The management of portal hypertension: Rational basis, available treatments and future options☆

Variceal bleeding is the last step in a chain of events initiated by an increase in portal pressure, followed by the development and progressive dilation of varices until these finally rupture and bleed. This sequence of events might be prevented – and reversed – by achieving a sufficient decrease in portal pressure. A different approach is the use of local endoscopic treatments at the varices. This article reviews the rationale for the management of patients with cirrhosis and portal hypertension, the current recommendations for the prevention and treatment of variceal bleeding, and outlines the unsolved issues and the perspectives for the future opened by new research developments.

Abbreviations: CSPH, clinically significant portal hypertension, HVPG, hepatic venous pressure gradient, WHVP, wedged hepatic venous pressure, FHVP, free hepatic venous pressure, PVT, portal vein thrombosis, NO, nitric oxide, VEGF, vascular endothelial grow factor, PDGF, platelet derived grow factor, TIPS, transjugular intrahepatic porto-systemic shunt, MRI, magnetic resonance imaging, NASH, non-alcoholic steato-hepatitis, BB, beta-blockers, EBL, endoscopic band ligation, ISMN, isosorbide 5-mononitrate, RCT, randomised controlled trial, PHG, portal hypertensive gastropathy, RR, relative risk, OR, odds ratio, HR, hazard ratio

Keywords: Portal pressure, Hepatic vascular resistance, Nitric oxide, Oesophageal/gastric varices, Portal hypertensive gastropathy, Variceal bleeding, HVPG, Non-selective beta-blockers, Endoscopic band ligation, TIPS