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Portal hypertensive biliopathy
  1. Radha K Dhiman1,
  2. Arunanshu Behera2,
  3. Yogesh K Chawla1,
  4. Jang B Dilawari4,
  5. Sudha Suri3
  1. 1Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  2. 2Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  3. 3Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  4. 4Department of Gastroenterology, Inver Clyde Royal Hospital, Greenock, UK
  1. Correspondence to:
    Dr R K Dhiman
    Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India;rkpsdhiman{at}

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Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertension in the developing countries, and constitutes up to 40% of all patients with portal hypertension.1,2 EHPVO is a common cause of major upper-gastrointestinal bleeding among children.2–4 The most common presentation in children is well-tolerated variceal bleeding and splenomegaly. In adults, EHPVO is often recognised when evaluating for other disorders or with uncommon presentations such as jaundice, pruritus, acute cholecystitis-like syndrome, ascites and so on, resulting from prolonged portal hypertension.5–7 The portal vein in EHPVO is transformed into a cavernoma, which is a bunch of multiple collateral veins around the obstructed portion of portal vein (fig 1). Marked improvements in the management of variceal bleeding in patients with EHPVO have resulted in an improved survival, thus presenting with unusual symptoms in adulthood.

Figure 1

 Splenoportovenogram showing multiple collaterals (portal cavernoma) replacing the portal vein (arrows) in a patient with extrahepatic portal venous obstruction. The splenic vein is normal (arrowheads).

The reasons for EHPVO are obscure in approximately half of the patients. Omphalitis and intra-abdominal sepsis are the common causes in neonates and children. Adults develop EHPVO due to increased blood coagulability, local inflammation, intra-abdominal sepsis, myeloproliferative disorders, underlying cirrhosis, or tumours in the liver, bile ducts or pancreas.7,8,9,10

Gibson et al11 first reported the relationship between EHPVO and jaundice in 1965. Since then, several cases of obstructive jaundice due to common bile duct (CBD) obstruction caused by cavernomatous transformation of portal vein (portal cavernoma) have been described. Williams et al12 were the first to report cholangiographic changes caused by choledochal varices. We, for the first time, describe abnormalities on endoscopic retrograde cholangiography (ERC) in a prospective study.13 These abnormalities were similar to those of primary sclerosing cholangitis and …

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  • Competing interests: None.