Portal Hypertension

PORTAL HYPERTENSION 1.

CHIEF COMPLAINT •Portal hypertension

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HPI

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ROS

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SYMPTOMS •Ascites •Hepatic encephalopathy •Splenomegaly •Mild pancytopenia •Esophageal varices •Hemorrhoids •Caput medusae

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HISTORY •FAMILY HISTORY o Hemochromatosis o Wilson disease •SOCIAL HISTORY o Alcohol abuse •PAST MEDICAL HISTORY o Jaundice o Blood transfusions o Intravenous drug use o Pruritus o Portal vein thrombosis o Splenic vein thrombosis o Right heart failure •SURGICAL HISTORY •CHRONIC CONDITIONS o Congenital atresia o Stenosis of portal vein o Splanchnic arteriovenous fistula o Schistosomiasis o Primary biliary cirrhosis

o o o o o o o o o o o o o o o o o o o o o

Idiopathic portal hypertension Nodular regenerative hyperplasia Polycystic disease Sarcoidosis Tuberculosis Hepatic cirrhosis Acute alcoholic hepatitis Schistosomiasis Primary biliary cirrhosis Idiopathic portal hypertension Acute and fulminant hepatitis Congenital hepatic fibrosis Vitamin A toxicity Peliosis hepatitis Venoocclusive disease Budd-Chiari syndrome Inferior vena cava (IVC) obstruction Constrictive pericarditis Tricuspid regurgitation Budd-Chiari syndrome Arterial-portal venous fistula

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ALLERGIES

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PHYSICAL EXAMINATION •Dilated veins in the anterior abdominal wall •Venous pattern on the flanks •Caput medusa •Rectal hemorrhoids •Ascites - Shifting dullness and fluid wave •Paraumbilical hernia •Ascites •Jaundice •Spider angiomas •Palmar erythema •Asterixis •Testicular atrophy •Gynecomastia •Dupuytren contracture •Muscle wasting •Splenomegaly

•Bounding pulses •Warm, well-perfused extremities •Arterial hypotension 8.

SPECIFIC DATA LIKE GRADING ETC

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TESTS TO BE ORDERED •Liver function tests •Prothrombin time •Serum Albumin •Viral hepatitis serologies •Platelet count •Antinuclear antibody •Antimitochondrial antibody •Antismooth muscle antibody •Iron indices •Alpha1-antitrypsin •SERUM Ceruloplasmin •24-hour urinary copper •Duplex-Doppler ultrasonography •CT scan •MRI •Liver-spleen scan •Angiography •Endoscopy

10. ASSESSMENT /PLAN o Medical Care •Endoscopic injection sclerotherapy •Endoscopic variceal ligation (EVL) •Balloon-tube tamponade •Endoscopic administration of cyanoacrylate monomer (superglue) o Surgical Care •Total portal systemic shunts •Side-to-side portacaval shunt •Partial portal systemic shunts •Distal splenorenal shunt •Splenectomy •Gastroesophageal devascularization

•Esophageal transection •Liver transplantation 11. EDUCATION 12. MEDICATION •Somatostatin •Octreotide •Propranolol •Nadolol •Timolol •Vasopressin •Terlipressin •Isosorbide mononitrate (ISMN) 13. FOLLOW-UP