Portal hypertension differential diagnosis
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 | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CBC | ESR | Alb | Iron | Ascites fluid | PBS | Cr | Abdominal tenderness | Pale conjunctiva | Fever | Pitting edema | Apnea/
Baradypnea |
Murmur | Weight loss | Weakness | Cough | Dyspnea | |||
| 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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