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

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

Liver cirrhosis is a progressive disease characterized by a continuum from compensated to decompensated stages. The development of portal hypertension is the main pathophysiological process in this clinical course. Clinically significant portal hypertension (CSPH) is one of the leading causes of complications, with the portal venous pressure gradient (PPGG) being the most powerful predictive factor for decompensation, showing a negative predictive value of 90% for PPG < 10 mmHg (1). In this context, nonselective beta-blockers (NSBBs) have proven effective in reducing the portal hypertension gradient and preventing variceal bleeding, with a reduction of >10% in HVPG considered clinically significant (2).
In our study, we aim to:
- Assess the safety and efficacy of portal pressure gradient measurement obtained via endoscopic ultrasound in patients diagnosed with liver cirrhosis who are indicated to start primary prophylaxis with non-cardioselective beta-blockers.
- Evaluate the acute hemodynamic response to intravenous propranolol through EUS-PPG measurement in patients diagnosed with liver cirrhosis.
- Identify patients who may benefit from NSBB treatment for primary prophylaxis to prevent decompensation using a strategy guided by EUS-PPG measurement.

Aims & Methods

Non-randomized, prospective, observational, single-center clinical trial including all patients at a tertiary care hospital (Hospital Virgen Macarena) who attend outpatient clinics or are hospitalized with a diagnosis of liver cirrhosis and are candidates for primary prophylaxis with NSBBs according to the Baveno VII guidelines. The following will be performed on all patients:
- Comprehensive laboratory tests: complete blood count, coagulation panel, liver function tests
- Complete Etiological study of liver disease.
- Abdominal ultrasound.
- FibroScan.

Results

Patient	Age	Sex	Etiology	Child-Pugh	MELD	Fibroscan	Platelets	HVPG pre	HVPG post
1	60	Male	Alcohol	B8	12	75	164.000	3 mmHg
2	67	Female	Alcohol	A5	8	19	108.000	3.75 mmHg
3	60	Female	Metabolic	A5	7	29	170.000	10.5 mmHg	4.75 mmHg
4	65	Male	Alcohol	B9	11	No	147.000	10.5 mmHg	2 mmHg

Four patients were included, whose characteristics are summarized in Table 1. Fifty percent were male (n=2), with a mean age of 63 ± 3.96 years. The etiology was alcoholic in 75% (n=3) and metabolic in 25% (n=1), with a mean FibroScan value (available in n=3) of 41 ± 29.87 kPa. Fifty percent (n=2) had decompensated liver function according to the Child-Pugh classification. The mean MELD score was 9.35 ± 2.38. The mean platelet count was 147,500 ± 27,921.

Fifty percent (n=2) had a normal pressure gradient, while the other 50% (n=2) had a gradient compatible with clinically significant portal hypertension (10.5 mmHg). These latter patients received the standard IV propranolol protocol (0.15 mg/kg body weight bolus administered over 10 minutes, with measurement taken 5 minutes later), showing a significant reduction >10% in both cases. No patient experienced complications during or immediately after the procedure.

Conclusion

The clinical efficacy of NSBBs is based on a significant reduction in portal pressure, estimated by measuring the PPG. However, the main limitation of NSBBs is the high interindividual variability in hemodynamic response. Therefore, the development of tools to identify patients most likely to benefit from beta-blocker therapy remains an unmet clinical need.

In this regard, measuring the portal pressure gradient before and after intravenous administration of an NSBB may help overcome these limitations and potentially predict the chronic hemodynamic response. This could serve as a strategy to guide therapy and identify patients who may benefit from it in a single hemodynamic study, substantially reducing the need for repeated measurements.

References

1. T. Reiberger, A. Puspok, M. Schoder, et al. Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr, 129 (2017), pp. 135–145.
2. L. Turco, C. Villanueva, V. La Mura, J.C. García-Pagán, T. Reiberger, J. Genescà, et al. Portal pressure reduction improves outcomes in patients with cirrhosis, with or without ascites: a meta-analysis. Clin Gastroenterol Hepatol, 18 (2020), pp. 313–327.

Introduction

Clinically significant portal hypertension (CSPH) in patients with advanced chronic liver disease (ACLD) is associated with increasing risk of decompensation and death. Several scores have been developed as non-invasive tests to assess portal hypertension (PH) severity, such as the novel hepatic venous pressure gradient (HVPG) score. This score, consisting of platelet count, total serum bilirubin, and international normalized ratio (INR), showed good sensibility in the prediction of severe PH.

