Recent Advances in Diagnosis of Portal Hypertension

Tae Hee Lee

doi:10.4166/kjg.2010.56.3.135

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Lee: Recent Advances in Diagnosis of Portal Hypertension

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Korean J Gastroenterol 2010;56(3):135-143.

Published online: 21 February 2010

DOI: https://doi.org/10.4166/kjg.2010.56.3.135

Recent Advances in Diagnosis of Portal Hypertension

Tae Hee Lee, M.D.

Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea

Correspondence to: Tae Hee Lee, M.D. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Konyang University Hospital, 685, Gasuwon- dong, Seo-gu, Daejeon 302-718, Korea Tel: +82-42-600-9370, Fax: +82-42-600-9095 E-mail: green740@naver.com

Abstract

Complications of portal hypertension are major concerns in liver cirrhosis and significant morbidity and mortality mainly because of variceal bleeding, ascites, bacterial infections, hepatic encephalopathy, and hepatorenal syndrome. Various modalities in the diagnosis of portal hypertension are reviewed. The measurement of hepatic venous pressure gradient (HVPG) is a simple, invasive, reproducible method and regarded as the gold standard for the diagnosis and staging of portal hypertension. Other tests such as transient elastography, per-endoscopic variceal pressure measurement, endoscopic ultrasonography, and Doppler ultrasonography may be complementary and promising.

Keywords: Hypertension, Portal, Diagnosis

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Fig. 1.

The measurement of HVPG in healthy individuals (A) and in patients with portal hypertension due to sinusoidal causes (B) (Adopted from ref. 8). PVP, portal vein pressure; IVC, inferior vena cava; FHVP, free hepatic venous pressure; WHVP, wedged hepatic venous pressure; HVPG, hepatic venous pressure gradient.

Table 1.

Various Modalities for Diagnosis of Portal Hypertension

Invasive	PVP measurement
	Splenic pulp pressure measurement
	HVPG
	Esophageal variceal pressure measurement
Noninvasive	CT angiography
	MR angiography
	USG
	Doppler USG
	EUS
	LSM
	MR elastography of liver, spleen
	Portal scintigraphy using ^99m Tc

PVP, portal vein pressure; HVPG, hepatic venous pressure gradient; USG, ultrasonography; EUS, endoscopic ultrasonography; LSM, liver stiffness measurement

Table 2.

Utility of HVPG Measurements in Clinical Practice (Adopted from ref. 8)

1.	Diagnose portal hypertension (except due to pre-sinusoidal causes)
2.	Monitor drug therapy in patients with esophageal varices
3.	Predict the prognosis of patients with alcoholic hepatitis
4.	Assess disease progression and effects of therapy in patients with chronic hepatitis C
5.	Assess the feasibility of resection of hepatocellular cancer
6.	Prognosticate patients with portal hypertension and cirrhosis

HVPG, hepatic venous pressure gradient.

Table 3.

Pressure Measurements in Different Types of Portal Hypertension (Modified from ref. 8)

Type	Pre-sinusoidal	Sinusoidal	Post-sinusoidal
PVP	↑	↑	↑
FHVP	Normal	Normal	↑
WHVP	Normal	↑	↑
HVPG	Normal	↑	↑

PVP, portal vein pressure; FHVP, free hepatic venous pressure; WHVP, wedged hepatic venous pressure; HVPG, hepatic venous pressure gradient.

Table 4.

Hemodynamic Parameters Measured by Doppler Ultrasound (Adopted from ref. 48)

Hemodynamic parameters	Calculation
Portal blood flow (mL/min)	Cross sectional area of portal vein× velocity of portal blood flow
Cross-sectional area of portal vein	π× portal vein radius
Congestion index	π× portal vein radius²/mean portal flow velocity
Arterial pulsatility index	(Peak systolic velocity− end diastolic velocity)/mean velocity
Arterial resistive index	(Peak systolic velocity− end diastolic velocity)/peak systolic velocity
Liver vascular index	Velocity of blood flow in PV/hepatic artery PI
Portal hypertension index	Hepatic artery RI×0.69× splenic artery RI×0.87/velocity of blood flow in PV
Hepatic buffer index	Hepatic artery PI maximum change/PV blood volume maximum change

PV, portal vein; PI, pulsatilty index; RI, resistive index.

Table 5.

Comparison of Portal Pressure Measurement by Hepatic Vein Catheterization and Doppler US (Modified from ref. 48)

	Hepatic vein catheterization	Doppler US
Technique	Measures HVPG, difference between WHVP and FHVP	Portal and or arterial hemodynamics on the Doppler mode provide surrogate markers for PHT severity
Standardization of equipment, technique	Required	Required
Setting	Inpatient, Outpatient	Outpatient
Sedation	Required	Not required
Effect of gas, obesity, and ascites on the quality	None	Yes
Variation with normal breathing	No	Yes
Interobserver variation	None	Yes
Intra-observer variation	None	Yes
Reproducibility	Excellent	Not good
Expertise	Required	Required
Invasiveness	Yes	No
Safety	Prone to local complications	Excellent safety profile
Feasibility for serial measurements	No	Yes
Other advantages	Transjugular liver biopsy, TIPS shunt placement, and hepatic blood flow estimation	Assessment of (a) patency of TIPS shunt, (b) patency of PV, and (c) stenosis of hepatic artery post LT
Correlation with portal pressure (PP)	Excellent and currently is the gold standard for measurement of PP	Not good and future studies are needed to refine the technique

TIPS, transjugular intrahepatic portosystemic shunt; PV, portal vein; LT, liver transplantation; FHVP, free hepatic venous pressure;

WHVP, wedged hepatic venous pressure; HVPG, hepatic venous pressure gradient.

Table 6.

Potential Role of EUS in Portal Hypertension (Adopted from ref. 60)

1.	Visualization of portal and azygos venous system changes
2.	Assessment and diagnosis of gastric fundic varices
3.	Diagnosis of watermelon stomach
4.	Diagnosis and confirmation of ectopic duodenal varices
5.	Demonstration of rectal venous system changes
6.	Hemodynamic study of left gastric and azygos venous changes
7.	Assessment and assistance with endoscopic therapy of esophageal and gastric varices
8.	Assessment of pharmacological effects of drugs on portal venous pressure

Table 7.

EUS Abnormalities in Portal Hypertension (Adopted from ref. 60)

1.	Submucosal anechoic vascular structures in esophageal mucosa
2.	Curved, serpiginous, and dilated submucosal anechoic vascular structures in gastric mucosa
3.	Paraesophageal and paragastric collateral veins
4.	Thickening of gastric mucosal and submucosal layers
5.	Dilated azygos vein and increased blood flow
6.	Dilated portal vein
7.	Increased diameter of left gastric vein
8.	Dilated thoracic duct

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