Introduction

Endoscopic ultrasound (EUS) has emerged as a new tool in assessing portal hypertension (PH). EUS portal pressure measurement (EUS-PPG) was described in few studies using a compact manometer, but the use of a pressure transducer connected to a pressure measurement monitor was previously described in a very small number of patients. The comparative assessment of portal pressure measured by EUS and tranjugular route has not been done before. Our study aimed to compare the value of EUS-PPG and transjugular measurements (HVP, PPG) in patients with portal hypertension.

Aims & Methods

Patients with signs of PH on transabdominal imaging and need for haemodynamic and/or endoscopic assessment were included. Patients with platelet count <50000/µL and INR>2.5 were excluded. EUS was performed using a 22 G fine needle aspiration attached to a central venous pressure measurement monitor, and it evaluated the presence of gastrointestinal varices, portal vein (PV) diameter and pressure, median hepatic vein/inferior vena cava pressure. All patients had HVPG measurements through the transjugular approach under fluoroscopic guidance, and portal pressure was assessed in patients scheduled for postosystemic shunt (TIPS). The results obtained by the two methods were statistically analysed.

Results

We prospectively enrolled (January to December 2023) 19 patients of 50±14 years old, male to female ratio=2,1:1). The aetiology of PH was porto-sinusoidal vascular disease (n=3, 15%), alcohol cirrhosis (n=15,75%), viral cirrhosis (n=1,5%) and metabolic cirrhosis (n=1, 5%). The patients with cirrhosis had Child-Pugh class B or C in 50% of cases. The mean INR was 1.41and the mean platelet level was 122.000/mcL
EUS-PPG was technically successful in 18 patients (94%), with one failure attributed to obesity and important perihepatic ascites which limited the needle deep advancement. The mean EUS-PPG was 13.15 ± 5.48 mmHg. 73% of patients had oesophageal and/or gastric varices present. The mean PV diameter was 12.8 ± 2.7 mm.
HVPG measurements were technically performed in 18 cases (94%), the one exception was related to anatomical factors impeding hepatic vein catheterisation. Mean HVPG was 14.7 ± 5.26 mmHg and it was similar to EUS-PPG (p = 0.09), with strong Pearson correlation coefficient (r=0.88).
In patients scheduled for TIPS (n=10), mean PPG was 16±4,15 mmHg and it correlated with EUS-PPG (r=0,81).
No difference was observed between the patients performing measurements during TIPS under general anaesthesia and the group assessed under mild sedation with midazolam. No adverse effects were noted.

Conclusion

The measurements of PH by transjugular route or EUS are comparable. EUS-PPG measurement with 22G needle proved to be an accurate and safe technique. Further investigation is required to determine its indications in patients requiring endoscopic assessment of portal hypertension

Introduction

Hepatic venous pressure gradient (HVPG) represents the gold standard for the evaluation of portal hypertension (PH). HVPG > 10 mmHg defines clinically significant portal hypertension (CSPH), a condition that is independently associated with the occurrence of decompensation events. Portal pressure measurement is of fundamental importance for prognostic stratification and assessment of response to therapies. Indeed, a decrement of HVPG by 20% and/or < 10 mmHg reduces the decompensation risk. HVPG, however, indirectly measures PH and it may underestimate portal pressure gradient (PPG) in patients with pre-sinusoidal forms or with a pre-sinusoidal component of PH such in the case of initial stages of primary biliary cholangitis (PBC), non-alcoholic fatty liver disease (NAFLD), porto-sinusoidal vascular disorder (PSVD). Moreover, HVPG procedure is invasive, involves radiographic exposure, and requires use of intravenous contrast media. Endoscopic ultrasound (EUS)-guided PPG measurement has recently become available. This technique allows measurement of portal pressure directly in the portal vein system and theoretically overcomes HVPG limitations.

Aims & Methods

We investigated the safety and accuracy of EUS measurements as compared to HVPG in evaluating PPG in a cohort of patients with CSPH. In patients naïve to non-selective beta-blockers (NSBBs) hemodynamic response to therapy was also evaluated.
Consecutive outpatients with liver disease characterized by pre-sinusoidal forms of PH who presented specific sign(s) of CSPH (gastro-oesophageal varices and/or portosystemic collaterals) underwent HVPG and EUS-guided PPG measurements with Echotip Insight 25G device (Cook Ireland Ltd.). In patients naive to NSBBs, treatment was started and after its titration EUS-PPG measurement was repeated. Definition and severity of adverse events (AEs) were based on classification of Cotton et al.

