Korean J Gastroenterol.  2010 Sep;56(3):135-143. 10.4166/kjg.2010.56.3.135.

Recent Advances in Diagnosis of Portal Hypertension

• Lee TH

• KMID: 948776
• DOI: http://doi.org/10.4166/kjg.2010.56.3.135

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.

Keyword

Hypertension, Portal; Diagnosis

MeSH Terms

Elasticity Imaging Techniques
Endosonography
Humans
Hypertension, Portal/*diagnosis/ultrasonography
Magnetic Resonance Imaging
Tomography, X-Ray Computed
Ultrasonography, Doppler
Venous Pressure

Figure

• 

  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.

Reference

1. Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology. 2001; 120:726–748.

2. Reynold TB, Redeker AG, Geller HM. Wedged hepatic venous pressure; a clinical evaluation. Am J Med. 1957; 22:341–350.

3. Boyer TD, Triger DR, Horisawa M, Redeker AG, Reynolds TB. Direct transhepatic measurement of portal vein pressure using a thin needle. Comparison with wedged hepatic vein pressure. Gastroenterology. 1977; 72:584–589.

4. Boyer TD. Transjugular intrahepatic portosystemic shunt: current status. Gastroenterology. 2003; 124:1700–1710.

5. Shah VH, Kamath PS. Portal hypertension and gastrointestinal bleeding. Sleisenger and Fordtran's gastrointestinal and liver disease: pathophysiology/diagnosis/management. 9th ed.Philadelphia: Saunders;2010. p. 1495–1496.

6. Keiding S, Solvig J, Gr⊘ nbaek H, Vilstrup H. Combined liver vein and spleen pulp pressure measurements in patients with portal or splenic vein thrombosis. Scand J Gastroenterol. 2004; 39:594–599.

7. Myers JD, Taylor WJ. An estimation of portal venous pressure by occlusive catheterization of a hepatic venule. J Clin Invest. 1951; 30:662–663.

8. Parikh S. Hepatic venous pressure gradient: worth another look? Dig Dis Sci. 2009; 54:1178–1183.

9. Thalheimer U, Leandro G, Samonakis DN, Triantos CK, Patch D, Burroughs AK. Assessment of the agreement between wedge hepatic vein pressure and portal vein pressure in cirrhotic patients. Dig Liver Dis. 2005; 37:601–608.

10. Armonis A, Patch D, Burroughs A. Hepatic venous pressure measurement: an old test as a new prognostic marker in cirrhosis? Hepatology. 1997; 25:245–248.

11. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology. 2004; 39:280–282.

12. Tandon P, Wongcharatrawee S, Ripoll C, Garcia-Tsao G, Groszmann RJ. The hepatic venous pressure gradient (HVPG): interobserver reliability among experienced and non-experienced observers [Abstract]. Gastroenterology. 2007; 132(suppl 2):A803.

13. Garcia-Tsao G, Bosch J, Groszmann RJ. Portal hypertension and variceal bleeding–unresolved issues. Summary of an American Association for the study of liver Diseases and European Association for the study of the liver single-topic conference. Hepatology. 2008; 47:1764–1772.

14. Groszmann RJ, Garcia-Tsao G, Bosch J, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005; 353:2254–2261.

15. Ripoll C, Groszmann R, Garcia-Tsao G, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology. 2007; 133:481–488.

16. Groszmann RJ, Bosch J, Grace ND, et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology. 1990; 99:1401–1407.

17. Turnes J, Garcia-Pagan JC, Abraldes JG, Hernandez-Guerra M, Dell'Era A, Bosch J. Pharmacological reduction of portal pressure and longterm risk of first variceal bleeding in patients with cirrhosis. Am J Gastroenterol. 2006; 101:506–512.

18. Choi YJ, Baik SK, Park DH, et al. Comparison of Doppler ultrasonography and the hepatic venous pressure gradient in assessing portal hypertension in liver cirrhosis. J Gastroenterol Hepatol. 2003; 18:424–429.

19. Bruix J, Castells A, Bosch J, et al. Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure. Gastroenterology. 1996; 111:1018–1022.

20. Capussotti L, Ferrero A, Viganò L, Muratore A, Polastri R, Bouzari H. Portal hypertension: contraindication to liver surgery? World J Surg. 2006; 30:992–999.

