Pediatric Portal Hypertension Ascites Complications
- On its own, PHT does not present with symptoms. Typically, it is not until a complication occurs that a diagnosis is confirmed. Sometimes a routine endoscopy will reveal esophageal varices. Varices occur when there is an obstruction and pressure builds in the portal vein, causing new veins called collaterals to appear. These collaterals are usually larger, bulging veins and they can rupture and hemorrhage, sometimes fatally. PHT is also diagnosed after a patient complains of fullness and discomfort in the abdomen or shortness of breath, usually due to ascites. Another complication of PHT is called hepatic encephalopathy. When the liver is diseased, it does not filter the blood optimally. Toxins that are normally removed from the blood stream stay in circulation or are rerouted, bypassing the liver completely by the new collateral vein system, until they reach the brain. This results in behavioral changes, drowsiness, or confusion
- The above complications work to diagnose PHT. Also, doctors can use ultrasound with a Doppler flow study or a computed tomography (CT) scan to watch the flow of blood through the portal system. Another tool is an angiogram, injecting dye into the circulation system and then observing the path of the dye with x-ray.
- One line of treatment is to reduce the blood pressure by slowing the heart rate with a beta-blocker medication such as Nadolol. Another remedy is for a surgeon to create a shunt or new connection between the portal venous system and the vena cava. The vena cava is the vein that carries the blood from the lower extremities and the kidneys to the heart. This redirection lowers the pressure and reduces the portal hypertension. If the PHT has caused bleeding from the esophageal varices, then another surgical procedure, an endoscopy, is performed. During an endoscopy the varices are ligated (tied off with rubber bands) to stop bleeding and shrink the veins. Subsequent ligation procedures are needed as a follow up, to observe and add further bands if needed, typically one or two more times following the initial emergency procedure.
- When certain body systems are compromised, fluid can leak from the liver, the intestine, the lymph system or surrounding blood vessels into the peritoneal cavity. Liver disease is the most common cause of ascites, but it can also occur with renal (kidney) failure, congestive heart failure, lymphoma, pancreatitis, or even tuberculosis. Symptoms include a full or even distended abdomen, diminished appetite, and sometimes shortness of breath. Great amounts of fluid cause the belly to become taut and sometimes the naval disappears or becomes pushed out and at times the ankles become swollen with extra fluid (edema).
A complication of ascites is the risk of spontaneous bacterial peritonitis (SBP) which is a serious infection of the ascitic fluid. It is treated with an antibiotic regimen. If SBP is untreated it can be fatal - Ascites is difficult to diagnose unless there is at least a quart of fluid already accumulated in the abdomen. A doctor can tap the patient's abdomen to check for dullness which indicates fluid. Another test called a "fluid wave." Pressure is applied at the mid-line of the abdomen by having the patient or an assistant place their hand firmly and vertically along the naval area. Then the doctor places his hands on both sides of the abdomen and taps the right side. A wave of fluid is felt on the opposite side if ascites is present.
- Depending on the severity of the ascites, the condition of the liver and kidneys, and other symptoms; the recommended treatment is a combination of bed rest, fluid restriction and sodium restriction. Sometimes a technique called paracentesis is used. Paracentesis is the draining of the ascitic fluid by a needle puncture. The fluid drains through a tube and is collected and examined in the lab to determine both the cause of the ascites and if infection is present.