Narketpally 2022-25 Portal Hypertension Clinical Complexity Outcomes Triad, Ascites, Encephalopathy and mortality!
Principal investigator: Dr Lohith Varma
The three most important words in the outcomes of this study are:
1. *Ascites*: Observed in 92% of patients on ultrasound, highlighting its significance in portal hypertension.
2. *Encephalopathy*: Hepatic encephalopathy was the most frequent complication (28%), emphasizing the need for early identification and management.
3. *Mortality*: Observed in 20% of patients, all during hospitalization, underscoring the severity and importance of prompt treatment.
These three words represent key aspects of the study's findings, including the prevalence of ascites, the frequency of hepatic encephalopathy, and the mortality rate associated with portal hypertension.
Timeline of first patient encounters over the project time period:
Web 2.0 to 3.0 conversational learnings that should have been done manually around every patient soon after admission to produce a richer higher quality prospective study data:
Project dp borrowed from: https://rishikadabbara.blogspot.com/2020/12/this-is-online-e-log-book-to-discuss_11.html?m=1
50 portal hypertension patient EMR summaries and their Web 3.0 AI driven thematic analysis prepared in May 2025
Initial Project plan link prepared in 2022:
Insights from this Portal Hypertension (PH) and Chronic Liver Disease (CLD) in low resource settings project:
Based on analysis of our cases from rural tertiary care settings, here are key under-recognized clinical and therapeutic nuances:
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#### **1. Scrotal and Penile Edema in PH**
- **Mechanism**: Hypoalbuminemia + lymphatic congestion due to portal hypertension.
- **Clinical Impact**: Often misdiagnosed as cellulitis or filariasis. Requires albumin infusions and diuretics, not just topical antibiotics (e.g., Neosporin).
- **Case Link**: Case 40 (77M with grade 4 scrotal edema, SAAG 2.1).
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#### **2. Portal Hypertensive Duodenopathy**
- **Finding**: Multiple D2 ulcers (Case 40) or duodenal inflammation in PH, distinct from typical PH gastropathy.
- **Why Missed**: Endoscopy often focuses on esophageal varices, missing duodenal lesions.
- **Implication**: Risk of occult GI bleeding; requires PPIs alongside PH management.
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#### **3. Lymphocytic Ascites with High SAAG**
- **Paradox**: SAAG >1.1 (indicative of PH) but lymphocytic predominance (90% lymphocytes, Case 38).
- **Causes**: Tuberculosis, occult malignancy, or idiopathic PH-associated inflammation.
- **Rural Gap**: Lack of ascitic fluid PCR/cytology delays diagnosis.
---
#### **4. Cholestasis Without Jaundice**
- **Biochemical Clue**: Elevated ALP (e.g., 565 IU/L in Case 39) with normal bilirubin.
- **Etiologies**:
- **Metabolic bone disease** (CLD + CKD comorbidity).
- **Early biliary obstruction** (e.g., gallbladder sludge in Case 36).
- **Action**: Screen for Vitamin D deficiency or occult cholangiocarcinoma.
---
#### **5. Hypoglycemia in CLD with Diabetes**
- **Mechanism**: Impaired gluconeogenesis due to liver failure, despite T2DM history.
- **Risk**: Overlooked in rural settings where insulin/OHA use continues unabated.
- **Case Link**: Case 33 (recurrent hypoglycemia led to antidiabetic withdrawal).
---
#### **6. Bone Marrow Suppression Beyond Hypersplenism**
- **Pattern**: Microcytic anemia (MCV <80) in CLD (Case 34) suggests **iron deficiency**, not just hypersplenism.
- **Rural Gap**: Iron studies rarely done; attributed to chronic disease alone.
- **Action**: Rule out GI bleeding (occult blood in stool) or nutritional deficits.
---
#### **7. Cardiorenal-Liver Axis in Edema**
- **Mixed Edema**: Ascites + pitting edema (e.g., Case 36) from overlapping PH, HFpEF, and CKD.
- **Therapeutic Conflict**: Diuretics (Lasix) worsen renal function in hypoalbuminemia (Alb <3 g/dl).
- **Solution**: Albumin infusions (often unavailable rurally) + slow diuresis.
---
#### **8. Pulmonary Hypertension in CLD**
- **Underlying Cause**: Portopulmonary syndrome or cor pulmonale (Case 39).
- **Clues**: Hypoxia (PO₂ <60 mmHg) + dilated RV on echo.
- **Rural Gap**: Echocardiography rarely done for CLD patients with dyspnea.
---
#### **9. Skin Breakdown in Genital Edema**
- **Complication**: Scrotal/penile edema → skin fissures → secondary infections.
- **Case Link**: Case 40 used topical Neosporin but missed PH-driven lymphatic root cause.
- **Prevention**: Elevation + compression garments (rarely prescribed in rural care).
---
#### **10. Beta-Blocker Risks in Rural PH**
- **Issue**: Propranolol (Inderal) started for grade I varices without endoscopy (Case 40).
- **Risk**: Hypotension (BP 130/70) in elderly patients with borderline perfusion.
- **Guideline Gap**: Rural reliance on ultrasound over endoscopy for variceal screening.
---
#### **11. Lactulose Prophylaxis Without Encephalopathy**
- **Practice**: Used preemptively in CLD (Cases 33, 38) despite no overt HE.
- **Risk**: Unnecessary diarrhea → electrolyte imbalances (e.g., hypokalemia).
- **Evidence Gap**: No trials support prophylactic lactulose in non-HE patients.
---
#### **12. Ethical Dilemmas in LAMA (Leave Against Medical Advice)**
- **Trend**: Families opt for LAMA due to futility (Case 39) or financial constraints.
- **Impact**: High post-discharge mortality from untreated complications (e.g., SBP, variceal bleed).
- **Action Needed**: Rural palliative care protocols and family counseling.
---
#### **13. Thrombocytopenia Neglect**
- **Pattern**: Platelets <1L ignored despite INR >1.5 (Case 38).
- **Risk**: Unaddressed bleeding risk during procedures (e.g., paracentesis).
- **Rural Barrier**: Platelet transfusions often unavailable.
---
#### **14. Viral vs. Alcohol Etiology Overlap**
- **Diagnostic Gap**: HBV+ patients (Case 38) assumed to have viral CLD, ignoring alcohol history.
- **Consequence**: Delayed alcohol cessation counseling and vice versa.
- **Action**: Dual screening and tailored therapy (e.g., Tenofovir + abstinence).
---
#### **15. Topical Antibiotics for PH-Driven Edema**
- **Misuse**: Neosporin for scrotal edema (Case 40) without systemic PH management.
- **Outcome**: Temporary relief but recurrence due to unaddressed hypoalbuminemia/PH.
- **Solution**: Address root cause ( diuretics).
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### **Key Takeaways for Rural Practice:**
1. **Scrotal edema** and **lymphocytic ascites** are red flags for advanced PH.
2. **Mixed etiology ascites** (high SAAG + high protein) demands cytology/PCR.
3. **Microcytic anemia** in CLD warrants iron studies, not just chronic disease labeling.
4. **Beta-blockers** require endoscopy-guided risk stratification.
5. **LAMA decisions** must integrate palliative care and family education.
**Conclusion**: These novel insights highlight the need for context-specific guidelines in rural PH management, emphasizing diagnostics (SAAG-cytology synergy), tailored therapies (albumin over protein powders), and ethical care frameworks.
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