Portal hypertension differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Portal hypertension must be differentiated from other diseases that cause ascites, splenomegaly, hematemesis or melena, bacterial peritonitis, hydrothorax, hypoxemia, and pulmonary hypertension. Diseases that must be differentiated from portal hypertension are malignant ascites, nephrogenic ascites, tuberculosis, thalassemia, sickle cell disease, hereditary spherocytosis, peptic ulcer disease, Mallory-Weiss tear, colorectal cancer, secondary bacterial peritonitis, malignant hydrothorax, sarcoidosis, nephrotic syndrome, heart failure, central nervous system depression, muscular weakness, idiopathic pulmonary hypertension, valvular heart disease, and connective tissue disease.

Differentiating Portal Hypertension from other Diseases

Portal hypertension must be differentiated from other diseases that cause ascites, splenomegaly, hematemesis or melena, bacterial peritonitis, hydrothorax, hypoxemia, and pulmonary hypertension.
Portal hypertension must be differentiated from various diseases as in the following table.^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]

Differentiating symptom	Diseases	Laboratory Findings							Physical Examination						History and Symptoms				Other Findings
	Diseases	CBC	ESR	Alb	Iron	Ascites fluid	PBS	Cr	Abdominal tenderness	Pale conjunctiva	Fever	Pitting edema	Apnea/ Baradypnea	Murmur	Weight loss	Weakness	Cough	Dyspnea	Other Findings
	Portal Hypertension	-	-	-	-	Transudate	-	↑	+	-	-	-	-	-	-	-	-	-	Cirrhosis
Ascites	Malignant ascites	-	↑↑	↓	-	Exudate	-	-	-	-	-	-	+/-	-	+	+	-	-	Jaundice
	Nephrogenic ascites	-	-	↓↓	↓	Exudate	-	↑↑	-	+	-	++	+	-	-	+	-	-	↑K, Na
	Tuberculosis	↑lymph.	↑	↓	-	Exudate	-	-	-	-	+	-	+	-	+	+	++	+	Sweating
Splenomegaly	Thalassemia	↓MCV ↓HGB	-	-	↓	-	Microcytic anemia	-	-	+	-	-	-	-	-	+	-	-	↑HGB-A2
	Sickle cell disease	↓HGB	-	-	↓	-	Sickle RBC	-	+	+	+	-	-	-	-	+	-	+	Bone pain
	Hereditary spherocytosis	↓MCV ↓HGB	-	-	↓	-	Spherocyte	-	-	+	-	-	-	-	+	+	-	-	Osmotic fragility test
Hematemesis/ Melena	Peptic ulcer disease	↓HGB	-	-	↓	-	-	-	+	+	-	-	-	-	+	+	-	-	Dyspepsia
	Mallory-Weiss tear	-	-	-	-	-	-	-	+	-	-	-	-	-	-	-	-	-	Hx of vomiting
	Colorectal cancer	↓HGB	↑↑	↓	↓↓	-	-	-	-	+	-	-	-	-	+	+	-	-	Changing bowel habit
Bacterial peritonitis	Secondary bacterial peritonitis	↑Neut.	↑	-	-	Exudate	-	-	++	+	+++	-	+	-	-	+	-	-	Guarding
Hydrothorax	Malignancy	↑↑WBC	↑↑	↓↓	-	-	-	-	-	+	-	-	+	-	+	+	+	+	Chest pain
	Sarcoidosis	↑WBC	↑↑	-	-	-	-	↑	-	+	-	-	+	-	+	+	+	+	Bilateral hilar adenopathy
	Nephrotic syndrome	-	↑	↓↓	↓	-	-	↑↑	-	+	-	++	-	-	-	+	-	-	↑K, Na
Hypoxemia	Heart failure	-	-	-	-	-	-	-	-	-	-	++	-	+	+	+	+	+	EF < 40%
	Central nervous system depression	-	-	-	-	-	-	-	-	-	-	-	+	-	-	-	-	+	Opioid overdose
	Muscular weakness	-	-	-	-	-	-	-	-	-	-	-	-	-	+	++	-	-	Neuromuscular disease
Pulmonary hypertension	Idiopathic pulmonary arterial hypertension	-	↑	-	-	-	-	-	-	-	-	-	-	-	+	+	+	+	Hemoptysis
	Valvular heart disease	-	-	-	-	-	-	-	-	-	-	-	-	++	-	+	-	-	Dyspnea on exertion
	Connective tissue diseases	-	↑	-	-	-	-	↑	-	-	-	-	-	+	-	+	-	-	Aortic dissection

