Hepatic venous pressure gradient: Inaccurately estimates portal venous pressure gradient in alcoholic cirrhosis and portal hypertension

BACKGROUND Portal hypertension(PHT)in patients with alcoholic cirrhosis causes a range of clinical symptoms,including gastroesophageal varices and ascites.The hepatic venous pressure gradient(HVPG),which is easier to measure,has replaced the portal venous pressure gradient(PPG)as the gold standard for diagnosing PHT in clinical practice.Therefore,attention should be paid to the correlation between HVPG and PPG.METHODS Between January 2017 and June 2020,134 patients with alcoholic cirrhosis and PHT who met the inclusion criteria underwent various pressure measurements during transjugular intrahepatic portosystemic shunt procedures.Correlations were assessed using Pearson’s correlation coefficient to estimate the correlation coefficient(r)and determination coefficient(R^(2)).Bland-Altman plots were constructed to further analyze the agreement between the measurements.Disagreements were analyzed using paired t tests,and P values<0.05 were considered statistically significant.RESULTS In this study,the correlation coefficient(r)and determination coefficient(R2)between HVPG and PPG were 0.201 and 0.040,respectively(P=0.020).In the 108 patients with no collateral branch,the average wedged hepatic venous pressure was lower than the average portal venous pressure(30.65±8.17 vs.33.25±6.60 mmHg,P=0.002).Hepatic collaterals were identified in 26 cases with balloon occlusion hepatic venography(19.4%),while the average PPG was significantly higher than the average HVPG(25.94±7.42 mmHg vs 9.86±7.44 mmHg;P<0.001).The differences between HVPG and PPG<5 mmHg in the collateral vs no collateral branch groups were three cases(11.54%)and 44 cases(40.74%),respectively.CONCLUSION In most patients,HVPG cannot accurately represent PPG.The formation of hepatic collaterals is a vital reason for the strong underestimation of HVPG.

Pre-transjugular-intrahepatic-portosystemic-shunt measurement of hepatic venous pressure gradient and its clinical application: A comparison study

BACKGROUND It is controversial whether transjugular intrahepatic portosystemic shunt(TIPS)placement can improve long-term survival.AIM To assess whether TIPS placement improves survival in patients with hepaticvenous-pressure-gradient(HVPG)≥16 mmHg,based on HVPG-related risk stratification.METHODS Consecutive variceal bleeding patients treated with endoscopic therapy+nonselectiveβ-blockers(NSBBs)or covered TIPS placement were retrospectively enrolled between January 2013 and December 2019.HVPG measurements were performed before therapy.The primary outcome was transplant-free survival;secondary endpoints were rebleeding and overt hepatic ence-phalopathy(OHE).RESULTS A total of 184 patients were analyzed(mean age,55.27 years±13.86,107 males;102 in the EVL+NSBB group,82 in the covered TIPS group).Based on the HVPG guided risk stratification,70 patients had HVPG<16 mmHg,and 114 patients had HVPG≥16 mmHg.The median follow-up time of the cohort was 49.5 mo.There was no significant difference in transplant-free survival between the two treatment groups overall(hazard ratio[HR],0.61;95%confidence interval[CI]:0.35-1.05;P=0.07).In the high-HVPG tier,transplant-free survival was higher in the TIPS group(HR,0.44;95%CI:0.23-0.85;P=0.004).In the low-HVPG tier,transplantfree survival after the two treatments was similar(HR,0.86;95%CI:0.33-0.23;P=0.74).Covered TIPS placement decreased the rate of rebleeding independent of the HVPG tier(P<0.001).The difference in OHE between the two groups was not statistically significant(P=0.09;P=0.48).CONCLUSION TIPS placement can effectively improve transplant-free survival when the HVPG is greater than 16 mmHg.

