Portal hypertension natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]


Portal hypertension is increased hepatic venous pressure gradient (HVPG) above 5 mmHg. The symptoms of portal hypertension usually develop in the third to fourth decades of life, and generally start with symptoms such as esophageal varices, caput medusae, spider angioma, and splenomegaly. Esophageal varices typically developes at the rate of 5-15% per year in cirrhosis patients. Most of the cirrhotic patients will develop the varices, atleast once during the lifetime. Approximately 60% of patients with cirrhosis develop ascites in 10 years. 10% of hospitalized patients with cirrhosis will involve in spontaneous bacterial peritonitis (SBP). If left untreated, 20-40% of patients with SBP may progress to death. The presence of variceal bleeding, spontaneous bacterial peritonitis, and hepatorenal syndrome are associated with a particularly poor prognosis among patients with portal hypertension. They are the leading causes of death among patients with portal hypertension.

Natural History, Complications, and Prognosis

Parameter Points
1 2 3
Ascites None Mild/Moderate Tense
Hepatic encephalopathy None Grade 1-2 Grade 3-4
Bilirubin μMol/L (mg/dL) <34.2 (<2) 34.2–51.3 (2-3) >51.3 (>3)
Albumin g/L (g/dL) >35 (>3.5) 28–35 (2.8–3.5) <28 (<2.8)
PT (Sec)
<4 4–6 >6
<1.7 1.7–2.3 >2.3

Natural History

Gastroesophageal varices type 1, via Wikipedia.org
Gastroesophageal varices type 2, via Wikipedia.org
Gastroesophageal varices type 1
Extend along the lesser curvature
Gastroesophageal varices type 2
Extend along the fundus
Isolated gastric varices type 1, via Wikipedia.org
Isolated gastric varices type 2, via Wikipedia.org
Isolated gastric varices type 1
Located in the fundus and tend to be tortuous and complex
Isolated gastric varices
Located in the body, antrum, or around the pylorus

Grade Definition
Grade 1 Mild ascites only detectable by ultrasound
Grade 2 Moderate ascites evident by moderate symmetrical distension of abdomen
Grade 3 Large or gross ascites with marked abdominal distension

Grading for different stages of hepatic encephalopathy, called West Haven Criteria[13]
West Haven Criteria
hepatic encephalopathy grading
Grade 1
Grade 2
Grade 3
Grade 4
•Mild loss of consciousness
Euphoria or anxiety
• Lowered attention span
•Impaired performance of addition
Lethargy or apathy
•Minimal disorientation to time and place
•Subtle personality change
•Inappropriate behavior
•Impaired performance of subtraction
Somnolence to semi-stupor, but
responsive to verbal stimuli
•Gross disorientation
Coma (unresponsive to verbal
or noxious stimuli)



HVPG of 10 mmHg
• Gastroesophageal varices
Hepatocellular carcinoma
• Decompensation after hepatocellular carcinoma resection
Compensated cirrhosis
HVPG of 12 mmHg
Variceal bleeding
HVPG of 16 mmHg
• First decompensation after varices
Prognostic significance of
HVPG in cirrhotic patients
HVPG of 16 mmHg
Variceal rebleeding
HVPG of 20 mmHg
• Uncontrollable active variceal bleeding
• Low 1-year survival
Decompensated cirrhosis
HVPG of 22 mmHg
Mortality in alcoholic cirrhosis and acute alcoholic hepatitis
HVPG of 30 mmHg
Spontaneous bacterial peritonitis (SBP)


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