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# Portal hypertension

Portal hypertension is raised pressure in the portal vein, the vein carrying gut blood to the liver; it causes varices, ascites and a large spleen.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Portal vein](https://durgical.com/en/anatomy/hepatic-portal-vein/)
- [Liver](https://durgical.com/en/anatomy/liver/)
- [Splenic vein](https://durgical.com/en/anatomy/splenic-vein/)
- [Mesenteric veins](https://durgical.com/en/anatomy/superior-mesenteric-vein/)
- [Spleen](https://durgical.com/en/anatomy/spleen/)
- [Esophagus](https://durgical.com/en/anatomy/esophagus-abdominal-part/)
- [Hepatic veins](https://durgical.com/en/anatomy/hepatic-veins/)
- [Inferior vena cava](https://durgical.com/en/anatomy/inferior-vena-cava/)
- [Peritoneum](https://durgical.com/en/anatomy/peritoneum/)

## Microorganisms that cause it

- [Schistosoma mansoni / S. haematobium / S. japonicum](https://durgical.com/en/microbiology/schistosoma-mansoni-s-haematobium-s-japonicum/)

## In embryology

- [Biliary atresia](https://durgical.com/en/embryology/biliary-atresia/)

## In the clinical exam

- [Abdominal inspection](https://durgical.com/en/clinical-exam/abdominal-inspection/)
- [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/)
- [Portal hypertension and the signs of chronic liver disease](https://durgical.com/en/clinical-exam/portal-hypertension-and-the-signs-of-chronic-liver-disease/)
- [Upper and lower gastrointestinal bleeding](https://durgical.com/en/clinical-exam/upper-and-lower-gastrointestinal-bleeding/)

## In physiology

- [Splanchnic and portal circulation](https://durgical.com/en/physiology/splanchnic-and-portal-circulation/)
- [Functions of the liver](https://durgical.com/en/physiology/functions-of-the-liver/)

## Why it happens

- [Hyperemia and congestion (the nutmeg liver, heart-failure cells)](https://durgical.com/en/general-pathology/hyperemia-and-congestion/)
- [Edema and effusions: the four mechanisms](https://durgical.com/en/general-pathology/edema-and-effusions-the-four-mechanisms/)
- [Flow, pressure and resistance: Poiseuille and turbulent flow](https://durgical.com/en/physiology/flow-pressure-and-resistance-poiseuille-and-turbulent-flow/)
- [Liver: lobule, acinus, hepatocytes, sinusoids, Kupffer cells](https://durgical.com/en/histology/liver-lobule-acinus-hepatocytes-sinusoids-kupffer-cells/)

## What it is

Raised pressure in the portal venous system, defined by a hepatic venous pressure gradient above the normal range. It causes varices, ascites and splenomegaly, and its main cause is cirrhosis.

## Who gets it

Cirrhosis causes most cases worldwide and in Latin America. Non-cirrhotic causes such as portal vein thrombosis and schistosomiasis (in endemic areas of South America) matter in some settings.

## Causes

- Prehepatic: portal or [splenic vein](https://durgical.com/en/anatomy/splenic-vein/) thrombosis, extrinsic compression
- Intrahepatic, presinusoidal: schistosomiasis, idiopathic non-cirrhotic portal hypertension
- Intrahepatic, sinusoidal: cirrhosis of any cause (most common)
- Intrahepatic, postsinusoidal: sinusoidal obstruction syndrome
- Posthepatic: Budd-Chiari syndrome, right heart failure, constrictive pericarditis

## Risk factors

- Chronic liver disease from alcohol, hepatitis B or C, or MASLD
- Thrombophilia, myeloproliferative disorders, abdominal infection or surgery (portal vein thrombosis)
- Living in or coming from schistosomiasis-endemic areas

## Pathophysiology

Portal pressure rises when resistance to flow increases (fibrosis, nodules, vasoconstriction in the liver) and when splanchnic vasodilation increases inflow. Blood diverts through portosystemic collaterals: gastro-oesophageal, rectal, paraumbilical (caput medusae) and retroperitoneal. Sinusoidal hypertension, low albumin and sodium retention lead to ascites; back-pressure enlarges the spleen.

## Classification

- By site: prehepatic, intrahepatic (presinusoidal, sinusoidal, postsinusoidal) or posthepatic
- Hepatic venous pressure gradient: normal up to about 5 mmHg; 10 mmHg or more is clinically significant portal hypertension
- Consensus groups (e.g., Baveno) define stages and non-invasive criteria

## Symptoms and signs

- Often silent until a complication appears
- Abdominal swelling from ascites
- Splenomegaly, with low platelets (hypersplenism)
- Dilated veins around the umbilicus (caput medusae)
- Vomiting blood or black stools from variceal bleeding
- Confusion from hepatic encephalopathy

## Red flags

- Haematemesis or melaena
- Fever, abdominal pain or confusion in a patient with ascites (possible spontaneous bacterial peritonitis)
- Hypotension or tachycardia
- Falling urine output

## Diagnosis

**Clinical**
Signs of chronic [liver](https://durgical.com/en/anatomy/liver/) disease, splenomegaly, ascites and caput medusae. In cirrhosis, clinically significant portal hypertension is often inferred from non-invasive tests.