Comparison of hepatic venous pressure gradient and endoscopic grading of esophageal varices

AIM: To determine the correlation between the hepatic venous pressure gradient and the endoscopic grade of esophageal varices.METHODS: From September 2009 to March 2013, a total of 176 measurements of hepatic venous pressure gradient (HVPG) were done in 146 patients. Each transjugular HVPG was measured twice, first using an end whole catheter (EH-HVPG), and then using a balloon catheter (B-HVPG). The HVPG was compared with the endoscopic grade of esophageal varices (according to the general rules for recording endoscopic findings of esophagogastric varices), which was recorded within a month of the measurement of HVPG.RESULTS: The study included 110 men and 36 women, with a mean age of 56.1 years (range, 43-76 years). The technical success rate of the pressure measurements was 100% and there were no complication related to the procedures. Mean HVPG was 15.3 mmHg as measured using the end hole catheter method and 16.5 mmHg as measured using the balloon catheter method. Mean HVPG (both EH-HVPG and B-HVPG) was not significantly different among patients with different characteristics, including sex and comorbid factors, except for cases with hepatocellular carcinoma (B-HVPG, P = 0.01; EH-HVPG, P = 0.02). Portal hypertension (&#x0003e; 12 mmHg HVPG) occurred in 66% of patients according to EH-HVPG and 83% of patients according to B-HVGP, and significantly correlated with Child&#x02019;s status (B-HVPG, P &#x0003c; 0.000; EH-HVGP, P &#x0003c; 0.000) and esophageal varies observed upon endoscopy (EH-HVGP, P = 0.003; B-HVGP, P = 0.006). One hundred and thirty-five endoscopies were performed, of which 15 showed normal findings, 27 showed grade 1 endoscopic esophageal varices, 49 showed grade 2 varices, and 44 showed grade 3 varices. When comparing endoscopic esophageal variceal grades and HVPG using univariate analysis, the P value was 0.004 for EH-HVPG and 0.002 for B-HVPG.CONCLUSION: Both EH-HVPG and B-HVPG showed a positive correlation with the endoscopic grade of esophageal varices, with B-HVPG showing a stronger correlation than EH-HVPG.

Hepatic venous pressure gradient measurement before TIPS for acute variceal bleeding

Hepatic venous pressure gradient(HVPG)is an independent predictor of variceal rebleeding in patients with cirrhosis.After pharmacological and/or endoscopic therapy,the use of a transjugular intrahepatic portosystemic shunt(TIPS)may be necessary in HVPG non-responders,but not in responders.Thus,HVPG measurement may be incorporated into the treatment algorithm for acute variceal bleeding,which further identifies the candidates that should undergo early insertion of TIPS or maintain the traditional pharmacological and/or endoscopic therapy.The potential benefits are to reduce the cost and prevent TIPS-related complications.

Computed tomography perfusion in liver and spleen for hepatitis B virus-related portal hypertension:A correlation study with hepatic venous pressure gradient

BACKGROUND Hepatic venous pressure gradient(HVPG)is the gold standard for diagnosis of portal hypertension(PH).However,its use can be limited because it is an invasive procedure.Therefore,it is necessary to explore a non-invasive method to assess PH.AIM To investigate the correlation of computed tomography(CT)perfusion of the liver with HVPG and Child-Pugh score in hepatitis B virus(HBV)-related PH.METHODS Twenty-eight patients(4 female,24 male)with gastroesophageal variceal bleeding induced by HBV-related PH were recruited in our study.All patients received CT perfusion of the liver before transjugular intrahepatic portosystemic stent-shunt(TIPS)therapy.Quantitative parameters of CT perfusion of the liver,including liver blood flow(LBF),liver blood volume(LBV),hepatic artery fraction,splenic blood flow and splenic blood volume were measured.HVPG was recorded during TIPS therapy.Correlation of liver perfusion with Child-Pugh score and HVPG were analyzed,and the receiver operating characteristic curve was analyzed.Based on HVPG(>12 mmHg vs≤12 mmHg),patients were divided into moderate and severe groups,and all parameters were compared.RESULTS Based on HVPG,18 patients were classified into the moderate group and 10 patients were classified into the severe group.The Child-Pugh score,HVPG,LBF and LBV were significantly higher in the moderate group compared to the severe group(all P<0.05).LBF and LBV were negatively associated with HVPG(r=-0.473,P<0.05 and r=-0.503,P<0.01,respectively),whereas splenic blood flow was positively associated with hepatic artery fraction(r=0.434,P<0.05).LBV was negatively correlated with Child-Pugh score.Child-Pugh score was not related to HVPG.Using a cutoff value of 17.85 mL/min/100 g for LBV,the sensitivity and specificity of HVPG≥12 mmHg for diagnosis were 80%and 89%,respectively.CONCLUSION LBV and LBF were negatively correlated with HVPG and Child-Pugh scores.CT perfusion imaging is a potential non-invasive quantitative predictor for PH in HBV-related liver cirrhosis.

