There are two questions that often bother patients with cirrhosis: 1) how to treat portal hypertension with gastrointestinal bleeding; 2) whether to surgically remove the spleen if there is portal hypertension without gastrointestinal bleeding, but with splenomegaly and hypersplenism. The portal vein is a confluence of the splenic vein and the superior mesenteric vein, and under normal circumstances the blood from the spleen and the intestines flows through the portal vein into the inferior vena cava and back into the heart. To make an analogy, the liver is a storehouse, and the portal vein is the way to enter the storehouse. If the portal vein is narrowed or blocked, a large amount of blood from the digestive tract and spleen cannot reach the liver and stagnates in the portal vein system, resulting in increased pressure in the portal vein, which is known as portal hypertension. There are many reasons for the increase of portal vein pressure, and in China, the main reasons are post hepatitis cirrhosis and schistosomal cirrhosis. I. Life-threatening hemorrhage After the blockage of this main channel of portal vein, its subordinate branch splenic vein is also not smooth, and there is no way out for the blood in the spleen, which leads to the enlargement of the spleen, and the function of spleen will be changed after stagnation for a period of time, which leads to the increase of the destruction of the formed components of the blood in the spleen, and the clinical manifestations are the lowering of the whole blood picture, the lowered immunity, the decreased resistance of the body, and the bleeding of the skin and gums, and so on. When portal hypertension persists, the stagnant blood flow in the portal vein must find another way out, and these ways out are the collateral circulation between the portal vein and the vena cava. Normally, these collateral branches rarely open because the main pathway is clear, but in portal hypertension, these collateral branches open and gradually dilate to divert blood and relieve portal hypertension. Of all the collateral circuits, the first to be affected, with the greatest pressure differences and the most pronounced alterations, are the veins located at the lower end of the esophagus at the base of the stomach. When portal vein blood is diverted through this pathway, a large number of twisted and dilated veins are left behind. Under certain conditions, these varicose veins can rupture, leading to life-threatening upper gastrointestinal hemorrhage. Treatment So, do all patients with portal hypertension need surgical treatment? Here we should firstly make clear the fact that since post-cirrhosis is the root cause of portal hypertension, and at the same time cirrhosis is irreversible, the treatment of portal hypertension is mainly aimed at the complications rather than the cause (except for liver transplantation). We can categorize patients with portal hypertension into three situations: no bleeding, acute hemorrhage and recovery after bleeding control, and the treatment is different in different situations. 1, there is no history of bleeding and only splenomegaly hypersplenism generally do not advocate prophylactic surgery, but there are 2 cases can be appropriately relaxed indications for surgery: (1) gastroscopy found that severe esophageal varices with erythema sign, and erythema sign area ratio is greater than 20%. (2) Splenomegaly hypersplenism restricts the patient’s life and work, and imposes a huge burden on family life and economy. 2.Acute hemorrhage is mainly treated with medication and endoscopy, and if it is not effective, it can also be treated with interventional therapy, which is generally not suitable for emergency surgery. Because the patient’s general condition, liver function and coagulation function are obviously deteriorated after hemorrhage, and they can’t withstand another blow of surgery, hasty surgery will only increase the risk of surgery and mortality, and nowadays non-surgical treatments can make the bleeding of the majority of patients be controlled, and pass through the dangerous period smoothly, and create systemic and local conditions for the prevention of rebleeding in the next step. 3, after bleeding control and recovery of the patient’s general condition and liver function gradually improve, then you can consider early surgical treatment, waiting too long may lead to re-bleeding. Data show that once upper gastrointestinal bleeding occurs in patients with portal hypertension, the rate of rebleeding within one year can reach 60%~70%, and the rate of rebleeding within two years is close to 100%, the mortality rate of the first bleeding is 40%~70%, and the mortality rate of each bleeding thereafter will be higher. Moreover, each hemorrhage will cause further damage to liver function and eventually lead to liver failure. Therefore, timely surgical treatment can bring many benefits to patients, including: ① the possibility of rebleeding is significantly reduced, which not only avoids the damage to the liver or other organs caused by each bleeding, but also saves the high cost of each treatment. ② Hypersplenism is improved, and white blood cell and platelet counts are significantly improved. ③ The portal vein pressure is moderately reduced, which significantly improves the gastrointestinal function and the nutritional level of the body, and at the same time facilitates the prevention and treatment of ascites. ④ Because the liver function tends to stabilize and improve, the quality of life will be significantly improved. There are two types of surgical methods, namely, shunt surgery and interruption of flow, each with its own advantages and disadvantages. Shunt surgery is to reduce the portal vein pressure by rerouting the blood flow, so as to achieve the purpose of hemostasis, with large surgical trauma, many complications, high requirements on liver function, and easy to produce hepatic encephalopathy after the operation, so the clinical application is limited. Dissection is to achieve hemostasis by blocking the fundic varices of the lower esophagus while preserving the natural shunt chain of the parietal esophagus, which is less traumatic, with fewer complications, lower requirements for liver function, and fewer hepatic encephalopathies. With the in-depth study of the anatomy of portal vein system and the improvement of surgical techniques in recent years, the rebleeding rate after the flow-disconnecting operation has been significantly reduced, basically reaching the level of shunt operation, so flow-disconnecting operation has become the mainstream operation for the surgical treatment of portal hypertension in China. For patients with recurrent gastrointestinal bleeding and poor liver function, who cannot tolerate flow-breaking surgery and shunt surgery, liver transplantation can be chosen if the economic condition permits.