**Tests**
Platelet count, liver tests, albumin, INR. Diagnostic paracentesis: a serum-ascites albumin gradient (SAAG) of 1.1 g/dL or more points to portal hypertension. Hepatic venous pressure gradient measurement is the reference standard where available.

**Imaging**
Doppler ultrasound: [portal vein](https://durgical.com/en/anatomy/hepatic-portal-vein/) size and flow, thrombosis, splenomegaly, ascites and collaterals. Elastography of liver and [spleen](https://durgical.com/en/anatomy/spleen/) stiffness. CT or MRI for vascular anatomy. Upper endoscopy screens for varices.

## Differential diagnosis

- Ascites from heart failure, peritoneal carcinomatosis or tuberculous peritonitis
- Nephrotic syndrome or protein-losing states
- Splenomegaly from haematological disease, malaria or leishmaniasis
- Upper GI bleeding from peptic ulcer

## Goal of treatment

Treat the cause, lower portal pressure, prevent and control variceal bleeding, manage ascites and its infections, and refer for transplant when indicated.

## Treatment

**Medical**
Non-selective beta-blockers lower portal pressure and help prevent first and repeat variceal bleeding.

**Procedure**
Endoscopic band ligation of oesophageal varices, as an alternative or addition to beta-blockers; tissue adhesive for some gastric varices.

**Acute**
Acute variceal bleeding: cautious resuscitation, vasoactive drugs (somatostatin or vasopressin analogues), antibiotic prophylaxis and endoscopy within about 12 hours.

**Medical**
Ascites: sodium restriction and diuretics (aldosterone antagonist with or without a loop diuretic); large-volume paracentesis with albumin when tense or refractory.

**Procedure**
TIPS (transjugular intrahepatic portosystemic shunt) for refractory ascites, uncontrolled bleeding or, in selected high-risk patients, early after a bleed.

**Medical**
Anticoagulation for portal vein thrombosis in selected patients; antiparasitic treatment for schistosomiasis.

**Surgical**
Liver transplantation for decompensated cirrhosis; surgical shunts are now rarely used.

## Drugs for this condition

- [Propranolol](https://durgical.com/en/pharmacology/propranolol/)

## Complications

- Variceal bleeding (oesophageal, gastric, ectopic)
- Ascites and spontaneous bacterial peritonitis
- Hepatic encephalopathy
- Hepatorenal syndrome
- Hypersplenism with thrombocytopenia
- Portal hypertensive gastropathy; hepatopulmonary syndrome and portopulmonary hypertension

## Prognosis

Depends on the cause and liver function. In cirrhosis, the first variceal bleed or ascites marks decompensation and a clear fall in survival; lowering portal pressure improves outcomes.

## Prevention

- Prevention and treatment of the causes of cirrhosis (alcohol, hepatitis B and C, MASLD)
- Screening for varices in cirrhosis
- Safe water and sanitation in schistosomiasis-endemic areas

## Test yourself

Think of the answer, then tap the question to see it.

## Which hepatic venous pressure gradient defines clinically significant portal hypertension?

A gradient of 10 mmHg or more; the normal value is up to about 5 mmHg.

## What serum-ascites albumin gradient suggests ascites from portal hypertension?

A SAAG of 1.1 g/dL or more; a lower gradient suggests causes such as carcinomatosis, tuberculosis or nephrotic syndrome.

## Which portosystemic collateral produces caput medusae?

Recanalised paraumbilical veins draining from the left portal vein to the veins of the anterior abdominal wall.

## Which two drug classes are used in acute variceal bleeding besides blood products?

Vasoactive drugs (somatostatin or vasopressin analogues) and prophylactic antibiotics.

## What is one prehepatic and one posthepatic cause of portal hypertension?

Prehepatic: portal vein thrombosis. Posthepatic: Budd-Chiari syndrome, right heart failure or constrictive pericarditis.

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## Related conditions

- [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/)
- [Upper gastrointestinal bleeding](https://durgical.com/en/conditions/upper-gastrointestinal-bleeding/)
- [Peritonitis](https://durgical.com/en/conditions/peritonitis/)
- [Viral hepatitis](https://durgical.com/en/conditions/viral-hepatitis/)
- [Hepatocellular carcinoma](https://durgical.com/en/conditions/hepatocellular-carcinoma/)
- [Heart failure](https://durgical.com/en/conditions/heart-failure/)
- [Chronic pancreatitis](https://durgical.com/en/conditions/chronic-pancreatitis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Portal Hypertension](https://www.ncbi.nlm.nih.gov/books/NBK507718/) (StatPearls (NCBI Bookshelf), 2025).

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Source: https://durgical.com/en/conditions/portal-hypertension/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/portal-hypertension/