Cirrhosis and portal hypertension: The importance of risk stratification, the role of hepatic venous pressure gradient measurement

Portal hypertension is the main prognostic factor in cirrhosis. The recent emergence of potent antiviral drugs and new algorithm of treatment for the management of complications due to portal hypertension have sensibly changed our perception of cirrhosis that can be now considered as a multistage liver disease whose mortality risk can be reduced by a tailored approachfor any stage of risk. Experts recommend to move toward a pathophysiological classification of cirrhosis that considers both structural and functional changes. The hepatic venous pressure gradient HVPG, is the reference gold standard to estimate the severity of portal hypertension in cirrhosis. It correlates with both structural and functional changes that occur in cirrhosis and carries valuable prognostic information to stratify the mortality risk. This article provides a general overview of the pathophysiology and natural course of cirrhosis and portal hypertension. We propose a simplified classification of cirrhosis based on low, intermediate and high mortality stage. The prognostic information provided by HVPG is presented according to each stage. A comparison with prognostic models based on clinical and endoscopic variables is discussed in order to evidence the additional contribute given by HVPG on top of other clinical and instrumental variables widely used in clinical practice.

Sildenafil does not influence hepatic venous pressure gradient in patients with cirrhosis

AIM： To investigate if sildenafil increases splanchnic blood flow and changes the hepatic venous pressure gradient （HVPG） in patients with cirrhosis. Phosphodiesterase type-5 inhibitors are valuable in the treatment of erectile dysfunction and pulmonary hypertension in patients with end-stage liver disease. However, the effect of phosphodiesterase type-5 inhibitors on splanchnic blood flow and portal hypertension remains essentially unknown. METHODS： Ten patients with biopsy proven cirrhosis （five females/five males, mean age 54：1：8 years） and an HVPG above 12 mmHg were studied after informed consent. Measurement of splanchnic blood flow and the HVPG during liver vein catheterization were done before and 80 min after oral administration of 50 mg sildenafil. Blood flow was estimated by use of indocyanine green clearance technique and Fick＇s principle, with correction for non-steady state. RESULTS： The plasma concentration of sildenafil was 222 ± 136 ng/mL 80 min after administration. Mean arterial blood pressure decreased from 77 ±7 mmHg to 66 ± 12 mmHg, P = 0.003, while the splanchnicblood flow and oxygen consumption remained unchanged at 1.14 ± 0.71 L/min and 2.3 ± 0.6 mmol/ min, respectively. Also the HVPG remained unchanged （18 ± 2 mmHg vs 16 ± 2 mmHg） with individual changes ranging from -8 mmHg to ±2 mmHg. In seven patients, HVPG decreased and in three it increased. CONCLUSION： In spite of arterial blood pressure decreases 80 min after administration of the phosphodiesterase type-5 inhibitor sildenafil, the present study could not demonstrate any clinical relevant influence on splanichnic blood flow, oxygen consumption or the HVPG.

