Non-invasive Measurement of Portal Pressure
- 41 Downloads
Purpose of Review
To provide an updated overview of the existing and emerging non-invasive diagnostic methods to assess portal hypertension.
Data on liver stiffness measurement confirmed that it is a mainstay for assessing the risk of clinically significant portal hypertension in patients with advanced chronic liver disease of any etiology. The Baveno criteria for identifying patients who can safely spare endoscopy have been validated in NASH and cholestatic liver disease. New expanded criteria and other simple non-invasive algorithms including MELD score or spleen stiffness have been proposed and can lead to a higher proportion of endoscopies without significantly increasing the risk of missing large esophageal varices. MR and CT improve the anatomical imaging of gastroesophageal varices and abdominal collaterals and dynamic imaging based on MR and able to quantify hepatic blood flow are in development. Contrast-enhanced ultrasound and methacetin breath test are emerging promising methods to estimate the HVPG non-invasively.
Several different non-invasive methods are now available and can be used in clinical practice to achieve a successful identification of patients with clinically significant portal hypertension in chronic liver disease. However, an exact estimation of HVPG is not available yet, and changes in portal pressure cannot yet be detected by non-invasive methods.
KeywordsLiver cirrhosis Ultrasound Elastography Magnetic resonance CEUS
Compliance with Ethical Standards
Conflict of Interest
Ahmed M.Elmahdy and Annalisa Berzigotti each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.•• Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310–35 Practical evidence-based guidance on the modern management of portal hypertension. CrossRefGoogle Scholar
- 5.•• de Franchis R, Baveno VI. Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–52 Summary of the most recent international consensus conference on portal hypertension. CrossRefGoogle Scholar
- 8.Thiele M, Madsen BS, Procopet B, Hansen JF, Moller LM, Detlefsen S, et al. Reliability criteria for liver stiffness measurements with real-time 2D shear wave elastography in different clinical scenarios of chronic liver disease. Ultraschall Med 2017;38(6):648–654.Google Scholar
- 13.• Dietrich CF, Bamber J, Berzigotti A, Bota S, Cantisani V, Castera L, et al. EFSUMB guidelines and recommendations on the clinical use of liver ultrasound elastography, Update 2017 (Long Version). Ultraschall Med. 2017;38(4):e48 Updated guidelines on the use of elastography in liver disease. CrossRefGoogle Scholar
- 18.• Petta S, Sebastiani G, Bugianesi E, Vigano M, Wong VW, Berzigotti A, et al. Noninvasive prediction of esophageal varices by stiffness and platelet in nonalcoholic fatty liver disease cirrhosis. Journal of hepatology. J Hepatol. 2018;69(4):878–85 First validation of the Baveno non-invasive criteria for avoiding endoscopy in patients with NASH. CrossRefGoogle Scholar
- 19.• Moctezuma-Velázquez C, Saffioti F, Tasayco-Huamán S, Casu S, Mason A, Roccarina D.V, et al. Non-invasive prediction of high-risk varices in patients with primary biliary cholangitis and primary sclerosing cholangitis. Am J Gastroenterol 2018. https://doi.org/10.1038/s41395-018-0265-7 First validation of the Baveno non-invasive criteria for avoiding endoscopy in patients with cholestatic liver disease.
- 25.•• Lens S, Alvarado-Tapias E, Marino Z, Londono MC, LL E, Martinez J, et al. Effects of all-Oral anti-viral therapy on HVPG and systemic hemodynamics in patients with hepatitis C virus-associated cirrhosis. Gastroenterology. 2017;153(5):1273–83 e1 Detailed description of portal pressure changes after modern antiviral therapy of HCV. CrossRefGoogle Scholar
- 33.Wagner M, Hectors S, Bane O, Gordic S, Kennedy P, Besa C, et al. Noninvasive prediction of portal pressure with MR elastography and DCE-MRI of the liver and spleen: preliminary results. J Magn Reson Imaging: JMRI. 2018;48(4):1091–1103.Google Scholar
- 34.• Palaniyappan N, Cox E, Bradley C, Scott R, Austin A, O'Neill R, et al. Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging. J Hepatol. 2016;65(6):1131–9 Proof of concept study showing the potential of quantitative MRI to assess portal pressure. CrossRefGoogle Scholar
- 35.Claudon M, Dietrich CF, Choi BI, Cosgrove DO, Kudo M, Nolsoe CP, et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultraschall Med. 2013;34(1):11–29.Google Scholar