Aims & Methods

The aim of this study is to evaluate the ability of HVPG score in the detection of PH in a cohort of patients with ACLD.
A retrospective study was conducted at the University of Naples and all patients, referred to our Liver Unit from 2012 to 2022, with compensated ACLD who underwent esophagogastroduodenoscopy (EGD) for portal hypertension assessment were enrolled. Exclusion criteria were patients < 18 years old, liver transplantation, treatment with NSBB, portal vein thrombosis and incomplete data. Clinical, biochemical, and imaging data were collected from medical records. Patients were stratified according to the presence of endoscopic signs of PH.

Results

Among 294 compensated ACLD patients who performed EGD, 204 subjects were enrolled (62.7% males, mean age 62 years) according to inclusion and exclusion criteria. The main etiologies of liver disease were HCV (39.2%), MAFLD (13.7%) and HBV (11.7%). One-hundred-eight patients (52.9%) showed endoscopic signs of PH (91 patients with esophageal varices, 13 subjects with gastric varices and 64 patients with portal hypertensive gastropathy). Patients with endoscopic signs of PH have higher HVPG score (14.14±1.62 vs 12.71±5.2 mmHg, p <0.001), higher spleen diameter (150±30.55 Vs 130±20.84 mm, p <0.001), lower platelet count (95*10³/cc vs 136*10³/cc, p<0.001) and lower platelets/spleen diameter ratio (682±397 vs 1090±604, p <0.01) than patients without signs of PH. Instead, liver stiffness was not different between the two groups (26±13.1 vs 23.7±9.96 kPa, p =0.233).
Among patients with endoscopic signs of PH, 11 (10.1%) patients experienced variceal bleeding after a mean of 29 months (range 124-2746 days); they had higher baseline HVPG score (14.82±0.93 vs 14.07±1.66 mmHg; p=0.04), higher spleen diameter (172±26.10 vs 150±30.23 mm; p=0.028) and lower PLT/spleen ratio (436±172 vs 710±405; p < 0.001) than patients who didn’t experience bleeding.

Conclusion

HVPG score is a simple tool for non-invasive prediction of PH and could be used to stratify the risk of bleeding in patients with ACLD. However, this score needs to be validated in larger cohorts.

References

Reiniš, J., Petrenko, O., Simbrunner, B., Hofer, B. S., Schepis, F., Scoppettuolo, M., ... & Reiberger, T. (2023). Assessment of portal hypertension severity using machine learning models in patients with compensated cirrhosis. Journal of Hepatology, 78(2), 390-400. DOI: 10.1016/j.jhep.2022.09.012

Introduction

Hepatic venous pressure gradient (HVPG) measurement is invasive. Non-invasive methods for evaluating the severity of portal hypertension in patients with transjugular intrahepatic portosystemic shunt (TIPS) are warranted.

Aims & Methods

This study aims to evaluate the efficacy of spleen stiffness in predicting HVPG and TIPS dysfunction. We performed a systematic review in PubMed, Embase and Cochrane databases, searching for studies comparing spleen stiffness measurements pre-TIPS and post-TIPS. The primary outcome was spleen stiffness. The secondary outcome was spleen stiffness in the context of TIPS dysfunction. The MD was used for continuous outcomes with their respective 95% confidence interval (CI). Heterogeneity was assessed using the Cochran Q test and I² statistics.

Results

The meta-analyses included 13 studies and 521 patients. There was a significant difference in spleen stiffness reduction after TIPS compared to baseline, measured by SSW m/s (MD -0.49; 95% CI -0.55 to -0.43; p<0.01; I²=0%) and by SSM kPa (MD -11.19; 95% CI -13.32 to -9.07; p<0.01; I²=0%). TIPS dysfunction was associated with increased spleen stiffness values (MD 0.35; 95% CI 0.24 to 0.45; p<0.01; I²=0%) compared to normal tips function similarly to those found in pre-TIPS patients.

Conclusion

Our study showed that spleen stiffness is a non-invasive measure to evaluate HPVG reduction after TIPS placement. Spleen stiffness may also be useful in monitoring TIPS dysfunction.

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