Noninvasive prediction of clinically significant portal hypertension in metabolic dysfunction-associated steatotic liver disease compared to other chronic liver diseases

Abstract

Liver biopsy is rarely performed for the diagnosis of compensated advanced chronic liver disease (cACLD) in the current clinical hepatology practice. In the early stage, cACLD presents without portal hypertension, and in the later stage, it presents with portal hypertension. Hepatic venous pressure gradient measurement is the gold standard for diagnosing portal hypertension, but it is rarely used due to its invasive nature. The recent Baveno VII consensus recommends a noninvasive strategy for the diagnosis of cACLD and clinically significant portal hypertension (CSPH). However, there is some uncertainty regarding the diagnostic accuracy of Baveno VII criteria for predicting CSPH among patients with metabolic dysfunction-associated steatotic liver disease (MASLD). This is pertinent as MASLD has become the most important cause of cACLD in the United States. This mini-review outlines the diagnostic performance of Baveno VII criteria and other noninvasive criteria for predicting CSPH in patients with cACLD from MASLD compared to non-MASLD causes.

Key Words: Clinically significant portal hypertension; Compensated advanced chronic liver disease; Metabolic dysfunction-associated steatotic liver disease; Metabolic dysfunction-associated steatohepatitis; Non-invasive tests

Core Tip: The management of chronic liver disease has increasingly become noninvasive. The Baveno VII consensus recommends a noninvasive strategy to diagnose compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension (CSPH). However, the diagnostic accuracy of the Baveno criteria for predicting CSPH among patients with metabolic dysfunction-associated steatotic liver disease (MASLD) is not well-established. This is pertinent as MASLD has become the leading cause of cACLD in the United States. In this mini-review, we outline the diagnostic performance of the Baveno criteria and other noninvasive scores for predicting CSPH in patients with MASLD and non-MASLD related cACLD.

INTRODUCTION

Cirrhosis refers to the development of bridging liver fibrosis with regenerative nodules and distortion of normal liver parenchymal architecture. Cirrhosis is primarily a histological diagnosis. With increased reliance on noninvasive diagnosis in current hepatology practice, liver biopsy is rarely performed. The term compensated advanced chronic liver disease (cACLD) is preferred (instead of cirrhosis), which refers to advanced chronic liver disease without features of liver decompensation[1]. Progression of cACLD leads to the development of portal hypertension, which is marked by esophageal or gastric varices, ascites, and hepatic encephalopathy. Portal hypertension is defined as an increase in portal pressure gradient (between the portal vein and the inferior vena cava) to ≥ 10 mmHg[1]. The gold standard for measuring portal venous pressure gradient is the hepatic venous pressure gradient (HVPG), which is an invasive procedure that involves inserting a balloon catheter through the right jugular vein to obtain the difference between the free hepatic venous pressure and the wedged hepatic venous pressure. An HVPG of ≥ 10 mmHg is considered clinically significant portal hypertension (CSPH). Early diagnosis of CSPH is critical for disease management and to prevent complications like esophageal and gastric variceal bleeding. However, the HVPG measurement is invasive and confers a procedural risk of bleeding and organ damage. In recent years, there has been a shift towards using noninvasive tests (NITs) to diagnose CSPH. The ANTICIPATE model proposed by Abraldes et al[2] incorporated platelet count and liver stiffness measurement (LSM) and was subsequently named the Baveno criteria. The Baveno VII consensus provided novel recommendations regarding the use of NITs to diagnose CSPH, incorporating LSM and platelet count[2-4]. As per the Baveno VII criteria, CSPH can be ruled out with LSM < 20 kPa using vibration-controlled transient elastography (VCTE), commercially known as FibroScan, and platelet count > 150 K/μL[4]. The most recent American Association for the Study of Liver Diseases guidance indicates that: (1) If the LSM is < 10 kPa, cACLD can be mostly excluded; (2) If LSM < 15 kPa, the presence of CSPH can be excluded; (3) If LSM is > 20 kPa, CSPH can be assumed; and (4) If LSM > 25, CSPH can be confirmed. This is often referred to as “Rule of Five”[5]. Some recent studies have raised concerns about the accuracy of the Baveno criteria for predicting CSPH among patients with metabolic dysfunction-associated steatotic liver disease (MASLD)[1,4]. This is pertinent as MASLD has become the most important cause of cACLD in the United States. We outline the diagnostic performance of the Baveno VII criteria and other noninvasive criteria for predicting CSPH in patients with cACLD from MASLD and non-MASLD causes.