Collagen proportionate area correlates to hepatic venous pressure gradient in non-abstinent cirrhotic patients with alcoholic liver disease

AIM To explore the relationship between collagen proportionate area(CPA) and portal hypertension-related clinical manifestations in alcoholic liver disease(ALD).METHODS Retrospective study with chart review of patients with ALD adressed to our center between January 2012 and December 2013 for a transjugular liver biopsy(TJLB) and hepatic hemodynamic study. Patients were included if they met the following criteria:(1) Medical indication for a liver biopsy in the setting of ALD;(2) recent(< 15 d) clinical, radiological, endoscopic and biological data available; and(3) estimated follow-up of at least 6 mo. Liver tissue from cirrhotic subjects obtained from transjugular liver biopsies was stained with Picro Sirius red and computer-assisted digital image analysis to determine fibrosis density using CPA was performed. RESULTS We included 61 patients with alcoholic ALD, subdivided in 41 active alcohol drinkers and 20 durably abstinent patients. Nine healthy liver donors served as controls. Mean CPA in patients with ALD was 7.1%, with no difference between active drinkers and abstinent patients(P = 0.17). Using a fibrosis density cutoff of 5%, we observed a positive correlation between high fibrosis density and the hepatic venous pressure gradient(HVPG) only in active drinkers(P = 0.02). At 12-mo of follow-up, in the group of active alcohol drinkers, patients reaching a composite outcome showed a higher HVPG value as compared to those who did not(18.5 mm Hg vs 14.5 mm Hg P < 0.04) whereas CPA values were similar(6.9% vs 11%, P = 0.23).CONCLUSION In active alcoholic ALD, CPA correlates to portal pressure but only HVPG predicts clinical events, pointing to the role of alcohol as a modulator of portal hypertension.

Correlation of pressure gradient in three hepatic veins with portal pressure gradient

BACKGROUND The liver is one of the most important organs in the human body,with functions such as detoxification,digestion,and blood coagulation.In terms of vascular anatomy,the liver is divided into the left and the right liver by the main portal vein,and there are three hepatic efferent veins(right,middle,and left)and two portal branches.Patients with impaired liver function have increased intrahepatic vascular resistance and splanchnic vasodilation,which may lead to an increase in the portal pressure gradient(PPG)and cause portal hypertension(PHT).In order to measure the increased pressure gradient of portal vein,the hepatic venous pressure gradient(HVPG)can be measured to reflect it in clinical practice.The accuracy of PPG measurements is directly related to patient prognosis.AIM To analyze the correlation between HVPG of three hepatic veins and PPG in patients with PHT.METHODS From January 2017 to December 2019,102 patients with PHT who met the inclusion criteria were evaluated during the transjugular intrahepatic portosystemic shunt procedure and analyzed.RESULTS The mean HVPG of the middle hepatic vein was 17.47±10.25 mmHg,and the mean HVPG of the right and left hepatic veins was 16.34±7.60 and 16.52±8.15 mmHg,respectively.The average PPG was 26.03±9.24 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.15 and 0.02(P=0.164);0.25 and 0.05(P=0.013);and 0.14 and 0.02(P=0.013),respectively.The mean wedged hepatic vein/venous pressure(WHVP)of the middle and left hepatic veins was similar at 29.71±12.48 and 29.1±10.91 mmHg,respectively,and the mean WHVP of the right hepatic vein was slightly lower at 28.01±8.95 mmHg.The mean portal vein pressure was 34.11±8.56 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.26 and 0.07(P=0.009);0.38 and 0.15(P<0.001);and 0.26 and 0.07(P=0.008),respectively.The average free hepatic venous pressure(FHVP)of the right hepatic vein was lowest at 11.67±5.34 mmHg,and the average FHVP of the middle and left hepatic veins was slightly higher at 12.19±4.88 and 11.67±5.34 mmHg,respectively.The average inferior vena cava pressure was 8.27±4.04 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.30 and 0.09(P=0.002);0.18 and 0.03(P=0.078);and 0.16 and 0.03(P=0.111),respectively.CONCLUSION Measurement of the middle hepatic vein HVPG could better represent PPG.Considering the high success rate of clinical measurement of the right hepatic vein,it can be the second choice.

