Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: A review

Abstract

Portal hypertension is a severe syndrome that may derive from pre-sinusoidal, sinusoidal and post-sinusoidal causes. As a consequence, several complications (i.e., ascites, oesophageal varices) may develop. In sinusoidal portal hypertension, hepatic venous pressure gradient (HVPG) is a reliable method for defining the grade of portal pressure, establishing the effectiveness of the treatment and predicting the occurrence of complications; however, some questions exist regarding its ability to discriminate bleeding from nonbleeding varices in cirrhotic patients. Other imaging techniques (transient elastography, endoscopy, endosonography and duplex Doppler sonography) for assessing causes and complications of portal hypertensive syndrome are available and may be valuable for the management of these patients. In this review, we evaluate invasive and non-invasive techniques currently employed to obtain a clinical prediction of deadly complications, such as variceal bleeding in patients affected by sinusoidal portal hypertension, in order to create a diagnostic algorithm to manage them. Again, HVPG appears to be the reference standard to evaluate portal hypertension and monitor the response to treatment, but its ability to predict several complications and support management decisions might be further improved through the diagnostic combination with other imaging techniques.

Cirrhotic cardiomyopathy in the pre- and post-liver transplantation phase

“…Furthermore, the American Association for the Study of Liver Diseases recommends that all liver transplant candidates must undergo transthoracic echocardiography. Since, cardiac dysfunction in cirrhosis seems not to be associated with the severity of liver disease [27], both an accurate patient selection for liver transplant [28,29] and a precise investigation for cirrhotic cardiomyopathy are mandatory. Indeed, cirrhotic cardiomyopathy may influence the outcome after liver transplantation [30][31][32]; moreover, liver transplantation may be responsible for additional intra-and postoperative short-and long-term cardiac morbidity [33].…”

Prediction of esophageal varices in cirrhotic patients with apparent diffusion coefficient of the spleen

“…Previous studies reported a consistent relation between the splenic size and the portal venous pressure. This could be due to increased splenic red pulp blood volume from blood congestion in cirrhotic patients [1][2][3][4]. Other studies added that the most common parameters associated with varices include low platelet count, high prothrombin time, and increase in the Child-Pugh score.…”

“…Ultrasound transient elastography [10][11][12] and magnetic resonance elastography [13] are used to measure liver stiffness and predict esophageal varices but their results are preliminary and overlapping [10][11][12][13]. Endoscopy detects and grades the esophageal varices, Abdominal Imaging but it is an invasive procedure and is not accepted by many patients [1][2][3]. The hepatic vein pressure gradient is considered to be the gold standard for diagnosis of portal hypertension and esophageal varices in cirrhotic patients, but this is an invasive and expensive procedure that may be associated with potential complications [3,14].…”

“…Therefore, precise and early diagnosis of the esophageal varices is important. Non-invasive methods are needed to identify the esophageal varices in patients with chronic liver diseases [1][2][3][4]. Clinical examination is unreliable method for diagnosis of varices.…”

Phase‐contrast MR flow imaging: A tool to determine hepatic hemodynamics in rats with a healthy, fibrotic, or cirrhotic liver

“…Both of these modalities have been investigated whether measurements of portal parameters (eg. flow velocity or volume rate) may correlate with the degree of portal hypertension with variable results …”