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Ask the Medical Expert Archives 2000-2004

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June 2000

Q. My mom has been diagnosed as having noncirrhotic portal hypertension. She had an episode of variceal bleed an year ago. Last week she had oozing from the site. Her liver functions have been normal throughout the year. She was put on prophylactic propranolol since Feb 1999. Should she keep taking the propranolol? Also what in your view could be the best and safest way to diagnose the etiology. Her Hb presently is 6.6 gm%, so liver biopsy appears risky. An ultrasound done a few days ago revealed normal hepatic architecture. Would a CT Scan help? She is presently being treated in India. Are there any new and better approach towards treatment and diagnosis in America? (She had endoscopic Sclerotherapy about 10 days ago).

A. Cirrhosis means that there has been irreversible damage to liver cells. The most common cause in the western world is Alcoholism. There are however, many other causes such as various infections, and drugs. Your mom has a much less common problem termed noncirrhotic portal hypertension (NCPH). This means that there is significant increase in the venous pressure in the portal vein. This increase pressure backs up and causes dilation of the stomach and esophageal veins leading to a much increase risk of bleeding varices (dilated veins). Also, the spleen gets enlarged and often fluid leaks into the abdomen (ascites). Portal vein thrombosis (clotting of the main vein that leads into the liver) is one of the most common causes of NCPH. It usually is idiopathic (cause is unknown). Certain diseases that lead to increase clotting (Hypercoagulable disorders) should be ruled out via blood tests.

A parasitic infection called schistosomiasis can cause portal hypertension. This is almost always able to be seen on ultrasound of the liver. Stool samples to check for the eggs (ova) can be done also.

Unfortunately, it sounds like your mom is very ill especially with such a low hemoglobin. It is possible that a doppler ultrasound to check venous flow of the liver may be helpful in locating the problem. CT scan of the abdomen is unlikely to be helpful. If she can tolerate Propranolol (Inderal), this should be continued as it has been shown to help reduce the risk of esophageal variceal rebleeding. She should be transfused with blood. Endoscopic ligation (rubber banding) of the esophageal varices may be preferable to sclerotherapy as ligation is at least as effective with fewer complications. Also, I would suggest a liver specialist be consulted if not done already. I hope this helps some. Good luck.

Ref: Harrison's Principles of Internal Medicine

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