Balloon dilatation for treatment of hepatic venous outflow obstruction following pediatric liver transplantation

AIM To assess the efficacy and safety of balloon dilatation for the treatment of hepatic venous outflow obstruction(HVOO) following pediatric liver transplantation.METHODS A total of 246 pediatric patients underwent liver transplantation at our hospital between June 2013 and September 2016. Among these patients, five were ultimately diagnosed with HVOO. Seven procedures(two patients underwent two balloon dilatation procedures) were included in this analysis. The demographic data,types of donor and liver transplant, interventional examination and therapeutic outcomes of these five children were analyzed. The median interval time between pediatric liver transplantation and balloon dilatation procedures was 9.8 mo(range: 1-32).RESULTS Five children with HVOO were successfully treated by balloon angioplasty without stent placement, with seven procedures performed for six stenotic lesions. All children underwent successful percutaneous intervention. Among these five patients, four were treated by single balloon angioplasty, and these patients did not develop recurrent stenosis. In seven episodes of balloon angioplasty across the stenosis, the pressure gradient was 12.0 ± 8.8 mm Hg before balloon dilatation and 1.1 ± 1.5 mm Hg after the procedures, which revealed a statistically significant reduction(P < 0.05). The overall technical success rate among these seven procedures was 100%(7/7), and clinical success was achieved in all five patients(100%). The patients were followed for 4-33 mo(median: 15 mo). No significant procedural complications or procedurerelated deaths occurred.CONCLUSION Balloon dilatation is an effective and safe therapeutic option for HVOO in children undergoing pediatric liver transplantation. Venous angioplasty is also recommended in cases with recurrent HVOO.

Extrahepatic aneurysm of the portal venous system and portal hypertension

Portal venous aneurysm (PVA) is a rare condition characterized by dilatation of the portal venous system. PVA manifestation of symptoms is varied and depends on the aneurysm size, location and related-complications, such as thrombosis. While the majority of reported cases of PVA are attributed to portal hypertension, very little is known about the condition's pathophysiology and clinical management remains a challenge. Here, we describe a 67-year-old woman who presented with complaint of dyspepsia and without a significant medical history, for whom PVA was incidentally diagnosed. The initial upper abdominal ultrasound revealed marked dilatation of the main portal vein, and subsequent contrast-enhanced computed tomography with angiography revealed a large aneurysm arising from the extrahepatic troncus portion of the portal vein, as well as gastroesophageal varices. A conservative approach using beta-blocker therapy was chosen. The patient was followed-up for 60 mo, during which time the asymptomatic status was unaltered and the PVA remained stable.

Hepatic venous pressure gradient measurement guiding nonselective beta-blocker therapy in a patient with clinically significant portal hypertension

Clinically significant portal hypertension(CSPH),defined as a hepatic venous pressure gradient(HVPG)≥10 mmHg,is an independent risk factor for decompensated events in patients with compensated cirrhosis.Currently,the Baveno VII consensus recommends using nonselective beta-blockers to treat compensated cirrhosis in patients with CSPH.Here,we report a unusual case of compensated cirrhosis with CSPH caused by hepatitis B,and we successfully adjust NSBBs drug treatment strategies monitoring by HVPG results and achieve response standards.Timely adjustment of NSBBs drug treatment strategies based on HVPG test results for patients with CSPH can improve the final response rate.

