Portal Hypertension

Hepatic venous pressure gradient (HVPG) is the difference between wedged and free hepatic venous pressures and remains the reference standard for portal-pressure measurement. Portal hypertension is conventionally defined by HVPG at least 5 mmHg; CSPH is defined by HVPG at least 10 mmHg and is associated with development of varices and clinical decompensation. Nature+1NatureNoninvasive Assessment of Portal Hypertension in Chronic Liver Disease | Gastroenterology and Hepatology | Clinical Sciences | Health sciences | Topics | Nature Indexcdn clinicaltrialsClinical Study of the BreathID MCS System to train the algorithm ...

Use HVPG selectively when a direct hemodynamic measurement will resolve an important management question. Interpret a normal or low HVPG cautiously when presinusoidal disease is suspected, because wedged hepatic venous pressure measurement does not detect presinusoidal portal hypertension, including portal-vein obstruction. cdn clinicaltrialscdn clinicaltrialsClinical Study of the BreathID MCS System to train the algorithm ...

Treat ascites, variceal hemorrhage, and hepatic encephalopathy as decompensating events rather than as isolated findings; compensated versus decompensated status is a major prognostic and therapeutic branch. cdn clinicaltrialscdn clinicaltrialsGawrieh et al. August 5, 2021 - 1 - Non-invasive Evaluation of ... Acute gastrointestinal bleeding requires immediate hemodynamic assessment and source-directed endoscopic management rather than outpatient noninvasive risk stratification.

Obtain vibration-controlled transient elastography liver stiffness measurement (LSM) and platelet count in compensated advanced chronic liver disease. LSM below 15 kPa with platelets above 150 × 10^9/L rules out CSPH, whereas LSM at least 25 kPa confirms CSPH. cdn clinicaltrialscdn clinicaltrialsAssessing the safety of discontinuing non-selective beta- ... Patients between these boundaries require individualized risk assessment rather than binary classification from either test alone.

LSM reflects cumulative stiffness from fibrosis and portal hypertension in cirrhosis and correlates with HVPG; however, values may vary materially between transient-elastography systems and agreement decreases with higher body mass index. Follow patients with the same validated platform when serial LSM will influence management. Nature+1NatureComparison of two transient elastography (TE) systems for measuring liver stiffness in clinical practice | Scientific Reportscdn clinicaltrialsGawrieh et al. August 5, 2021 - 1 - Non-invasive Evaluation of ...

Spleen stiffness may add information when LSM is indeterminate. A spleen stiffness threshold of at least 21 kPa has been used to screen for CSPH, but this threshold should not replace the better-established LSM/platelet rule-out and rule-in criteria. Nature+1NatureClinically significant portal hypertension assessed by ...cdn clinicaltrialsAssessing the safety of discontinuing non-selective beta- ...

For compensated cirrhosis with CSPH, use a nonselective beta-blocker (NSBB) to prevent decompensation. Current consensus cited in the clinical literature places NSBBs first-line for this objective. clinicaltrialsclinicaltrialsStudy Details | NCT06594783 | Carvedilol Plus EVL or Not for the Primary Prevention of Esophageal Variceal Bleeding in Carvedilol Non-responders | ClinicalTrials.gov Carvedilol, propranolol, and nadolol reduce portal pressure, but agent selection must account for bradycardia, hypotension, fatigue, respiratory adverse effects, and the potential to worsen refractory ascites, hepatorenal syndrome, or hepatic encephalopathy. PubMedPubMedTransjugular intrahepatic portosystemic shunt and non-selective beta-blockers act as friends or foe in decompensated cirrhosis: A comparative review - PMC

For a compensated patient with high-risk esophageal varices who has a contraindication to or intolerance of NSBB therapy, perform endoscopic variceal ligation (EVL). EVL is an alternative in this setting rather than a routine add-on to tolerated NSBB therapy for primary prevention. clinicaltrialsclinicaltrialsStudy Details | NCT06594783 | Carvedilol Plus EVL or Not for the Primary Prevention of Esophageal Variceal Bleeding in Carvedilol Non-responders | ClinicalTrials.gov

Reassess the risk-benefit balance of NSBB therapy when circulatory intolerance, refractory ascites, hepatorenal syndrome, or recurrent encephalopathy develops. The relevant tradeoff is portal-pressure reduction versus adverse cardiovascular effects and potential deterioration in vulnerable decompensated patients. PubMedPubMedTransjugular intrahepatic portosystemic shunt and non-selective beta-blockers act as friends or foe in decompensated cirrhosis: A comparative review - PMC

For refractory ascites, large-volume paracentesis with human albumin is a first-line strategy cited by Baveno guidance; some patients require procedures every 2 weeks, while others require intervals of 4 to 6 weeks. Consider TIPS as an elective alternative or escalation strategy, recognizing that some patients will still require paracentesis after TIPS. nice org uknice org ukCirrhosis in over 16s: assessment and management (update)

TIPS is a minimally invasive radiologic portosystemic shunt that directly decompresses portal pressure. Established major indications include treatment of refractory ascites and secondary prophylaxis of esophageal variceal hemorrhage; additional uses include selected early treatment of esophageal variceal hemorrhage, Budd-Chiari syndrome, ectopic varices, and portal-vein thrombosis. PubMedPubMedTransjugular Intrahepatic Portosystemic Shunt: Indications, Contraindications, and Patient Work-Up - PMC

Before TIPS referral, evaluate whether expected decompression benefit outweighs the risk of hepatic encephalopathy and adverse outcomes in patients with cardiopulmonary or hepatic vulnerability. TIPS reduces variceal rebleeding and can control refractory ascites, but encephalopathy is a key tradeoff; NSBBs instead carry hemodynamic and respiratory tolerability constraints. PubMed+1PubMedTransjugular intrahepatic portosystemic shunt and non-selective beta-blockers act as friends or foe in decompensated cirrhosis: A comparative review - PMCPubMedTransjugular Intrahepatic Portosystemic Shunt: Indications, Contraindications, and Patient Work-Up - PMC

In noncirrhotic portal-vein thrombosis, long-term complications include gastrointestinal bleeding related to portal hypertension and recurrent thrombosis. NEJMNEJMRivaroxaban Prophylaxis in Noncirrhotic Portal Vein Thrombosis Confirm the vascular anatomy and distinguish this phenotype from cirrhotic portal hypertension because HVPG may not detect presinusoidal portal hypertension due to portal-vein obstruction. cdn clinicaltrialscdn clinicaltrialsClinical Study of the BreathID MCS System to train the algorithm ...

Rivaroxaban prophylaxis has been studied to reduce venous thromboembolism and portal-hypertension-related bleeding outcomes in noncirrhotic portal-vein thrombosis. NEJM+1NEJMRivaroxaban Prophylaxis in Noncirrhotic Portal Vein ThrombosisNEJMRivaroxaban Prophylaxis in Noncirrhotic Portal Vein ... Treatment selection should incorporate the competing risks of recurrent thrombosis and portal-hypertensive gastrointestinal bleeding rather than extrapolating directly from cirrhosis algorithms. NEJMNEJMRivaroxaban Prophylaxis in Noncirrhotic Portal Vein Thrombosis