The complications of portal hypertension are:
» variceal bleeds
» ascites and fluid overload
» spontaneous bacterial peritonitis in patients with ascites
Ascites: salt restriction, i.e. < 2 g/day.
Monitor weight regularly.
Encephalopathy: low protein diet. Severe protein restriction may accentuate
catabolism. Use increments of 20 g protein per day as tolerated.
Exclude infection, high protein load, occult bleed, sedatives and electrolyte
Variceal bleeding: endoscopic sclerotherapy and/or banding.
If no response to strict bed rest after 2–3 days:
Spironolactone, oral, 50–200 mg daily.
o Titrate to higher dosages with caution.
o Maximum dose: 400 mg daily.
o May cause hyperkalemia.
o Can be combined with furosemide.
o Potassium supplementation is not necessary.
If there is no response to spironolactone or if there is gross fluid retention:
Furosemide, oral, 20–40 mg daily, initially for a few days to increase
o Titrate carefully to desired effect as rapid fluid shift may precipitate
o Optimal dose: 160 mg daily.
o Measure response to diuretics. Aim for weight loss of:
300–500 g/day patients without oedema
800–1 000 g/day patients with peripheral oedema
Patients not responding to optimal diuretic therapy, sufficient salt restriction
and avoiding NSAIDs.
These patients may require regular large volume paracentesis, i.e. > 5 L, as
outpatients, if possible.
Protect against haemodynamic collapse.
Large volume paracentesis is the method of choice as it is faster, more
effective and has fewer adverse effects compared to diuretics.
Diuretics are indicated as maintenance therapy to prevent recurrence of
Lactulose, oral, 10–30 mL 8 hourly.
To reduce the risk of bleeding:
Propranolol, oral 10–20 mg 12 hourly.
Reference and further reading
Standard Treatment Guidelines and Essential Medicines List for South Africa 2012 Edition