BRTO治疗后肝静脉压力梯度水平与肝硬化患者食管静脉曲张破裂出血的相关性研究

目的:探讨胃底静脉曲张(GV)患者行BRTO治疗前后肝静脉压力梯度(HVPG)水平在早期评估肝硬化患者食管静脉曲张破裂出血(EVB)发生风险的价值。方法:纳入2021年10月至2022年6月在我院接受BRTO术治疗的失代偿期肝硬化合并GV患者94例。收集患者临床资料;测量BRTO治疗前后HVPG水平。随访1年,根据患者是否发生EVB分为EVB组和对照组。采用Logistic回归分析BTRO术后EVB的相关因素;绘制ROC曲线分析BRTO术后HVPG水平在早期预测EVB的应用价值。结果:经过1年随访,94例患者共发生21例EVB,发生率为22.34%。临床资料显示EVB组患者Alb水平低于对照组,BRTO术后HVPG水平、男性比例高于对照组,差异具有统计学意义(P<0.05);Logistic回归分析显示,Alb水平(OR=0.807)是肝硬化患者BRTO术后近期发生EVB的独立保护因素(P<0.05),BRTO术后HVPG水平(OR=1.378)是肝硬化患者BRTO术后近期发生EVB的独立危险因素(P<0.05)。ROC曲线分析显示,BRTO术后HVPG水平在早期预测肝硬化患者发生EVB的敏感性为76.19%,特异性为82.19%,截点值为15.54 mmHg。结论:BRTO治疗GV后通过测定术后HVPG水平能够早期预警肝硬化患者EVB发生风险。

病毒性肝硬化患者肝脾脏硬度变化及与肝静脉压力梯度的相关性分析

目的:探究病毒性肝硬化患者肝脾脏硬度变化及与肝静脉压力梯度的相关性。方法:将2020年9月至2021年12月在兰州市第二人民医院超声科进行病毒性肝硬化治疗的82例患者作为研究对象,检测患者肝静脉压力梯度(hepatic venous pressure gradient,HVPG)和肝脾硬度。采用Pearson相关性分析评估病毒性肝硬化患者肝脾脏硬度变化与肝静脉压力梯度的相关性;并采用受试者工作特征(receiver operating characteristic,ROC)曲线评估肝脾脏硬度对肝硬化患者HVPG≥12 mmHg的预测价值。结果:病毒性肝硬化Child-pugh B级和Child-pugh C级患者HVPG(F=16.643,P<0.001)、肝脏硬度(F=14.403,P<0.001)、脾脏硬度(F=11.775,P<0.001)明显高于Child-pugh A级患者。患者HVPG与肝脏硬度和脾脏硬度均呈正相关(r=0.591,0.502,P<0.001)。肝脏硬度、脾脏硬度及联合分析预测肝硬化患者HVPG≥12 mmHg的ROC曲线下面积(area under the curve,AUC)分别为0.866、0.821、0.914。结论:病毒性肝硬化患者肝脾脏硬度与HVPG呈正相关,且对门静脉高压的无创诊断有一定预测价值。

特利加压素和奥曲肽对肝硬化患者HVPG、BFV的影响

目的研究特利加压素和奥曲肽对肝硬化(LC)患者肝静脉压力梯度(HVPG)及血流速度(BFV)的影响。方法回顾性分析2014年5月-2016年4月该院66例LC合并静脉曲张患者的资料,按治疗方法分为特利加压素组、奥曲肽组、联合组,于治疗前后测定肝静脉楔压(WHVP)、肝静脉游离压(FHVP)、HVPG、BFV。结果不同时间点的HVPG水平比较,差异有统计学意义(P<0.05);联合组、奥曲肽组与特利加压素组的WHVP、HVPG比较,差异有统计学意义(P<0.05),联合组与奥曲肽组的HVPG水平比较,差异有统计学意义(P<0.05);3组治疗后门静脉BFV比较,差异有统计学意义(P<0.05);联合组与特利加压素组、奥曲肽组的FHVP、HVPG、门静脉BFV变化趋势比较,差异有统计学意义(P<0.05)。结论特利加压素和奥曲肽均能降低HVPG,升高BFV,两者联合用药降低HVPG,升高BFV的作用优于单独用药。

Future directions of noninvasive prediction of esophageal variceal bleeding:No worry about the present computed tomography inefficiency