Results

Between March 2022 and December 2022, fourteen patients (mean age 58 ± 15; 57% males; etiology NAFLD related-cirrhosis 21.4%, PBC 7.2%, PSVD 71.4%) were enrolled. Mean platelet count was 71.000 U/microliter with 21% of patients having platelet count < 50.000 U/microliter. A total of 18 EUS-guided PPG and 14 HVPG measurements were performed. EUS-PPG was technically successful in all cases, without any AEs and requirement for platelet transfusion. EUS-PPG mean value was 18.7 ± 3.4 mmHg versus 9 ± 4.4 mmHg of HVPG (p<0.0001). In four patients naive to NSBBs we repeated a new EUS-PPG measurement after drug titration. The average PPG value in these patients before and after NSBBs titration was respectively 19.7 (± 3.4) and 17 (± 2.7) mmHg, with one patient out of four who achieved a decrement of PPG > 20 %.

Conclusion

Direct EUS-guided PPG measurement is safe and significantly more reliable than HVPG in the evaluation of PH in patients with pre-sinusoidal forms of PH. This technique could be also used to assess hemodynamic response to therapy in these patients.

Disclosure

N/A

Introduction

Portal hypertension is a major complication of advanced chronic liver disease (ACLD) and is associated with gastro-oesophageal varices, a leading cause of morbidity and mortality. The British Society of Gastroenterology (BSG) recommends oesophagogastroduodenoscopy (OGD) for variceal screening in all patients with cirrhosis, which could result in a high volume of unnecessary procedures. Given increasing demands on NHS services and the need for cost-effective resource allocation, strategies to reduce unnecessary endoscopy are critical.
The Baveno VI and VII consensus workshops propose non-invasive criteria to optimise variceal screening. Baveno VI suggests that patients with a liver stiffness measurement (LSM) less than 20 kPa and a platelet count greater than 150×10⁹/L can safely avoid OGD. Baveno VII further refines this by recommending non-selective beta-blocker (NSBB) therapy in patients with clinically significant portal hypertension (CSPH), defined as LSM greater than 25 kPa, thereby eliminating the need for screening endoscopy in this group. For patients not clearly stratified by Baveno VI or VII criteria, splenic stiffness measurement (SSM) offers an additional non-invasive tool to refine risk assessment. Incorporating SSM in this intermediate-risk group may further reduce the need for OGD, with recent data showing a high negative predictive value for ​ruling out high-risk varices.

Aims & Methods

We aim to quantify the reduction in endoscopy burden achieved by applying Baveno VI and VII criteria in ACLD patients.
A retrospective analysis was conducted on 1,703 patients who underwent 1,802 FibroScans between January 1, 2024, and December 31, 2024. Patients were stratified based on LSM and platelet counts into the following categories:
1. BSG Criteria: All patients with LSM ≥10 kPa requiring OGD.
2. Baveno VI Criteria: Patients with LSM <20 kPa and platelet count ≥150×10⁹/L, for whom OGD could be safely avoided.
3. Baveno VII Criteria: Patients with CSPH (LSM ≥25 kPa) recommended for NSBB therapy without the need for screening OGD.
4. Patients requiring OGD: Those not meeting Baveno VI criteria and without CSPH.

Results

Liver stiffness distribution:
• <10 kPa: 1,534 patients
• 10–14.9 kPa: 136 patients
• 15–19.9 kPa: 44 patients
• 20–24.9 kPa: 31 patients
• ≥25 kPa: 57 patients
Impact of Adopting Baveno VI and VII:
• BSG Guidelines: 274 patients (LSM ≥10 kPa) would require OGD.
• Baveno VI: 149 patients (LSM <20 kPa, platelets ≥150) could avoid OGD.
• Baveno VII: 57 patients (LSM ≥25 kPa) would be managed with NSBB, avoiding OGD.
• Total Reduction: 206 out of 274 patients (~75%) could avoid OGD.

Conclusion

Adopting Baveno VI and VII criteria would significantly reduce the need for variceal screening endoscopy in ACLD patients. By applying these thresholds, up to 75% of OGDs could be avoided, optimising NHS resources and reducing patient burden. These findings support the routine use of non-invasive risk stratification in ACLD management.

