enters the bloodstream. This phenomenon is known as hepatopulmonary syndrome [4]. Increased pressure in the hepatic vein contributes to the symptoms by causing blood flow obstruction and the development of collateral circulation. Individuals may notice they become short of breath more easily, especially when upright.

Symptoms

Shortness of breath during daily activities

Low oxygen levels confirmed by blood tests or pulse oximetry

Treatment

Oxygen Support: Using supplemental oxygen can alleviate symptoms and help maintain healthy oxygen levels.

Liver Transplantation: Transplant is the only truly definitive treatment. Over time, replacing the damaged liver can lead to the blood vessel changes in the lungs returning closer to normal [4].

Diagnosis often requires specific imaging tests and measurement of oxygen levels. People with advanced liver disease should promptly report any persistent breathing issues to their healthcare provider.

Portopulmonary Hypertension (High Blood Pressure in Lung Arteries)

What Happens? Portopulmonary hypertension emerges when high pressure in the portal system affects the arteries in the lungs. These arteries narrow or tighten, forcing the heart to work harder to move blood through them [4]. Over time, this strain can lead to heart and lung challenges.

Symptoms

Feeling tired more quickly than normal

Chest discomfort

Trouble breathing with mild exercise or daily tasks

Treatment

Medications: Certain drugs help relax and open up the lung arteries, improving blood flow and reducing stress on the heart.

Liver Transplant: In select patients, a successful transplant can improve lung artery pressures and heart function [4].

Because this complication involves both the liver and the lungs, specialists typically coordinate care—often including a gastroenterologist, a hepatologist, and a pulmonologist.

Hepatorenal Syndrome (Kidney Failure Due to Liver Disease)

What Happens? With severe liver damage, overall circulation is disrupted. As a result, not enough blood reaches the kidneys, leading them to fail. This condition is called hepatorenal syndrome (HRS) [3]. It can develop quickly and is a serious concern for those with advanced cirrhosis.

The splenic vein, which drains blood from the spleen into the portal vein, plays a significant role in contributing to elevated portal venous pressure. Increased blood flow or obstruction in the splenic vein can lead to complications such as portal hypertension.

Symptoms

Dark urine or reduced urine production

Swelling in the belly and legs

Marked fatigue, confusion, or other signs related to toxin buildup

Treatment

Albumin and Vasoconstrictor Medications (Terlipressin, Midodrine): These can help improve kidney blood flow in certain patients.

TIPS Procedure: May restore normal circulation within the portal system, supporting better kidney function.

Liver Transplant: If the kidneys continue to fail, liver transplant remains the most comprehensive solution. In some advanced scenarios, a combined liver-kidney transplant may be considered [3].

Hepatorenal syndrome usually signals an urgent state of liver disease. Monitoring kidney function through regular tests can help catch early warning signs and begin treatments sooner.

Final Thoughts

Portal hypertension is far more than just high pressure in a single vein. Its far-reaching effects can strain multiple organs and systems throughout the body. Varices in the esophagus and stomach may burst, causing life-threatening bleeding. If portal hypertension compromises blood flow to the kidneys, hepatorenal syndrome can result in kidney failure.

Portal hypertension, often complicated by inferior vena cava obstruction, can be managed through medication, procedures like endoscopic band ligation or TIPS, and in severe cases, liver transplantation. Recognizing warning signs like sudden weight gain, confusion, difficulty breathing, or unusual bleeding allows for quicker intervention and better outcomes. Routine checkups and tests are vital for early detection and effective management, enabling many patients to live fuller, healthier lives.

References

[1] Simonetto, D. A., Liu, M., & Kamath, P. S. (2019). Portal Hypertension and Related Complications: Diagnosis and Management. Mayo Clinic proceedings, 94(4), 714–726. Https://doi.Org/10.1016/j.Mayocp.2018.12.020

[2] Bosch, J., & García-Pagán, J. C. (2000). Complications of cirrhosis. I. Portal hypertension. Journal of hepatology, 32(1 Suppl), 141–156. Https://doi.Org/10.1016/s0168-8278(00)80422-5

[3] Garcia-Tsao G. (2005). Portal hypertension. Current opinion in gastroenterology, 21(3), 313–322. Https://doi.Org/10.1097/01.Mog.0000158110.13722.E0

[4] Bommena, S., & Fallon, M. B. (2024). Pulmonary Complications of Portal Hypertension. Clinics in liver disease, 28(3), 467–482. Https://doi.Org/10.1016/j.Cld.2024.03.005

MORE DOCTORS & SCIENTISTS

---