Portal hypertension: symptoms, varices, treatment and when to get urgent help

Liver UK explains that a lot of blood goes through the liver from the digestive system. It comes in through the portal vein, flows through the liver and leaves through the hepatic vein, then goes back to the heart. In cirrhosis, serious scarring makes the liver stiff and lumpy, so it is hard for all the blood to get through. Pressure builds up in the portal vein as the blood tries to get into the liver.

Liver UK likens this to a blocked motorway: blood tries to find different routes through smaller veins, which do not usually carry so much blood. This causes problems in those veins and in other parts of the body. In rare cases portal hypertension can be caused by conditions that are not liver disease, such as ones that affect the blood and circulatory system.

Liver UK says there are usually no symptoms of portal hypertension in the early stages. If it causes complications, you will usually have symptoms of those complications.

Because portal hypertension comes from cirrhosis, the symptoms of cirrhosis are also relevant. The NHS says many people with cirrhosis do not have symptoms, especially early on. As it gets worse, symptoms may include:

• bleeding or bruising easily, and itchy skin

• yellow skin and whites of the eyes (jaundice), which may be harder to see on brown or black skin

• a swollen tummy, legs, ankles or feet

• trembling hands, slurred speech, confusion or difficulty concentrating

• vomiting blood, or very dark or black poo

Liver UK says there are two main complications of portal hypertension, and that both can be treated and managed.

Varices are enlarged veins, most commonly in the food pipe (oesophagus) or stomach. NHS inform says the raised pressure forces blood through smaller, fragile vessels lining the stomach and gullet. Varices can sometimes leak or burst, causing bleeding, which can be very serious if it happens suddenly. NHS inform says that if you vomit blood or pass blood in your stools, you probably have swollen veins in your oesophagus.

Ascites is swelling in the tummy caused by a build-up of fluid. Liver UK says it can be treated with medicines or by draining the fluid.

The most common cause is cirrhosis, which is caused by long-term damage to the liver. The NHS says you may be more likely to have cirrhosis if you regularly drink a lot of alcohol (over 50 units a week for a man and over 35 units a week for a woman), have hepatitis B or hepatitis C, live with obesity, have type 2 diabetes or non-alcoholic fatty liver disease, have an autoimmune liver condition such as autoimmune hepatitis, primary biliary cholangitis or primary sclerosing cholangitis, or have a genetic condition such as haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency or cystic fibrosis.

Liver UK says that if you have cirrhosis you should have a test to check for varices, so that they can be found and treated before they cause any bleeding. NHS inform describes this test as an endoscopy, where images of the oesophagus and stomach are shown on a screen and swollen vessels (varices) can be seen.

NICE Clinical Knowledge Summaries says cirrhosis assessment includes liver blood tests and additional tests for the underlying cause and severity, with referral for further investigations such as transient elastography, and referral to a hepatologist or gastroenterologist for newly diagnosed cirrhosis.

Treatment aims to treat the cause of the liver disease, lower the pressure in the portal vein and prevent or treat complications. Liver UK says you may be given a beta-blocker, especially if you have varices, which can reduce the pressure in the blood vessels. NHS inform adds that a beta-blocker such as propranolol can reduce the risk of bleeding or reduce the severity of a bleed.

Liver UK says the TIPS procedure can reduce portal hypertension by giving the blood an easier way through the liver. You usually have a general anaesthetic, and a small tube called a shunt or stent is placed in the liver to give blood a route from the portal vein to the hepatic vein. It can increase your risk of hepatic encephalopathy, so risks and benefits are discussed with your medical team.

If varices bleed, NHS inform describes procedures to help stop the bleeding and reduce the chance of it happening again: banding, where a small band is placed around the base of the varices during an endoscopy; injection of a glue to make the blood clot; a balloon tube to press on the varices; or a TIPS shunt.

The NHS says that if you have been diagnosed with cirrhosis you should call 999 or go to A&E if you are vomiting blood, your poo is very dark or black, or you suddenly become confused or have slurred speech. Do not drive yourself, and bring your medicines.

Ask for an urgent GP appointment or get help from NHS 111 if you have cirrhosis and your skin or the whites of your eyes look yellow, you are more short of breath than usual, or you have a swollen tummy, legs, ankles or feet.

The NHS says many people with cirrhosis can feel well and live for many years, though how serious it is depends on the cause and how early it is diagnosed and treated. Liver UK says you should not drink alcohol if you have portal hypertension, whatever the cause of your liver condition, and that staying active and eating a healthy, balanced diet can help. If you have ascites or are struggling to eat enough, ask to be referred to a registered dietitian.

• Do not drink alcohol, and do not smoke.

• Have a healthy, balanced diet, exercise regularly and try to keep to a healthy weight.

• Check with a pharmacist or doctor before taking any medicines, including herbal ones.

• Stay up to date with vaccinations such as the flu and pneumococcal vaccines.

• Know the symptoms of varices and ascites, and who to contact if you are worried.

On the NHS, people with cirrhosis are supported by a group of specialists that the NHS says may include a hepatologist, a gastroenterologist, a dietitian and alcohol support services. Emergency bleeding is treated through A&E and endoscopy services. Some people also choose to see a private hepatologist for consultations and tests; emergency bleeding should always be treated through 999 or A&E.