Measurement of Portal Pressure

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Two methods are routinely used to measure PVP. The direct method, which is more technically challenging and rarely used, involves direct percutaneous, transhepatic puncture of the portal or splenic vein proximal (away from the liver and with reference to direction of normal blood flow) to the suspected site of obstruction. The indirect

Hepatic veno blood

Hepatic veno blood

Sinusoidal Obstruction Syndrome Sos

Hepatic arterial blood

Portal-venous blood

Sinusoidal endothelium Space of Disse

FIGURE 118-1 Schematic representation of the microvascular anatomy of the hepatic sinusoid. Hepatic arterial blood mixes with portal venous blood, crosses the sinusoid, and drains into the hepatic veins. Obstruction along this pathway can lead to portal hypertension. The sinusoid is lined with specialized, porous endothelium, and is separated from the hepatocytes by the spaces of Disse.

Hepatic arterial blood

Portal-venous blood

Sinusoidal endothelium Space of Disse

Hepatocytes

Post-sinusoidal

Sinusoidal

Pre-sinusoidal

FIGURE 118-1 Schematic representation of the microvascular anatomy of the hepatic sinusoid. Hepatic arterial blood mixes with portal venous blood, crosses the sinusoid, and drains into the hepatic veins. Obstruction along this pathway can lead to portal hypertension. The sinusoid is lined with specialized, porous endothelium, and is separated from the hepatocytes by the spaces of Disse.

TABLE 118-1. Hypertension

Causes of Noncirrhotic Portal

TABLE 118-2. Causes of Budd-Chiari Syndrome

Presinusoidal

Perisinusoidal

Postsinusdoidal

Portal, splenic, or superior Congenital hepatic Budd-Chiari mesenteric vein thrombosis fibrosis IPH Sarcoidosis

Schistosomiasis Precirrhotic stage, primary biliary cirrhosis Alcoholic central sclerosis Endothelitis (liver rejection, radiation injury) Arterioportovenous fistula (traumatic or Olser-Weber-Rendu) Hyperdynamic splenomegaly (infectious or myelodysplastic) Nodular regenerative hyperplasia syndrome Veno-occlusive disease (SOS) Chronic passive congestion (Nutmeg liver)

Mass effect (ie, tumor)

IPH = idiopathic portal hypertension; SOS = sinusoidal obstruction syndrome.

Primary (60 to 70% of Cases)

Secondary (5 to 15%)

Idiopathic (25%)

Primary thrombosis (75%) Oral contraceptive pill

Pregnancy

Polycythemia rubra vera Paroxysmal nocturnal hemoglobinuria Factor V Leiden Antiphospholipid antibody Lupus anticoagulant Idiopathic thrombocytopenic puprura Nephrotic syndrome Protein losing enteropathy Myeloproliferative disorders Protein C, S or antithrombin deficiency Factor II, VIII, X and XI deficiency Homocysteinuria Hepatitis Trauma Membraneous web (25%) (usually suprahepatic inferior vena cava)

Extrinsic compression Benign or malignant neoplasm Bacterial, fungal, or parasitic collections Benign cysts method is technically simpler and has significantly less complications. It involves accessing the jugular vein and selecting one of the main hepatic veins with a wedge balloon catheter. Two pressure measurements are obtained, one with the balloon deflated and the catheter nonwedged (free hepatic vein pressure [FHP]), and one with the balloon inflated and the catheter wedged as distally as possible within the hepatic vein (hepatic wedged venous pressure [HWP]). The PVP can be obtained by the following equation:

The indirect method has been shown to be accurate except in cases of perisinusoidal noncirrhotic portal hypertension and portal vein thrombosis (PVT), where the above equation underestimates the true PVP.

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