Non invasive evaluation of portal hypertension using transient elastography

Abstract

The development of portal hypertension is a common consequence of chronic liver diseases leading to the formation of esophageal and gastric varices responsible for variceal bleeding, associated with a high mortality rate, as well as other severe complications such as portosystemic encephalopathy and sepsis. Measurement of hepatic venous pressure gradient (HVPG) and upper GI endoscopy are considered the gold standards for portal hypertension assessment in patients with cirrhosis. However, both types of investigation are invasive and HVPG measurement is routinely available and/or performed with adequate standards only in expert centres. There is thus a need for non invasive methods able to predict, with acceptable diagnostic accuracy, the progression of portal hypertension toward the levels of clinically significant (i.e. HVPG ≥ 10 mmHg) and severe (HVPG ≥ 12 mmHg) as well as the presence and the size of oesophageal varices. Transient elastography (TE) is a novel non invasive technology that allows measuring liver stiffness and that has gained popularity over the past few years. Although TE has been initially proposed to assess liver fibrosis, a good correlation has been reported between liver stiffness values and HVPG as well as the presence of oesophageal varices, suggesting that it could be an interesting tool for the non invasive evaluation of portal hypertension. This review is aimed at discussing the advantages and limits of TE and the perspectives for its rationale use in clinical practice for the management of patients with portal hypertension.

Elastography, Spleen Size, and Platelet Count Identify Portal Hypertension in Patients With Compensated Cirrhosis

“…Indeed, in the training set, 14 patients (10.6%) originally evaluated were excluded due to technical failure of transient elastography, confirming previous observations. 19 New transient elastography probes (XL probe), as well as new sonoelastography methods, might overcome this limitation of transient elastography, 34 with the added advantage of improving the applicability of measurement of spleen stiffness, which is emerging as a novel noninvasive parameter closely correlating with HVPG and presence of EVs. 35,36 Second, the prevalence of EVs in our population of compensated patients was relatively low, which might represent a bias for the generalizability of our results 37 ; however, the prevalence of varices in the validation cohort was exactly as anticipated.…”

“…While the accuracy of LS in predicting CSPH seems good, its discriminative ability in the prediction of EVs appears inadequate. 19 The combination of different methods might ameliorate the accuracy of single tests by assessing different pathophysiological components of portal hypertension. Recently, the combination of 3 simple methods-LS, spleen size, and platelet count (LSPS)-in a single score showed high accuracy for diagnosing and ruling out EVs in patients with compensated hepatitis B virusϪrelated chronic liver disease 20 ; however, this score has not been tested for the prediction of CSPH and there are no data on its ability to identify varices in patients with different etiologies of liver disease.…”

Non-invasive diagnosis of esophageal varices after Baveno VI

“…The most commonly used method has been vibration-controlled transient elastography (TE) (FibroScan®; Echosens, Paris, France). LSM-TE has been extensively studied in the prediction of large varices with some variability in the results but in most studies showing a negative predictive value (NPV) above 90% (19)(20)(21). Nevertheless, studies were highly heterogeneous and this made it difficult to establish a defined threshold value that could be used to triage patients not needing endoscopy.…”

Hagen-Poiseuille’s law: The link between cirrhosis, liver stiffness, portal hypertension and hepatic decompensation

“…Liver stiffness is an independent predictor of hepatocellular carcinoma (HCC) outcome [24] . A number of recent studies have shown that transient elastography correlates well with HVPG [12,25] . These tests may be more predictive of post resection outcomes [10] .…”

“…There is the compensated stage, with a median survival of 12 years and the decompensated (variceal bleeding, hepatic encephalopathy and ascites) with a median survival of only two years [5] . In the cirrhotic patient, the hepatic venous pressure gradient, hepatic venous pressure gradient (HVPG) stands alone, in multiple logistic regression analysis, as the only independent variable predictive of post resection decompensation [6][7][8][9][10][11][12] . This pivotal role of HVPG is unexplained.…”