In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepatic venous pressure gradient(HVPG)and endoscopy with noninvasive methods for predicting esophageal variceal bleeding.The risk factors for bleeding were the size of the varices,the red sign and the Child-Pugh score.The intrinsic core factor that drove these changes was the HVPG.Therefore,the present studies investigating noninvasive methods,including computed tomography,magnetic resonance imaging,elastography,and laboratory tests,are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes,such as bleeding.A single parameter is usually not enough to construct an efficient model.Therefore,multiple factors were used in most of the studies to construct predictive models.Encouraging results have been obtained,in which bleeding prediction was partly reached.However,these methods are not satisfactory enough to replace invasive methods,due to the many drawbacks of different studies.There is still plenty of room for future improvement.Prediction of the precise timing of bleeding using various models,and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.

内镜超声在肝硬化门脉高压症诊治中的研究进展

内镜超声(endoscopic ultrasound,EUS)的发展及创新扩大了其在肝脏疾病诊治中的作用,EUS不仅被广泛应用于胆胰疾病的诊治,其在肝实质和门脉系统疾病中的应用也在迅速发展。本文回顾相关文献,概述了EUS在肝硬化门脉高压症的诊断及其并发症治疗中的研究现状及前景,重点介绍EUS引导下肝活检、EUS引导下门静脉压力梯度测量及EUS引导下胃静脉曲张治疗的研究进展。目前的数据表明:EUS引导下肝活检安全有效,在取样充分性上可与传统活检方式相媲美,而且术后恢复更快、疼痛程度更低。EUS引导下门静脉压力梯度测量较肝静脉压力梯度更准确地反映以窦前性门脉高压为主疾病的门静脉压力的程度,适用疾病更广。与常规内镜相比,EUS引导下血管介入术治疗胃静脉曲张优势众多,其中EUS引导弹簧圈联合组织胶治疗比单独使用弹簧圈或组织胶治疗更有效、并发症更少。

Portal hypertension in patients with nonalcoholic fatty liver disease:Current knowledge and challenges

Portal hypertension(PH)has traditionally been observed as a consequence of significant fibrosis and cirrhosis in advanced non-alcoholic fatty liver disease(NAFLD).However,recent studies have provided evidence that PH may develop in earlier stages of NAFLD,suggesting that there are additional pathogenetic mechanisms at work in addition to liver fibrosis.The early development of PH in NAFLD is associated with hepatocellular lipid accumulation and ballooning,leading to the compression of liver sinusoids.External compression and intraluminal obstacles cause mechanical forces such as strain,shear stress and elevated hydrostatic pressure that in turn activate mechanotransduction pathways,resulting in endothelial dysfunction and the development of fibrosis.The spatial distribution of histological and functional changes in the periportal and perisinusoidal areas of the liver lobule are considered responsible for the pre-sinusoidal component of PH in patients with NAFLD.Thus,current diagnostic methods such as hepatic venous pressure gradient(HVPG)measurement tend to underestimate portal pressure(PP)in NAFLD patients,who might decompensate below the HVPG threshold of 10 mmHg,which is traditionally considered the most relevant indicator of clinically significant portal hypertension(CSPH).This creates further challenges in finding a reliable diagnostic method to stratify the prognostic risk in this population of patients.In theory,the measurement of the portal pressure gradient guided by endoscopic ultrasound might overcome the limitations of HVPG measurement by avoiding the influence of the pre-sinusoidal component,but more investigations are needed to test its clinical utility for this indication.Liver and spleen stiffness measurement in combination with platelet count is currently the best-validated non-invasive approach for diagnosing CSPH and varices needing treatment.Lifestyle change remains the cornerstone of the treatment of PH in NAFLD,together with correcting the components of metabolic syndrome,using nonselective beta blockers,whereas emerging candidate drugs require more robust confirmation from clinical trials.