References

1. Tripathi D, Stanley AJ, Hayes PC, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64(11):1680–1704. doi:10.1136/gutjnl-2015-309262
2. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–752. doi:10.1016/j.jhep.2015.05.022
3. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974. doi:10.1016/j.jhep.2021.12.022

Introduction

EUS-guided portal pressure gradient measurement (EUS-PPGm) would be a useful procedure in patients with liver diseases (1). However, there is scarcely data on the clinical relevance of this EUS-guided procedure.

Aims & Methods

We report our experience on EUS-PPGm focus on safety, clinical relevant findings, technical drawbacks and how to overcome them.
We used a therapeutic echoendoscope and a 25G dedicated needle as previously reported (1, 2). To minimize the risk of infection, periprocedural antibiotherapy was administered and the working channel of the echoendoscope was flushed with povidone-iodine.

Results

EUS-PPGm was performed in 30 patients, median age 42±3 yo. Indications: assessment of NAFLD, 25 patients; idiopathic portal hypertension, 3 patients; evaluation for curative therapy in hepatocellular carcinoma (HCC), 2 patients. Anticoagulants were withdrawn in 4 patients. EUS-guided bilobar liver biopsies (EUS-BLB) were also immediately performed in 26 patients (87%) with a 19G needle. EUS-PPGm was successfully obtained in 25/30 patients (83%). EUS-PPGm was >5 mmHg in 14/25 cases (56%). In idiopathic portal hypertension 3/3 patients. In NAFLD 10/22 patients (45%) without endoscopic and/or ultrasonographic signs of portal hypertension and without liver fibrosis on EUS-BLB. Mean time to obtain EUS-PPGm was 21±2 minutes. Mean time for EUS-PPGm plus EUS-BLB was 45±2 minutes. Idiopathic portal hypertension was assessed by this procedure with the complementary information given by the EUS-BLB. In the 2 patients with HCC, one patient did not have reliable results and, in the other, EUS-PPGm was useful ruling out portal hypertension and the patient was referred to curative surgery that was successfully carried out.
Technical drawbacks: In 5 cases (17%) EUS-PPGm was not obtained due to non-reliable measurements in 4 cases probably due to excesive use of the elevator and up&down wheel of the echoendoscope and bending of the needle, that would be avoided. In the fifth case the EUS-PPGm was not performed for exacerbating breathing movements that precluded the procedure for safety concerns. We experienced difficulty in punctioning the hepatic and the portal vein in one and two cases, respectively, having to transverse these vessels and repositioning the needle in the lumen of these veins. In one case the 25G needle passed in close proximity to the hepatic artery. We think dedicated 25G needles have more flexibility and penetrability than larger caliber needles and, probably could lead for a safer and easier procedure and could be more accurate in the puncture of narrow vessels in liver cirrhosis (3).
Adverse events: A self-limited bleeding from the cardias was immediately observed after one EUS-PPGm in a patient with idiopathic portal hypertension. One mild epigastric pain 2 day after a combined procedure was observed. No other adverse events were registered one month later.

Conclusion

EUS-guided PPGm, even when combined with EUS-BLB, seems safe providing useful clinical information. Almost half of patients affected with NAFLD have portal hypertension diagnosed precociously in reversible stages providing a useful tool in precision Medicine, especially in the setting of obesity pandemic. Idiopathic portal hypertension was confirmed by this procedure with the complementary information provided by the EUS-BLB. In the patient with HCC, EUS-PPGm rule out portal hypertension and allowed for curative surgery. There are technical aspects related to the needle and the position of the echoendoscope that could be useful to know to improve the safety and accuracy of this procedure.

References

(1) Samarasena J, Chang KJ. Endo-hepatology: A new paradigm. Endosc Ultrasound. 72018. p. 219-22.
(2) Hashimoto R, Chang KJ. Endoscopic ultrasound guided hepatic interventions. Dig Endosc. 2021;33(1):54-65.
(3) Romero-Castro, R; Carmona-Soria, I; Jimenez-Garcia, VA; et al. Endoscopic ultrasound-guided portal pressure gradient measurement: Improving its safety overcoming technical drawbacks. Endoscopy (In press).

Disclosure

Rafael Romero-Castro is consultant to Cook Medical since February, 28th, 2023.

Introduction

Endoscopic ultrasound (EUS) is an important tool for the evaluation of patients with common bile duct (CBD) dilation without obvious identified aetiology after ultrasonography (US), computed tomography (CT) and/or magnetic resonance cholangiopancreatography (MRCP).

