Complications of Cirrhosis and Portal Hypertension
Portal hypertension
Cirrhosis complications include varices, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension, and hypersplenism. In children, growth failure and malnutrition are additional markers. Portal hypertension is suggested by splenomegaly, thrombocytopenia, varices, and ascites; ultrasound with Doppler is first-line, and endoscopy screens for varices in high-risk disease such as biliary atresia after Kasai.
Ascites and SBP
New ascites or fever in a child with ascites requires diagnostic paracentesis. Measure cell count with differential, albumin, protein, and culture. SBP is an ascitic polymorphonuclear cell count of at least 250/mm3; treat empirically with a third-generation cephalosporin and albumin if indicated, then tailor. Do not rely on ascitic protein; low protein increases SBP risk. Hyponatremia suggests advanced disease; creatinine may be falsely low because of low muscle mass.
HE and renal complications
Hepatic encephalopathy is clinical; ammonia correlates poorly. Treat precipitating factors: GI bleeding, infection, constipation, dehydration, and drugs. Hepatorenal syndrome is functional renal failure after volume challenge in advanced cirrhosis with ascites, after excluding shock, nephrotoxins, and intrinsic renal disease. Hepatopulmonary syndrome causes hypoxemia and platypnea-orthodeoxia; portopulmonary hypertension causes pulmonary arterial hypertension and right heart strain.
Traps
Do not diagnose SBP only by fever; it can be painless. Do not give NSAIDs. Avoid large-volume paracentesis without albumin in vulnerable children. Beta-blockers are used selectively and require caution in small children.
Worked example
A 10-year-old with biliary atresia cirrhosis presents with fever and distension. Diagnostic tap shows 600 WBC/mm3, 80% neutrophils (ANC 480). This meets SBP criteria. Start IV cefotaxime, send culture, give albumin for renal protection if high-risk, and evaluate for GI bleeding or another precipitant.
Rule of thumb: tap every new ascites and every fever with ascites.