21. Tandon P, Garcia-Tsao G. Portal hypertension and hepatocellular carcinoma: prognosis and beyond. Clin Gastroenterol Hepatol. 2006; 4:1318–1319.

22. Burroughs AK, Groszmann R, Bosch J, et al. Assessment of therapeutic benefit of antiviral therapy in chronic hepatitis C: is hepatic venous pressure gradient a better end point? Gut. 2002; 50:425–427.

23. Roberts S, Gordon A, McLean C, et al. Effect of sustained viral response on hepatic venous pressure gradient in hepatitis C-related cirrhosis. Clin Gastroenterol Hepatol. 2007; 5:932–937.

24. Rincon D, Ripoll C, Lo Iacono O, et al. Antiviral therapy decreases hepatic venous pressure gradient in patients with chronic hepatitis C and advanced fibrosis. Am J Gastroenterol. 2006; 101:2269–2274.

25. de Franchis R; On behalf of the Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010; 53:762–768.

26. Kleber G, Sauerbruch T, Fischer G, Paumgartner G. Pressure of intraoesophageal varices assessed by fine needle puncture: its relation to endoscopic signs and severity of liver disease in patients with cirrhosis. Gut. 1989; 30:228–232.

27. Sarin SK, Sethi KK, Nanda R. Measurement and correlation of wedged hepatic, intrahepatic, intrasplenic and intravariceal pressures in patients with cirrhosis of liver and non-cirrhotic portal fibrosis. Gut. 1987; 28:260–266.

28. Rigau J, Bosch J, Bordas JM, et al. Endoscopic measurement of variceal pressure in cirrhosis: correlation with portal pressure and variceal hemorrhage. Gastroenterology. 1989; 96:873–880.

29. Bosch J, Bordas JM, Rigau J, et al. Noninvasive measurement of the pressure of esophageal varices using an endoscopic gauge: comparison with measurements by variceal puncture in patients undergoing endoscopic sclerotherapy. Hepatology. 1986; 6:667–672.

30. El Atti EA, Nevens F, Bogaerts K, Verbeke G, Fevery J. Variceal pressure is a strong predictor of variceal haemorrhage in patients with cirrhosis as well as in patients with non-cirrhotic portal hypertension. Gut. 1999; 45:618–621.

31. Nevens F, Van Steenbergen W, Yap SH, Fevery J. Assessment of variceal pressure by continuous non-invasive endoscopic registration: a placebo controlled evaluation of the effect of terlipressin and octreotide. Gut. 1996; 38:129–134.

32. Nevens F, Sprengers D, Feu F, Bosch J, Fevery J. Measurement of variceal pressure with an endoscopic pressure sensitive gauge: validation and effect of propranolol therapy in chronic conditions. J Hepatol. 1996; 24:66–73.

33. Nevens F, Lijnen P, VanBilloen H, Fevery J. The effect of longterm treatment with spironolactone on variceal pressure in patients with portal hypertension without ascites. Hepatology. 1996; 23:1047–1052.

34. Gertsch P, Fischer G, Kleber G, Wheatley AM, Geigenberger G, Sauerbruch T. Manometry of esophageal varices: comparison of an endoscopic balloon technique with needle puncture. Gastroenterology. 1993; 105:1159–1166.

35. Pontes JM, Leitã o MC, Portela F, Nunes A, Freitas D. Endosonographic Doppler-guided manometry of esophageal varices: experimental validation and clinical feasibility. Endoscopy. 2002; 34:966–972.

36. Miller ES, Kim JK, Gandehok J, et al. A new device for measuring esophageal variceal pressure. Gastrointest Endosc. 2002; 56:284–291.

37. Miller LS, Dai O, Thomas A, et al. A new ultrasound-guided esophageal variceal pressure-measuring device. Am J Gastroenterol. 2004; 99:1267–1273.

38. Spahr L, Giostra E, Morard I, Mentha G, Hadengue A. Parendoscopic variceal pressure measurement: a reliable estimation of portal pressure in patients with cirrhosis? Gastroenterol Clin Biol. 2006; 30:1012–1018.

