Management of portal hypertension, Budd–Chiari syndrome and portal vein thrombosis

The risk of variceal bleeding can be estimated by the size of varices, the presence of endoscopic red signs and the degree of liver dysfunction. All patients with large varices, and those with cirrhosis and severe liver disease, irrespective of the size of varices, should be given primary prophylaxis with non-selective β-blockers. Banding ligation is equivalent and is used if there are contraindications or intolerance to these drugs. Acute variceal bleeding should be managed in a gastrointestinal bleeding unit. Prophylactic third-generation cephalosporins and vasoactive drugs should always be given. Ligation or sclerotherapy should take place at diagnostic endoscopy. Secondary prophylaxis of variceal bleeding is mandatory with combined β-blockers and ligation. Hepatic outflow obstruction syndromes have a wide spectrum of presentation. Underlying thrombophilic conditions should be sought. A fulminant presentation requires liver transplantation. Decompression with transjugular intrahepatic stent shunt is effective in many cases and can also be used in cases of portal vein thrombosis. Hepatic and other venous webs can be treated with interventional radiological techniques. Anticoagulation is first-line therapy and should be continued lifelong; it should also be used in non-cirrhotic portal vein thrombosis, and considered in cirrhotic portal vein thrombosis.