Hep C Discussion Forum

Hi guys, I have seen at least 4 posts where patients have been told they have cirrhosis, on the basis of a palpable spleen and portal hypertension ( PH ). This is without a biopsy or Fibroscan. I'll explain why this may be incorrect.

Spleen come in all shapes and sizes. It is usually accepted that 12cms in length is the upper limit of normal. Up to 5% of patients may have a palpable splenic tip, particularly in slim females. There are dozens of causes for slight splenic enlargement apart from cirrhosis ( with PH ). If a spleen is palpable, an U/S or CT should be performed to get real measurements of splenic size.

Portal hypertension is a serious complication of cirrhosis. Again, there are many causes but we are only interested in HCV. PH only develops in cirrhosis (F4) and may take many years to develop. The bands of liver fibrosis block small branches of the portal vein causing increased resistance, so the pressure in the portal vein starts to rise. Back pressure is transmitted to the portal vein branches (splenic vein and superior mesenteric vein)- eventually splenic vein pressure rises and the spleen becomes passively enlarged. The portal vein dilates and this may be measured by U/S. The portal venous system is a 'closed' system, and does not usually communicate with the rest of the circulation (systemic). As pressure rises, 'relief valves' open in the form of old veins that close at birth. The most important are the veins in the lower oesophagus- as these dilate, they form oesophageal varices. These varices can be seen on oesophagoscopy (endoscopy) and they are likely to bleed. Death from bleeding varices is one of the most worrying complications of cirrhosis.

Portal hypertension cannot be diagnosed from a palpable spleen alone. A dilated portal vein on U/S or varices seen on Endoscopy confirm PH. High resolution MRI can show these varices around the stomach and lower oesophagus before they are clinically apparent . If none of these signs are present, I would not accept a diagnosis of Portal Hypertension!