BAVENO VII CRITERIA AND OTHER NONINVASIVE CRITERIA FOR MASLD-RELATED CACLD

In the Anticipate study by Abraldes et al[2], 518 patients with cACLD from five international centers were included. The authors compared HVPG/endoscopy findings with the following noninvasive models for predicting CSPH: (1) LSM by VCTE; (2) LSM and platelet count; (3) LSM to spleen/platelet score; and (4) Platelet-spleen ratio (PSR). All noninvasive models performed well in identifying patients with CSPH. The proportion of MASLD in the study group was low. However, the authors found that adding etiology to the predictive models did not modify their performance[2]. Augustin et al[6] reported the Expanded Baveno VI criteria for esophageal variceal screening, which included platelet count > 110 × 10⁹ cells/L and LSM < 25 kPa. Patients from the Anticipate cohort were assessed, and the criteria were validated in two additional cohorts. Investigators found that the Expanded-Baveno VI criteria spared more endoscopies with a minimal risk of missing varices needing treatment (VNT) in patients with cACLD from various etiologies, including metabolic dysfunction-associated steatohepatitis (MASH)[6]. Chronic hepatitis C virus (HCV), alcohol, and MASH were the most common causes for cACLD in this study cohort, and the investigators reported similar diagnostic performance of the Expanded-Baveno VI criteria in these groups. Pons et al[7] in a validation study revealed excellent diagnostic performance of the ANTICIPATE model in identifying CSPH in patients with cACLD from viral, alcohol, and non-obese nonalcoholic steatohepatitis (MASH) causes. However, the authors demonstrated that the ANTICIPATE model overestimated the presence of CSPH in obese MASH patients, and proposed an ANTICIPATE MASH model, which incorporated body mass index into the nomogram[7]. The authors reported that among patients with LSM using VCTE ≥ 25 kPa, the positive predictive value of CSPH was only 62.8% in patients with obese MASH compared to 91.7% for those with non-obese MASH, and nearly 100% for those with hepatitis B virus (HBV), HCV, and alcohol-associated liver disease. Rabiee et al[8] externally validated the ANTICIPATE and ANTICIPATE- MASH models in a cohort of patients with compensated MASLD cirrhosis. They reported excellent discrimination of both models (> 0.8) in the entire cohort and the obese population. The study also described a novel model using the fibrosis-4 (FIB-4) index (age, aspartate aminotransferase, alanine aminotransferase, and platelet count) plus serum albumin, termed FIB4+, to predict CSPH, which can be used where VCTE is not readily available[8].

In a study of 209 patients with cACLD from Peru, with MASLD as the most common etiology, followed by viral hepatitis and mean LSM of 27.2 ± 14.6 kPa, the Baveno VII criteria were noted to have a sensitivity of 96.7% and a negative predictive value of 76.9%. However, the sensitivity and negative predictive value of Baveno VII criteria improved to 98.4% and 90.9% after excluding patients with MASLD from the analysis, respectively[9]. A retrospective cohort study of 17076 United States veterans evaluated the Baveno VII criteria as a risk stratification tool for death and hepatic decompensation events[10]. Each “Rule-of-Five” category was associated with an increased risk of mortality and hepatic decompensation. Similar results were documented in a subgroup analysis for patients with non-obese MASLD and those with obese MASLD. The authors suggested that the Baveno “Rule-of-Five” classification schema can be used for all patients, including those with obese and non-obese MASLD.

In an international, multicenter study of 633 patients with cACLD, Wong et al[11] described a new CHESS-ALARM score, which incorporated age, platelet count, gender, and LSM. This score demonstrated significantly higher accuracy than the model for end-stage liver disease, albumin-bilirubin (ALBI), ALBI-FIB-4, and LSM > 25 kPa in predicting liver decompensation at 5 years. The cohort primarily included patients with cACLD from viral hepatitis, and there were only a few patients with MASH[11]. Further studies are warranted to validate the CHESS-ALARM score in patients with MASH. In a retrospective cohort study of 5849 United States veterans, the FIB-4 score and the LSM by VCTE were combined into a single score, the FIB-5 score, which demonstrated superior discrimination compared to the LSM or FIB-4 score alone for identifying patients with cACLD at risk for complications of portal hypertension[12]. The study also had a limited representation of MASLD, as alcohol and HCV were the predominant etiologies.

