Hi,

Portal hypertension results from reversal of blood flow from liver into portal vein [which drains the entire splanchnic blood] and subsequent portal vasodilatation resulting from release of various mediators into the portal circulation which causes the hyperdynamic circulation. All drugs act by lowering the fluid overload or on the splanchnic veins. So it is not truly arterial hypertension. The beneficial effect of splenic pulp embolisation [via splenic artery] may act in some cases of segmental varices or increasing the platelet count.

Dear Dr. Kozlov

There are two types of theory for the esophageal varices. I think the splenic artery is the most common form of "forward flow"-type esophageal varix of hyperdynamic state caused by splanchnic A-V shunts.

Splenic artery embolization or ligation is the treatment of choice for this type of varix.

I paste the following abstract of my case report for your reference.

Two cases of esophageal varix caused by local hyperdynamic state of gastric arteries -- May 1999 Hepato-gastroenterology 46(27):1774-7

Abstract

With increasing evidence on the role of endogenous nitric oxide in the splanchnic hyperdynamics, the existence of esophageal varix induced by hepatopetal flow of portal hypertension in a cirrhotic patient has become more convincing. Herein, we report 2 cases of esophageal varix caused by local hyperdynamic states of the right, left and posterior gastric arteries, respectively. Angiographic evidence suggests the existence of forward flows via the submucosal A-V shunt of the gastric arteries as the etiologic causes of the varices. The treatment of the current cases was unsatisfactory due to improper recognition of the local hyperdynamic state before the treatment. Unlike the "backward flow"-type esophageal varix, the treatment strategies of the "forward flow"-type esophageal varix of hyperdynamic state caused by splanchnic A-V shunts should be considered differently.

Thank all for attention and sharing points of view. The main question is if PH has "arterial" nature (forward flow theory) the most effective clinical approach is to limit arterial input to portal system instead treating permanent leakages from varices in esoph or elsewhere. Additional options are continuous blood volume reduction and cardiac output as we treat arterial hypertension.

The example cited by Dr.Chang is one of "segmental" portal hypertension which mostly results from isolated Splenic vein thrombosis [which may be secondary to acute or chronic pancreatitis for example]. But this is not the case with portal hypertension due to cirrhosis of liver. The "forward and backward flow" theories are presently outdated and it is now believed that portal hypertension is the result of vasodilatation due to which the splenic artery blood flow increases. NSBB opposes this effect and diuretics decrease the blood volume.

Dear Dr. Ray:

Thank you for your comments.

But there was no splenic vein thrombosis at all in my case, and there is no pancreatitis as well. My case is not a segmental hypertension.

I will be very appreciated if you can introduce me a article about the outdated of forward theory about the mechanism of portal hypertension.

30 years ago, we had been tried to measure the direction of the left gastric vein during the operation without success owing to lack of the instrument to show the flow direction.

Thanks for your interest

Please go through the most recent Edition of Sleisenger and Fordtran's Textbook of Gastroneterology, which is one of the standard textbooks followed all over the world.

Dear Dr. Kozlov:

I get the PDF file of Chapter 92, Portal Hypertension and Esophageal Bleeding,10th edition of Sleisenger and Fordtran's Textbook of Gastroneterology and read the hemodyanamic principle of portal hypertension. The pathophisiology of splanchnic hyperdynamics is still the same as what I have understood.

An mechanism of A-V shunting may exists between the splanchnic, intrahepatic or pulmonary vessels. Splenic A-V shunting is the most common type of splanchnic hyperdynamic state and your result can support this theory, better than my case report.