of the patient’s functional intravascular volume status Patients with portal hypertension are at high risk of infectious complications, such as spontaneous bacterial peritonitis in patients with ascites Indeed, an underlying infection is often the cause for a sudden clinical deterioration Hematologic complications are generally, but not completely, related to splenomegaly, and patients may present with thrombocytopenia, leukopenia, and anemia Coagulopathies are often present, but are secondary to the underlying liver disease and liver failure, as opposed to the portal hypertension itself When the patient is not actively bleeding, these hematologic abnormalities should not be treated aggressively as treatment may result in hypervolemia and place a patient at higher risk for GI bleeding A provider should not attempt to correct thrombocytopenia and anemia to normal levels Active and life-threatening bleeding should be treated aggressively with blood products The management of GI bleeding and transfusion parameters are discussed in the GI bleeding section of this chapter Pulmonary complications include hepatopulmonary syndrome and portopulmonary hypertension Hepatopulmonary syndrome occurs when there is an increase in the levels of vasoactive agents, causing pulmonary vasodilation and subsequent ventilation–perfusion mismatch There is also likely a degree of venous–arterial shunting within the pulmonary vasculature Both can result in hypoxemia Portopulmonary hypertension may also occur and likely results from vascular remodeling and endothelial cell dysfunction Ultimately, significant pulmonary hypertension may result in right-sided heart failure Renal complications are secondary to the changes in circulatory physiology described above and may result in hepatorenal syndrome Ultimately, portal hypertension is a chronic and complex problem that requires a multidisciplinary team to manage Emergency management is directly related to the presenting complications The emergency provider must be familiar with the complex pathophysiology in patients with advanced portal hypertension as it directly affects the emergency management of conditions that may carry significant morbidity and mortality ACUTE VIRAL HEPATITIS Goals of Emergency Therapy