Causes of Portal Hypertension: A High-Yield USMLE Review

Portal hypertension—an increase in pressure within the portal venous system—is a classic high-yield topic for the USMLE Step 1 and Step 2 exams. It often appears in GI, hepatic, and cardiovascular case-based questions.

In this post, we’ll break down its causes using a King of the Curve visual that separates etiologies by anatomical level—making it easy to remember and clinically relevant.

🏥 What Is Portal Hypertension?

Portal hypertension is defined as elevated pressure in the portal venous system, typically above 10 mmHg, leading to complications like varices, ascites, and splenomegaly.

It results from resistance to blood flow, which can occur before, within, or after the liver.

🔍 Etiology by Level

Level	Etiology
Prehepatic	Portal vein thrombosis Splenic vein thrombosis
Intrahepatic	Cirrhosis (most common cause) Schistosomiasis Sinusoidal Obstruction Syndrome (blockage of small hepatic veins)
Posthepatic	Budd-Chiari Syndrome Right Heart Failure Constrictive Pericarditis

🧪 USMLE-Style Question Example

Question:
A 42-year-old patient with a history of cirrhosis presents with ascites and esophageal varices. Which of the following best explains the patient's condition?

A. Increased renal sodium retention
B. Reduced hepatic artery perfusion
C. Portal venous system obstruction
D. Intra-alveolar hemorrhage

✅ Correct Answer: C — The patient has signs of portal hypertension, commonly due to intrahepatic obstruction (e.g., cirrhosis).

💡 Related Clinical Pearls

• Schistosomiasis is a leading cause in developing countries.

• Budd-Chiari syndrome often presents with hepatomegaly + ascites + abdominal pain.

• Cardiac causes can be confused with liver disease—especially right-sided heart failure.

🧠 Final Thoughts

Portal hypertension is more than a buzzword—it’s a diagnostic window into vascular, hepatic, and cardiac pathology. King of the Curve’s visual makes this complex system digestible and memorable, so you’re never caught off guard on exam day.

📲 Call-to-Action (CTA)

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