References

↑ Boonpongmanee S, Fleischer DE, Pezzullo JC, Collier K, Mayoral W, Al-Kawas F, Chutkan R, Lewis JH, Tio TL, Benjamin SB (2004). "The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated". Gastrointest. Endosc. 59 (7): 788–94. PMID 15173790.
↑ Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen G (2008). "An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium". Gastrointest. Endosc. 67 (3): 422–9. doi:10.1016/j.gie.2007.09.024. PMID 18206878.
↑ Balderas V, Bhore R, Lara LF, Spesivtseva J, Rockey DC (2011). "The hematocrit level in upper gastrointestinal hemorrhage: safety of endoscopy and outcomes". Am. J. Med. 124 (10): 970–6. doi:10.1016/j.amjmed.2011.04.032. PMID 21962318.
↑ Wollenman CS, Chason R, Reisch JS, Rockey DC (2014). "Impact of ethnicity in upper gastrointestinal hemorrhage". J. Clin. Gastroenterol. 48 (4): 343–50. doi:10.1097/MCG.0000000000000025. PMC 4157370. PMID 24275716.
↑ Lee YT, Walmsley RS, Leong RW, Sung JJ (2003). "Dieulafoy's lesion". Gastrointest. Endosc. 58 (2): 236–43. doi:10.1067/mge.2003.328. PMID 12872092.
↑ Runyon BA (1994). "Care of patients with ascites". N. Engl. J. Med. 330 (5): 337–42. doi:10.1056/NEJM199402033300508. PMID 8277955.
↑ O'Reilly RA (1998). "Splenomegaly in 2,505 patients at a large university medical center from 1913 to 1995. 1963 to 1995: 449 patients". West. J. Med. 169 (2): 88–97. PMC 1305177. PMID 9735689.
↑ Soriano G, Castellote J, Alvarez C, Girbau A, Gordillo J, Baliellas C, Casas M, Pons C, Román EM, Maisterra S, Xiol X, Guarner C (2010). "Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management". J. Hepatol. 52 (1): 39–44. doi:10.1016/j.jhep.2009.10.012. PMID 19897273.
↑ Azfar Ali H, Lippmann M, Mundathaje U, Khaleeq G (2008). "Spontaneous hemothorax: a comprehensive review". Chest. 134 (5): 1056–1065. doi:10.1378/chest.08-0725. PMID 18988781.
↑ Rodríguez-Roisin R, Roca J (2005). "Mechanisms of hypoxemia". Intensive Care Med. 31 (8): 1017–9. doi:10.1007/s00134-005-2678-1. PMID 16052273.
↑ Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Gomez Sanchez MA, Krishna Kumar R, Landzberg M, Machado RF, Olschewski H, Robbins IM, Souza R (2013). "Updated clinical classification of pulmonary hypertension". J. Am. Coll. Cardiol. 62 (25 Suppl): D34–41. doi:10.1016/j.jacc.2013.10.029. PMID 24355639.

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[pmid15173790-1] Boonpongmanee S, Fleischer DE, Pezzullo JC, Collier K, Mayoral W, Al-Kawas F, Chutkan R, Lewis JH, Tio TL, Benjamin SB (2004). "The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated". Gastrointest. Endosc. 59 (7): 788–94. PMID 15173790.

[pmid18206878-2] Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen G (2008). "An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium". Gastrointest. Endosc. 67 (3): 422–9. doi:10.1016/j.gie.2007.09.024. PMID 18206878.

[pmid21962318-3] Balderas V, Bhore R, Lara LF, Spesivtseva J, Rockey DC (2011). "The hematocrit level in upper gastrointestinal hemorrhage: safety of endoscopy and outcomes". Am. J. Med. 124 (10): 970–6. doi:10.1016/j.amjmed.2011.04.032. PMID 21962318.

[pmid24275716-4] Wollenman CS, Chason R, Reisch JS, Rockey DC (2014). "Impact of ethnicity in upper gastrointestinal hemorrhage". J. Clin. Gastroenterol. 48 (4): 343–50. doi:10.1097/MCG.0000000000000025. PMC 4157370. PMID 24275716.

[pmid12872092-5] Lee YT, Walmsley RS, Leong RW, Sung JJ (2003). "Dieulafoy's lesion". Gastrointest. Endosc. 58 (2): 236–43. doi:10.1067/mge.2003.328. PMID 12872092.

[pmid8277955-6] Runyon BA (1994). "Care of patients with ascites". N. Engl. J. Med. 330 (5): 337–42. doi:10.1056/NEJM199402033300508. PMID 8277955.

[pmid9735689-7] O'Reilly RA (1998). "Splenomegaly in 2,505 patients at a large university medical center from 1913 to 1995. 1963 to 1995: 449 patients". West. J. Med. 169 (2): 88–97. PMC 1305177. PMID 9735689.

[pmid19897273-8] Soriano G, Castellote J, Alvarez C, Girbau A, Gordillo J, Baliellas C, Casas M, Pons C, Román EM, Maisterra S, Xiol X, Guarner C (2010). "Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management". J. Hepatol. 52 (1): 39–44. doi:10.1016/j.jhep.2009.10.012. PMID 19897273.

[pmid18988781-9] Azfar Ali H, Lippmann M, Mundathaje U, Khaleeq G (2008). "Spontaneous hemothorax: a comprehensive review". Chest. 134 (5): 1056–1065. doi:10.1378/chest.08-0725. PMID 18988781.

[pmid16052273-10] Rodríguez-Roisin R, Roca J (2005). "Mechanisms of hypoxemia". Intensive Care Med. 31 (8): 1017–9. doi:10.1007/s00134-005-2678-1. PMID 16052273.

[pmid24355639-11] Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Gomez Sanchez MA, Krishna Kumar R, Landzberg M, Machado RF, Olschewski H, Robbins IM, Souza R (2013). "Updated clinical classification of pulmonary hypertension". J. Am. Coll. Cardiol. 62 (25 Suppl): D34–41. doi:10.1016/j.jacc.2013.10.029. PMID 24355639.

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Portal hypertension differential diagnosis

Overview

Differentiating Portal Hypertension from other Diseases

References

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