Use of portal pressure studies in the management of variceal haemorrhage

Portal hypertension occurs as a complication of liver cirrhosis and complications such as variceal bleeding lead to significant demands on resources. Endoscopy is the gold standard method for screening cirrhotic patients however universal endoscopic screening may mean a lot of unnecessary procedures as the presence of oesophageal varices is variable hence a large time and cost burden on endoscopy units to carry out both screening and subsequent follow up of variceal bleeds. A less invasive method to identify those at high risk of bleeding would allow earlier prophylactic measures to be applied. Hepatic venous pressure gradient (HVPG) is an acceptable indirect measurement of portal hypertension and predictor of the complications of portal hypertension in adult cirrhotics. Varices develop at a HVPG of 10-12 mmHg with the appearance of other complications with HPVG > 12 mmHg. Variceal bleeding does not occur in pressures under 12 mmHg. HPVG > 20 mmHg measured early after admission is a significant prognostic indicator of failure to control bleeding varices, indeed early transjugular intrahepatic portosystemic shunt (TIPS) in such circumstances reduces mortality significantly. HVPG can be used to identify responders to medical therapy. Patients who do not achieve the suggested reduction targets in HVPG have a high risk of rebleeding despite endoscopic ligation and may not derive significant overall mortality benefit from endoscopic intervention alone, ultimately requiring TIPS or liver transplantation. Early HVPG measurements following a variceal bleed can help to identify those at risk of treatment failure who may benefit from early intervention with TIPS. Therefore, we suggest using HVPG measurement as the investigation of choice in those with confirmed cirrhosis in place of endoscopy for intitial variceal screening and, where indicated, a trial of B-blockade, either intravenously during the initial pressure study with assessment of response or oral therapy with repeat HVPG six weeks later. In those with elevated pressures, primary medical prophylaxis could be commenced with subsequent close monitoring of HVPG thus negating the need for endoscopy at this point. All patients presenting with variceal haemorrhage should undergo HVPG measurement and those with a gradient greater than 20 mmHg should be considered for early TIPS. By introducing portal pressure studies into a management algorithm for variceal bleeding, the number of endoscopies required for further intervention and follow up can be reduced leading to significant savings in terms of cost and demand on resources.

Usefulness of portal vein pressure for predicting the effects of tolvaptan in cirrhotic patients

AIM: To elucidate influencing factors of treatment response, then tolvaptan has been approved in Japan for liquid retention.METHODS: We herein conducted this study to clarify the influencing factors in 40 patients with decompensated liver cirrhosis complicated by liquid retention. Tolvaptan was administered at a dosage of 7.5 mg once a day for patients with conventional diuretic-resistant hepatic edema for 7 d. At the initiation of tolvaptan, the estimated hepatic venous pressure gradient (HVPG) value which was estimated portal vein pressure was measured using hepatic venous catheterization. We analyzed the effects of tolvaptan and influencing factors associated with treatment response.RESULTS: Subjects comprised patients with a median age of 65 (range, 40-82) years. According to the Child-Pugh classification, class A was 3 patients, class B was 19, and class C was 18. Changes from the baseline in body weight were -1.0 kg (P = 2.04 × 10-6) and -1.3 kg (P = 1.83 × 10-5), respectively. The median HVPG value was 240 (range, 105-580) mmH2O. HVPG was only significant influencing factor of the weight loss effect. When patients with body weight loss of 2 kg or greater from the baseline was defined as responders, receiver operating characteristic curve analysis showed that the optimal HVPG cutoff value was 190 mmH2O in predicting treatment response. The response rate was 87.5% (7/8) in patients with HVPG of 190 mmH2O or less, whereas it was only 12.5% (2/16) in those with HVPG of greater than 190 mmH2O (P = 7.46 × 10-4). We compared each characteristics factors between responders and non-responders. As a result, HVPG (P = 0.045) and serum hyaluronic acid (P = 0.017) were detected as useful factors.CONCLUSION: The present study suggests that tolvaptan in the treatment of liquid retention could be more effective for patients with lower portal vein pressure.