[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Abdomen](https://durgical.com/en/clinical-exam/#a-abdomen) › Portal hypertension and the signs of chronic liver disease [Clinical exam](https://durgical.com/en/clinical-exam/) · [Abdomen](https://durgical.com/en/clinical-exam/#a-abdomen) # Portal hypertension and the signs of chronic liver disease - Syndrome When blood cannot flow well through the liver, pressure in the portal vein rises: varices, ascites and a large spleen appear. Updated 2026-11-01 **See it in 3D:** [Portal vein](https://durgical.com/en/anatomy/hepatic-portal-vein/) · [Liver](https://durgical.com/en/anatomy/liver/) · [Spleen](https://durgical.com/en/anatomy/spleen/) · [Splenic vein](https://durgical.com/en/anatomy/splenic-vein/) · [Esophagus](https://durgical.com/en/anatomy/esophagus-abdominal-part/) · [Hepatic veins](https://durgical.com/en/anatomy/hepatic-veins/) ## Key points - Cirrhosis is the commonest cause; by site it is classified as prehepatic, intrahepatic and posthepatic. - Collateral circulation: esophageal and gastric varices, caput medusae around the umbilicus and rectal varices. - Congestive splenomegaly causes hypersplenism with a low platelet count. - Stigmata of chronic liver disease: spider angiomas, palmar erythema, gynecomastia, testicular atrophy, jaundice and asterixis. - In caput medusae blood flows away from the umbilicus; upward flow in the lower abdominal wall suggests inferior vena cava obstruction. ## What it is Portal hypertension is raised pressure in the portal venous system, almost always from cirrhosis. On examination it shows as collateral veins, splenomegaly and ascites, usually together with the stigmata of chronic liver failure. Its most feared complication is bleeding from esophageal varices. ## Key findings - Abdomen: ascites (shifting dullness, fluid wave), splenomegaly, periumbilical venous pattern; a small or hard, nodular liver. - Skin: jaundice, spider angiomas on the chest and face, palmar erythema, bruising, leukonychia. - Endocrine: gynecomastia, testicular atrophy, loss of body hair. - Neurological: asterixis, confusion, reversed sleep pattern (hepatic encephalopathy). - Other: fetor hepaticus, leg edema, Dupuytren contracture and parotid enlargement with chronic alcohol use. ## Pathophysiology - In cirrhosis, fibrosis and regenerative nodules raise resistance to blood flow through the liver; splanchnic vasodilation also increases inflow. - Blood seeks alternative routes to the systemic circulation: the left gastric vein to the esophageal veins (varices), the paraumbilical veins to the abdominal wall (caput medusae) and the rectal veins. - Pressure transmitted to the splenic vein enlarges the spleen, which sequesters platelets and blood cells. - Ascites results from high sinusoidal pressure, low albumin (less oncotic pressure) and renal sodium retention. - The diseased liver makes less albumin and fewer clotting factors and clears less estrogen and ammonia: hence bruising, spider angiomas and encephalopathy. ## Common causes - Intrahepatic: cirrhosis from alcohol, chronic hepatitis B or C and metabolic dysfunction-associated fatty liver disease; schistosomiasis in endemic areas. - Prehepatic: portal or splenic vein thrombosis. - Posthepatic: Budd-Chiari syndrome, right heart failure and constrictive pericarditis. - Complications: variceal bleeding, spontaneous bacterial peritonitis, hepatorenal syndrome and hepatic encephalopathy. ## Tests that confirm it - Doppler ultrasound: spleen size, portal flow, ascites and the look of the liver. - Upper endoscopy to look for varices. - Low platelets, low albumin and a prolonged prothrombin time reflect hypersplenism and failing synthesis. ## Test yourself Think of the answer, then tap the question to see it. ## Which veins form esophageal varices in portal hypertension? Collaterals between the left gastric vein (portal system) and the esophageal veins draining to the azygos (caval system), which dilate as blood is diverted. ## Why does a patient with cirrhosis have a low platelet count? Portal hypertension enlarges the spleen (congestive splenomegaly), which sequesters platelets; lower thrombopoietin production by the liver also contributes. ## Which three mechanisms explain ascites in cirrhosis? High sinusoidal pressure, low albumin that reduces oncotic pressure, and renal retention of sodium and water. ## Which stigmata of chronic liver disease are attributed to estrogen excess? Spider angiomas, palmar erythema, gynecomastia, testicular atrophy and loss of body hair, because the diseased liver clears estrogens less well. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/portal-hypertension-and-the-signs-of-chronic-liver-disease/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Portal vein](https://durgical.com/en/anatomy/hepatic-portal-vein/) - [Liver](https://durgical.com/en/anatomy/liver/) - [Spleen](https://durgical.com/en/anatomy/spleen/) - [Splenic vein](https://durgical.com/en/anatomy/splenic-vein/) - [Esophagus](https://durgical.com/en/anatomy/esophagus-abdominal-part/) - [Hepatic veins](https://durgical.com/en/anatomy/hepatic-veins/) ## Related - [Ascites: shifting dullness and fluid wave](https://durgical.com/en/clinical-exam/ascites-shifting-dullness-and-fluid-wave/) - [Palpation of the liver and spleen](https://durgical.com/en/clinical-exam/palpation-of-the-liver-and-spleen/) - [Abdominal inspection](https://durgical.com/en/clinical-exam/abdominal-inspection/) - [Jaundice: prehepatic, hepatic and posthepatic](https://durgical.com/en/clinical-exam/jaundice-prehepatic-hepatic-and-posthepatic/) - [Upper and lower gastrointestinal bleeding](https://durgical.com/en/clinical-exam/upper-and-lower-gastrointestinal-bleeding/) - [Edema: pitting, grading and distribution](https://durgical.com/en/clinical-exam/edema-pitting-grading-and-distribution/) - [Pallor, cyanosis and jaundice](https://durgical.com/en/clinical-exam/pallor-cyanosis-and-jaundice/) ## Related conditions - [Portal hypertension](https://durgical.com/en/conditions/portal-hypertension/) - [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/) - [Budd-Chiari syndrome](https://durgical.com/en/conditions/budd-chiari-syndrome/) - [Hepatic encephalopathy](https://durgical.com/en/conditions/hepatic-encephalopathy/) - [Ascites and spontaneous bacterial peritonitis](https://durgical.com/en/conditions/ascites-and-spontaneous-bacterial-peritonitis/) - [Hepatorenal syndrome](https://durgical.com/en/conditions/hepatorenal-syndrome/) - [Metabolic dysfunction-associated steatotic liver disease (MASLD/NAFLD)](https://durgical.com/en/conditions/metabolic-dysfunction-associated-steatotic-liver-disease/) - [Viral hepatitis](https://durgical.com/en/conditions/viral-hepatitis/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [Cirrhosis | Cirrhosis of the Liver | MedlinePlus](https://medlineplus.gov/cirrhosis.html) (MedlinePlus, U.S. National Library of Medicine, 2026); [Ascites: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000286.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [23.6 Accessory Organs in Digestion: The Liver, Pancreas, and Gallbladder](https://openstax.org/books/anatomy-and-physiology-2e/pages/23-6-accessory-organs-in-digestion-the-liver-pancreas-and-gallbladder) (OpenStax, Rice University, 2022). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/portal-hypertension-and-the-signs-of-chronic-liver-disease/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/portal-hypertension-and-the-signs-of-chronic-liver-disease/