Portal hypertension differential diagnosis

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

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.

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