Akbar FN, Darnindro N, Wardhani AA, Choirida SR, Saphira SN, Ismed G, Kshanti IAM, Mustika S, Hendarto H. Diagnostic challenges of clinically significant portal hypertension in geriatric metabolic dysfunction-associated fatty liver disease: A case report. World J Hepatol 2026; 18(2): 115063 [DOI: 10.4254/wjh.v18.i2.115063]
Corresponding Author of This Article
Femmy Nurul Akbar, MD, Associate Professor, Department of Internal Medicine, Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta, Ir H. Juanda Street No. 95 Ciputat District, South Tangerang 15412, Banten, Indonesia. femmy.nurul@uinjkt.ac.id
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Feb 27, 2026; 18(2): 115063 Published online Feb 27, 2026. doi: 10.4254/wjh.v18.i2.115063
Diagnostic challenges of clinically significant portal hypertension in geriatric metabolic dysfunction-associated fatty liver disease: A case report
Femmy Nurul Akbar, Nikko Darnindro, Annisa Ayu Wardhani, Safira Rosiana Choirida, Shafa Nada Saphira, Griffith Ismed, Ida Ayu Made Kshanti, Syifa Mustika, Hari Hendarto
Femmy Nurul Akbar, Annisa Ayu Wardhani, Safira Rosiana Choirida, Hari Hendarto, Department of Internal Medicine, Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta, South Tangerang 15412, Banten, Indonesia
Nikko Darnindro, Ida Ayu Made Kshanti, Department of Internal Medicine, Fatmawati General Hospital, South Jakarta 12430, Jakarta, Indonesia
Shafa Nada Saphira, Griffith Ismed, Faculty of Medicine, Universitas Trisakti, Jakarta 11620, Jakarta, Indonesia
Syifa Mustika, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang 65145, Jawa Timur, Indonesia
Author contributions: Akbar FN, Choirida SR, Wardhani AA, Saphira SN, and Ismed G contributed to manuscript writing and editing, and data collection; Akbar FN, Darnindro N, and Kshanti IAM contributed to data analysis; Akbar FN, Darnindro N, Hendarto H, and Mustika S contributed to conceptualization and supervision; all authors have read and approved the final manuscript.
Informed consent statement: Written informed consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All authors have no potential conflicts of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Femmy Nurul Akbar, MD, Associate Professor, Department of Internal Medicine, Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta, Ir H. Juanda Street No. 95 Ciputat District, South Tangerang 15412, Banten, Indonesia. femmy.nurul@uinjkt.ac.id
Received: October 13, 2025 Revised: November 12, 2025 Accepted: December 16, 2025 Published online: February 27, 2026 Processing time: 128 Days and 22.5 Hours
Abstract
BACKGROUND
Metabolic dysfunction-associated fatty liver disease (MAFLD) may progress to cirrhosis and lead to serious complications. Lipid accumulation, hepatocellular ballooning, and sinusoidal endothelial dysfunction increase intrahepatic vascular resistance, resulting in early clinically significant portal hypertension (CSPH). Although hepatic venous pressure gradient (HVPG) remains the gold standard, decompensated cirrhosis may yield deceptively low values. Transient elastography and platelet count provide supportive diagnostic evidence, yet obesity can overestimate disease severity. This report highlights the diagnostic challenge of CSPH, especially MAFLD in geriatric patients.
CASE SUMMARY
A 78-year-old woman with class I obesity, type 2 diabetes mellitus, and dyslipidemia presented with hematemesis and melena for a three-day period. A prior computed tomography scan revealed moderate diffuse hepatic steatosis, splenic vein dilatation, and splenomegaly. On admission, she presented with pallor, epigastric tenderness, splenomegaly, and mild ascites. Laboratory findings showed anemia, thrombocytopenia, hypoalbuminemia, and hyperglycemia. Abdominal ultrasound confirmed chronic liver disease with splenomegaly. Esophagogastroduodenoscopy demonstrated grade II-III esophageal varices and portal hypertensive gastropathy. Noninvasive fibrosis assessments (non-alcoholic fatty liver disease fibrosis score, aspartate transaminase-to-platelet ratio index, fibrosis-4 index, and FibroScan: E = 28 kPa, controlled attenuation parameter = 191 dB/m) indicated advanced hepatic fibrosis. HVPG measurement was not performed, however due to the Baveno VII criteria (transient elastography ≥ 25 kPa and platelet count < 150 × 109/L), confirmed the diagnosis of CSPH. The patient received endoscopic variceal ligation, a nonselective beta-blocker, a proton pump inhibitor, insulin, a sodium-glucose cotransporter 2 inhibitor, and lifestyle modification, resulting in clinical improvement.
CONCLUSION
Early and precise evaluation of CSPH in geriatric MAFLD requires an integrated clinical assessment to optimize diagnosis, management, and improve outcomes.
Core Tip: Metabolic dysfunction-associated fatty liver disease (MAFLD) is a chronic condition characterized by excess fat accumulation in the liver along with at least one cardiometabolic risk factor. MAFLD can progress silently to liver cirrhosis, often without noticeable symptoms, until clinically significant portal hypertension (CSPH) develops. CSPH can develop early in MAFLD, even before advanced hepatic fibrosis or cirrhosis sets in. We reported a case of a geriatric patient with MAFLD who had CSPH. Following variceal ligation and medical treatment, the patient showed notable improvement. However, diagnosing such cases in daily clinical practice remains quite challenging.
