Esophageal varices without liver cirrhosis

[hyrule]

I encountered a question about a possible cause of esophageal varices without any abnormal liver findings. Options were Budd-Chiari, Constrictive pericarditis, and Portal Vein thrombosis. While all 3 can lead to esophageal varices, the answer was portal vein thrombosis.

Wouldn't portal vein thrombosis result in ischemia to the liver, resulting in liver damage as well? Or would that occur more with the hepatic artery? Either way what would be the consequences of a "pre" liver problem such as thrombus in the portal vein?

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[nkhan]

Budd Chiari--usually in hepatic veins--flows to IVC--systemic circulation ( not portal htn)

Constrictive pericarditis--don't see how this could be related

Portal vein thrombosis--obstructs portal v (just like cirrhosis would but on a much larger, functional scale)--increase portal venous pressure-->backs up in to anastomosis of L. gastric vein and esophageal veins

It wouldn't result in ischemia (it's venous blood, even though blood is flowing INTO the liver; it is more from absorbing stuff from GI tract etc.--thus if you block it you cause portal hypertension throughout all its tributaries).

 

[RadOncRocks]

Budd Chiari--usually in hepatic veins--flows to IVC--systemic circulation ( not portal htn)

Constrictive pericarditis--don't see how this could be related

Portal vein thrombosis--obstructs portal v (just like cirrhosis would but on a much larger, functional scale)--increase portal venous pressure-->backs up in to anastomosis of L. gastric vein and esophageal veins

It wouldn't result in ischemia (it's venous blood, even though blood is flowing INTO the liver; it is more from absorbing stuff from GI tract etc.--thus if you block it you cause portal hypertension throughout all its tributaries).

Just to piggy back: When you hear esophageal varices you want to think portal hypertension, so ANYTHING that can cause that. nkhan did a great job breaking them out individually, just wanted to highlight that. Portal HTN = portal-systemic shunt = varices (esophageal, peri-umbilical, etc)

 

[jfgavina]

Hi. I'm not a pro, but I think it is difficult to have liver ischemia because of multiple sources of blood supply to the liver, so only in conditions like DIC for example you get liver ischemia. On the other hand, if you have portal vein trombosis you automatically have portal hypertension since the amount of blood behind the liver increases, so there is an increase in capillary pressure of portal vein which eventually leads to collateral circulation and esophageal varices (the blood must go somewhere). The mechanism is similar to cirrosis, the difference is that the obstruction site is in the portal vein, not in the liver.

 

[Vergie]

Both the hepatic artery and portal vein supply blood to the Liver. So while a portal vein thrombosis would cut off some supply to the liver it wouldnt cut off all of it. I'm not sure what the ratio of O2 supply is between the two is but I think it's close to even.

If you think about the pathway of budd chiari and constrictive pericarditis, the buildup of backward pressure goes through the liver before reaching the esogeal veins. That's why those answers are incorrect.

Preliver blockage would affect everything in the portal circulation. complications could be esophogeal varicies and splenomegaly, maybe some hemmorrhoids too. There may be more.

hope this helps

 

[jfgavina]

Constrictive pericarditis--don't see how this could be related

you can relate that to heart failure (if you have constritive pericarditis you have a diastolic disfunction, the ventricle capacity to accomodate incoming blood is restricted by the constrictive pericarditis, loss of compliance) which leads to hepatomegaly and liver fluid congestion. But it can't cause esophageal varices because the fluid doesn't accumulate only in the portal system, instead it goes everywhere.

 

[hyrule]

Budd Chiari--usually in hepatic veins--flows to IVC--systemic circulation ( not portal htn)

not talking about the question I originally posted but

if there is a backflow of blood due to Budd Chiari. wouldn't that lead to backflow of blood to the liver --> cirrhosis --> portal hypertension --> varices

just like with nutmeg liver as a result of R-sided heart failure.

 

[nkhan]

not talking about the question I originally posted but

if there is a backflow of blood due to Budd Chiari. wouldn't that lead to backflow of blood to the liver --> cirrhosis --> portal hypertension --> varices

just like with nutmeg liver as a result of R-sided heart failure.

Yeah eventually. But you should see the signs of budd chiari a long time before (hepatomegaly/ascites) vs. the signs of portal HTN. anything that obstructs your systemic venous system (before returning to RA) long enough could eventually cause portal HTN (nutmeg liver like you said) if it went on for a long time which is probably what they were trying to get you confused with on the q--but this is not classically associated with portal htn as it usually doesn't make it that far (and other symptoms take precedence over it)

 

[theTruth_97]

I got a Uworld question regarding portal vein thrombosis- in it the patient had a normal liver biopsy? Why would the biopsy be normal?

Essentially initially my first thought was that oh portal hypertension causes cirrhosis.....but now after searching online and reading through various things I think that its cirrhosis which causes portal hypertension- not the other way around. Is that correct? If so then that would make sense why portal vein thrombosis wouldn't really affect the liver but it would cause portal hypertension

 

[Shjanzey]

I got a Uworld question regarding portal vein thrombosis- in it the patient had a normal liver biopsy? Why would the biopsy be normal?

Essentially initially my first thought was that oh portal hypertension causes cirrhosis.....but now after searching online and reading through various things I think that its cirrhosis which causes portal hypertension- not the other way around. Is that correct? If so then that would make sense why portal vein thrombosis wouldn't really affect the liver but it would cause portal hypertension

Did you read the other responses in this thread? I thought it was answered fairly adequately. It has been mentioned several times that cirrhosis can cause portal hypertension, but that doesn't necessarily mean that the underlying cause of the portal hypertension is due to cirrhosis. There is more than one cause. When you think of portal hypertension you should also think of an occlusive process causing a backup. This could be as simple as a tumor, it could be vascular disease (any of the vasculitides I think), it could be sarcoidosis, etc.

 

[cs24]

I got a Uworld question regarding portal vein thrombosis- in it the patient had a normal liver biopsy? Why would the biopsy be normal?

Essentially initially my first thought was that oh portal hypertension causes cirrhosis.....but now after searching online and reading through various things I think that its cirrhosis which causes portal hypertension- not the other way around. Is that correct? If so then that would make sense why portal vein thrombosis wouldn't really affect the liver but it would cause portal hypertension

Portal vein --> liver --> hepatic vein

Liver has a dual blood supply, so portal vein thrombosis won't cause ischemia to the liver, nor will you have congestion like you would have with an occlusion of the hepatic vein. You would still have portal HTN though.