39. Henseler KP, Pozniak MA, Lee FT Jr, Winter TC 3rd. Three-dimensional CT angiography of spontaneous portosystemic shunts. Radiographics. 2001; 21:691–704.

40. Willmann JK, Weishaupt D, Bö hm T, et al. Detection of submucosal gastric fundal varices with multidetector row CT angiography. Gut. 2003; 52:886–892.

41. Matsumoto A, Kitamoto M, Imamura M, et al. Three-dimensional portography using multislice helical CT is clinically useful for management of gastric fundic varices. AJR Am J Roentgenol. 2001; 176:899–905.

42. Chung DJ, Kim YJ, Park YS, Lee TH, Kim CS, Kang HK. Evaluation of portal hypertension: a comparison of the use of liver perfusion CT with wedge hepatic venous pressure and hepatic venous pressure gradient. J Korean Radiol Soc. 2008; 59:173–181.

43. Sgouros SN, Vasiliadis KV, Pereira SP. Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding. Aliment Pharmacol Ther. 2009; 30:965–976.

44. Annet L, Materne R, Danse E, Jamart J, Horsmans Y, Van Beers BE. Hepatic flow parameters measured with MR imaging and Doppler US: correlations with degree of cirrhosis and portal hypertension. Radiology. 2003; 229:409–414.

45. Cottone M, D'Amico G, Maringhini A, et al. Predictive value of ultrasonography in the screening of non-ascitic cirrhotic patients with large varices. J Ultrasound Med. 1986; 5:189–192.

46. Kudo M, Zheng RQ, Kim SR, et al. Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. A multicenter collaborative study. Intervirology. 2008; 51(suppl 1):17–26.

47. Berzigotti A, Gilabert R, Abraldes JG, et al. Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J Gastroenterol. 2008; 103:1159–1167.

48. Singal AK, Ahmad M, Soloway RD. Duplex Doppler ultrasound examination of the portal venous system: an emerging novel technique for the estimation of portal vein pressure. Dig Dis Sci. 2010; 55:1230–1240.

49. Baik SK, Kim JW, Kim HS, et al. Recent variceal bleeding: Doppler US hepatic vein waveform in assessment of severity of portal hypertension and vasoactive drug response. Radiology. 2006; 240:574–580.

50. Kim MY, Baik SK, Park DH, et al. Damping index of Doppler hepatic vein waveform to assess the severity of portal hypertension and response to propranolol in liver cirrhosis: a prospective nonrandomized study. Liver Int. 2007; 27:1103–1110.

51. Zironi G, Gaiani S, Fenyves D, Rigamonti A, Bolondi L, Barbara L. Value of measurement of mean portal flow velocity by Doppler flowmetry in the diagnosis of portal hypertension. J Hepatol. 1992; 16:298–303.

52. Bolognesi M, Sacerdoti D, Merkel C, Bombonato G, Enzo E, Gatta A. Effects of chronic therapy with nadolol on portal hemodynamics and on splanchnic impedance indices using Doppler sonography: comparison between acute and chronic effects. J Hepatol. 1997; 26:305–311.

53. Iwao T, Oho K, Sakai T, et al. Noninvasive hemodynamic measurements of superior mesenteric artery in the prediction of portal pressure response to propranolol. J Hepatol. 1998; 28:847–855.

54. Berzigotti A, Casadei A, Magalotti D, et al. Renovascular impedance correlates with portal pressure in patients with liver cirrhosis. Radiology. 2006; 240:581–586.

55. Baik SK, Jee MG, Jeong PH, et al. Relationship of hemodynamic indices and prognosis in patients with liver cirrhosis. Korean J Intern Med. 2004; 19:165–170.

56. Kim MY, Baik SK, Park DH, et al. Damping index of Doppler hepatic vein waveform to assess the severity of portal hypertension and response to propranolol in liver cirrhosis: a prospective nonrandomized study. Liver Int. 2007; 27:1103–1110.

57. Baik SK. Assessment and current treatment of portal hypertension. Korean J Hepatol. 2005; 11:211–217.

58. Lee YT, Chan FK, Ching JY, et al. Diagnosis of gastroesophageal varices and portal collateral venous abnormalities by endosonography in cirrhotic patients. Endoscopy. 2002; 34:391–398.

