From the Guidelines
Evaluation for portal hypertension should begin with a thorough clinical assessment, laboratory testing, and imaging studies, prioritizing the use of liver stiffness measurement (LSM) by transient elastography (TE) with a cut-off of >20-25 kPa to diagnose clinically significant portal hypertension (CSPH) 1. The initial evaluation includes a complete blood count, liver function tests, coagulation profile, and serum albumin to assess liver function and identify potential complications.
- Abdominal ultrasound with Doppler is the first-line imaging study to evaluate portal vein patency, liver morphology, and detect ascites or splenomegaly.
- Endoscopy is essential to identify and grade esophageal or gastric varices, which are major complications of portal hypertension.
- For more detailed assessment, contrast-enhanced CT or MRI can provide information about collateral vessels and the extent of portal hypertension.
- Hepatic venous pressure gradient (HVPG) measurement is the gold standard for diagnosing and quantifying portal hypertension, with values above 10 mmHg indicating clinically significant portal hypertension, as supported by the study published in the Journal of the American College of Radiology 1. The presence of porto-systemic collaterals on ultrasound, CT or MRI is a highly specific sign of CSPH in patients with cirrhosis and should be routinely reported, as recommended by the EASL clinical practice guidelines 1. Liver biopsy may be necessary to determine the underlying cause of portal hypertension, particularly in cases where the etiology remains unclear after initial evaluation. This comprehensive approach allows for accurate diagnosis, risk stratification, and appropriate management planning for patients with portal hypertension, ultimately reducing morbidity, mortality, and improving quality of life.
- The use of non-invasive tests, such as liver elastography, can help reduce the need for invasive procedures and improve patient outcomes, as suggested by the study published in the Journal of Hepatology 1.
- A multidisciplinary approach, including collaboration between hepatologists, interventional radiologists, and interventional endoscopists, is essential for the management of portal hypertension and its complications, as recommended by the AGA clinical practice update 1.
From the Research
Evaluation of Portal Hypertension
The evaluation of portal hypertension involves various diagnostic tests and procedures. The following are some of the key methods used:
- Ultrasonography, preferably using the duplex technique, to disclose the patency of the portal venous system and signs of portal hypertension 2
- Upper gastrointestinal endoscopy to assess the presence and size of gastroesophageal varices, the appearance of the variceal wall, and the presence and severity of portal hypertensive gastropathy 2
- Hepatic vein catheterization to evaluate the presence of presinusoidal, sinusoidal, or postsinusoidal portal hypertension 2
- Liver biopsy and percutaneous transhepatic measurement of portal pressure in patients with presinusoidal portal hypertension 2
- Non-invasive tests, such as liver stiffness measurement (LSM) and spleen stiffness measurement (SSM), which have been proven accurate to predict clinically significant portal hypertension (CSPH) and high-risk esophageal varices 3, 4, 5
Diagnostic Criteria
The diagnostic criteria for portal hypertension include:
- Hepatic venous pressure gradient (HVPG) >5 mmHg, with values ≥10 mmHg indicating clinically significant portal hypertension (CSPH) 3, 4, 6
- Liver stiffness (LS) ≥25 kPa, which can be used as a surrogate of HVPG ≥10 mmHg to rule in CSPH 4
- Presence of signs of portal hypertension, such as splenomegaly, portocollateral vessels, and repermeabilization of the umbilical vein, on ultrasonography 2
Treatment and Management
The treatment and management of portal hypertension involve:
- Non-selective beta-blockers, such as carvedilol, to prevent the first hepatic decompensation event and reduce the risk of variceal bleeding 4, 6
- Endoscopic and pharmacological treatment of acute variceal bleeding and other complications of portal hypertension 6
- Transjugular intrahepatic portosystemic shunt (TIPS) in selected cases 6