Portal hypertension and ascites

Portal pressure is the product of portal blood flow and resistance; an increase in either leads to increased portal pressure. Cirrhosis is the underlying cause in most cases, but portal hypertension can develop due to pre-, intra- and post-hepatic obstruction to the flow, secondary to variety of causes. Diagnosis can be established by a combination of non-invasive imaging or portal vasculature and clinical or serological markers for the cause underlying cirrhosis. Development of gastro-oesophageal varices and ascites is the most important clinical manifestation of portal hypertension. Non-selective beta-blockers and endoscopic band ligation are effective in primary and secondary prevention of variceal bleeding. Active variceal haemorrhage is managed using a combination of vasoactive drug (for example terlipressin) and endoscopic band ligation. If these measures fail, transjugular intrahepatic portosystemic shunt (TIPS) insertion achieves haemostasis. Diuretic therapy with spironolactone and furosemide are the mainstays of management of ascites. If ascites becomes refractory, repeat large-volume paracentesis and TIPS in selected cases help to control symptoms. Development of ascites is an important landmark in the natural history of cirrhosis and liver transplantation should be considered definitive treatment.