59. Caletti G, Brocchi E, Baraldini M, Fervari A, Gibilaro M, Barbara L. Assessment of portal hypertension by endoscopic ultrasonography. Gastrointest Endosc. 1990; 36(2 suppl):S21–S27.

60. El-Saadany M, Jalil S, Irisawa A, Shibukawa G, Ohira H, Bhutani MS. EUS for portal hypertension: a comprehensive and critical appraisal of clinical and experimental indications. Endoscopy. 2008; 40:690–696.

61. Burtin P, Calès P, Oberti F, et al. Endoscopic ultrasono-graphic signs of portal hypertension in cirrhosis. Gastrointest Endosc. 1996; 44:257–261.

62. Boustiè re C, Dumas O, Jouffre C, et al. Endoscopic ultrasonography classification of gastric varices in patients with cirrhosis. Comparison with endoscopic findings. J Hepatol. 1993; 19:268–272.

63. Caletti G, Brocchi E, Zani L, Barbara L. The important role of EUS in the assessment of patients with portal hypertension. Gastrointest Endosc. 1988; 34:154–155.

64. Choudhuri G, Dhiman RK, Agarwal DK. Endosonographic evaluation of the venous anatomy around the gastroesophageal junction in patients with portal hypertension. Hepatogastroenterology. 1996; 43:1250–1255.

65. Irisawa A, Obara K, Sato Y, et al. EUS analysis of collateral veins inside and outside the esophageal wall in portal hypertension. Gastrointest Endosc. 1999; 50:374–380.

66. Faigel DO, Rosen HR, Sasaki A, Flora K, Benner K. EUS in cirrhotic patients with and without prior variceal hemorrhage in comparison with noncirrhotic control subjects. Gastrointest Endosc. 2000; 52:455–462.

67. Sandrin L, Fourquet B, Hasquenoph JM, et al. Transient elastography: a new noninvasive method for assessment of hepatic fibrosis. Ultrasound Med Biol. 2003; 29:1705–1713.

68. Fraquelli M, Rigamonti C, Casazza G, et al. Reproducibility of transient elastography in the evaluation of liver fibrosis in patients with chronic liver disease. Gut. 2007; 56:968–973.

69. Carrió n JA, Navasa M, Bosch J, Bruguera M, Gilabert R, Forns X. Transient elastography for diagnosis of advanced fibrosis and portal hypertension in patients with hepatitis C recurrence after liver transplantation. Liver Transpl. 2006; 12:1791–1798.

70. Vizzutti F, Arena U, Romanelli RG, et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology. 2007; 45:1290–1297.

71. Lemoine M, Nahon P, Ganne-Carrie N, et al. Liver stiffness measurement is correlated with hepatic venous pressure gradient in patients with uncomplicated alcoholic and/or HCV related cirrhosis [Abstract]. Hepatology. 2006; 44(suppl 1):204A.

72. Talwalkar JA, Yin M, Venkatesh S, et al. Feasibility of in vivo MR elastographic splenic stiffness measurements in the assessment of portal hypertension. AJR Am J Roentgenol. 2009; 193:122–127.

73. D'Arienzo A, Celentano L, Cimino L, et al. Per-rectal portal scintigraphy with technetium-99m pertechnetate for the early diagnosis of cirrhosis in patients with chronic hepatitis. J Hepatol. 1992; 14:188–193.

74. Wang JY, Chen SL, Chen FZ, et al. A non-invasive method for evaluating cirrhotic portal hypertension by administration of 99mTc-MIBI per rectum. J Gastroenterol Hepatol. 1995; 10:169–173.

75. Namwongprom S, Ekmahachai M, Vilasdechanon N, Chank-aew N, Boonyaprapa S, Chitapanarux T. Clinical usefulness of per-rectal portal scintigraphy by Tc-99m pertechnetate in evaluation of the severity of portal hypertension in cirrhotic patients. Singapore Med J. 2007; 48:1125–1130.

76. Gao L, Yang F, Ren C, Han J, Zhao Y, Li H. Diagnosis of cirrhotic portal hypertension and compensatory circulation using transsplenic portal scintigraphy with (99m)Tc-phytate. J Nucl Med. 2010; 51:52–56.