Aims & Methods

The aim of this study was to evaluate the diagnostic performance of EUS for CBD dilation in patients with a negative initial study.
Retrospective, unicentric and cohort study including patients who underwent EUS for CBD dilation (diameter ≥7mm if intact anatomy or ≥10mm if prior cholecystectomy) in the absence of obvious pathology on prior imaging, including US, CT and/or MRCP, from January 2016 until June 2022. All EUS procedures were performed with a linear echoendoscope.

Results

Totally, 109 patients were included, 50 patients without symptoms or altered liver biochemistry (45.9%). Among the 41 patients with positive EUS, 33 patients had choledocholithiasis (30.3%), 6 chronic pancreatitis (5.5%) and 2 had ampullary cancer (1.8%). Older age was associated with positive EUS (median 79 vs 71 years, p=0.030). Patients with jaundice, cholelithiasis and altered liver biochemistry were 16.2 (p=0.002), 3.1 (p=0.024) and 2.9 (p=0.009) times more likely to have positive EUS, respectively.
A total of 53 patients underwent MRCP with a negative result (48.6%). In this group, 12 patients had a positive EUS, 10 had choledocholithiasis (18.9%) and 2 had chronic pancreatitis (3.8%). Of those, patients with abdominal pain and jaundice were 15.4 (p<0.001) and 20.0 (p=0.007) times more likely to have positive EUS, respectively. CBD diameter in MRCP was not associated with finding a causative lesion (p=0.473).
Considering only asymptomatic patients without altered liver biochemistry, CBD diameter ≥8.5mm, evaluated by CT, had a sensibility of 100% and specificity of 75% in predicting a positive EUS (AUC 0.734, p=0.048).

Conclusion

EUS is a useful diagnostic method for patients with unexplained CBD dilation, with a higher yield, even in patients with negative MRCP, and especially in patients with older age, symptoms such as abdominal pain and jaundice, cholelithiasis and/or altered liver biochemistry. CBD diameter evaluated by CT had a moderate discriminative ability in predicting a positive EUS in asymptomatic patients without altered liver biochemistry.

Introduction

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has gained popularity as an alternative to percutaneous biliary drainage for patients in whom endoscopic retrograde cholangiopancreatography (ERCP) has failed. Several studies have compared EUS-CDS versus ERCP for primary biliary decompression for distal malignant biliary obstruction (MBO). These studies have reported variable results and were limited because of small sample sizes.

Aims & Methods

The aim of this study was to compare EUS-CDS versus ERCP for primary biliary decompression in distal MBO. A prospective randomized controlled study conducted on patients with unresectable distal MBO. Enrolled patients were randomized to EUS-CDS or ERCP. Technical success was defined as the placement of the metal stent across the stricture site via the papilla (ERCP) or across the duodenum (EUS-CDS), along with the flow of the bile through the stent. Clinical success was defined as reduction of total serum bilirubin levels to less than half of the pretreatment level within 2 weeks. Patients were hospitalized and observed for early complications in the first 2 days. Laboratory investigation were repeated in regular out patients visits at 2, 4, 12 and 24 weeks or until death.

Results

From May 2021 to December 2022, a total of 62 patients were enrolled (28 EUS-CDS and 34 ERCP) and 54 completed the study (4 patients in each group have dropped out due to non-procedural related mortality within 2 weeks). There was 32 males and 22 females. Their median age was 64 years (45-82). Technical success rates were similar in both groups (100%). Clinical success rates were 95.8% (23/24) in EUS-CDS group and 93.3% (28/30) in ERCP group. There was no statistically significant difference in the median procedure time between EUS-CDS group (13 (IQR 7-32) mins) and ERCP group (16 (IQR 6-75) mins) (p=0.57). The rate of overall adverse events was not statistically significant between both groups (EUS-CDS 8.3%, ERCP 3.3%; p=0.45). In EUS-CDS group, post procedural biliary peritonitis was observed in 1 patient and post procedural bleeding that required endoscopic intervention with Argon plasma coagulation was observed in 1 patient. Post procedural mild pancreatitis was observed in 1 patient in ERCP group. For late adverse events, stent patency was similar, and none required reintervention in both groups.

Conclusion

EUS-CDS and ERCP had comparable levels of efficacy and safety for the primary palliation of unresectable distal MBO based on rates of technical, clinical success and over all adverse events.