A recent multicenter study of 340 patients with MASLD-cACLD, with a median follow-up of 41.5 months, revealed that HVPG had a high prognostic value[13]. The investigators found that CSPH correlated with liver decompensation in MASLD, similar to non-MASLD-related cACLD. Many novel markers, such as serum-free light chains, mean hemoglobin A1c, and splenic stiffness measurement (SSM), have been explored in patients with MASLD-cACLD and compared with LSM in predicting CSPH, with variable results (Table 1)[2,6-20].

Table 1 Overview of studies on tests and models for clinically significant portal hypertension in patients with compensated, advanced chronic liver disease due to metabolic dysfunction-associated steatotic liver disease.

Ref.	Journal name	Sample size	Test or model	Implications	Limitations
Pons et al[7], 2021	American Journal of Gastroenterology	n = 836	HVPG	Among patients with VCTE LSM > 25 kPa, the positive predictive value of CSPH was only 62.8% for obese MASH compared to other etiologies	Invasive test
Campoverde Cueva et al[9], 2024	Revista Colombiana de Gastroenterologia	n = 209	Baveno VII criteria	The Baveno VII criteria was noted to have a sensitivity of 96.7% and a NPV of 76.9% although the sensitivity and NPV improved to 98.4% and 90.9% after excluding patients with MASLD, respectively	Single center, ross-sectional study
Vutien et al[10], 2024	Hepatology	n = 17076	Baveno VII criteria, “Rule-of-Five” categories	Each “Rule-of-Five” category was associated with an increased risk of mortality and decompensation. In a subgroup analysis for patients with MASLD with body mass index > 30 kg/m2, similar results were noted	Retrospective study, limited number of patients with MASLD
Abraldes et al[2], 2016	Hepatology	n = 518	LSM by TE. LSM by TE and platelet count. Liver stiffness-spleen size-platelet ratio. Platelet-spleen ratio. Endoscopy/HVPG	All NITs identified patients with high risk of CSPH and a low risk of VNT. No significant interactions were reported between the NITs and the etiology of cirrhosis in any of the models	Limited number of patients with MASLD
Augustin et al[6], 2017	Hepatology	n = 925	Expanded Baveno VI criteria	The Expanded-Baveno VI criteria reportedly spared more endoscopies with a minimal risk of missing VNT in patients with cACLD from various etiologies including non-alcoholic steatohepatitis	Relatively limited number of patients with MASLD
Rabiee et al[8], 2022	Hepatology Communications	n = 222	FIB4+	Externally validated the Anticipate and Anticipate-MASH models in a cohort of patients with compensated MASH cirrhosis. Described a novel model using the FIB-4 index plus serum albumin, termed FIB4+, to predict CSPH which can be used where TE is not readily available	Higher pretest probability of CSPH in one of the cohorts. Further validation in patients with MASH
Wong et al[11], 2022	Journal of Gastroenterology and Hepatology	n = 633	CHESS-ALARM score	CHESS-ALARM score had significantly higher accuracy than model for end-stage liver disease, ALBI, ALBI-FIB-4 and LSM > 25 kPa to predict liver decompensation at 5 years	Limited number of patients with MASLD
Vutien et al[12], 2022	American Journal of Gastroenterology	n = 5849	FIB-5 score	The FIB-4 score and LS from FibroScan were combined into a single score, the FIB-5, which demonstrated superior discrimination compared to LS or FIB-4 alone, for patients with cACLD at risk for complications of portal hypertension	Retrospective study. Data from Veteran Affairs population. Further validation in patients with MASH
Paternostro et al[13], 2024	Journal of Hepatology	n = 340	HVPG	HVPG had a high prognostic value in patients with cACLD and MASLD	Invasive test
Liguori et al[14], 2024	Liver International	n = 254	Serum-free light chains	Serum-free light chain was demonstrated to be a dependable biomarker for stratification of cACLD in patients with MASLD	Case-control study
Huang et al[15], 2025	Hepatology	n = 1231	LSM, T2DM, HbA1c	The presence of T2DM and mean HbA1c were independent predictors of the progression of LSM in biopsy-proven MASLD	Data may not be generalized to regions outside of the United States. Possible selection bias
Williams et al[16], 2024	Digestive Disease and Sciences	n = 154	Spleen stiffness measurement	SSM was noted to have a higher failure rate in individuals with lower fibrosis stage, higher body-mas index, and a larger waist circumference. SSM was useful for excluding esophageal varices and high-risk esophageal varices in the study	Small sample size
Calès et al[20], 2025	Journal of Hepatology	n = 1051	FIB-9, FIB-11, FIB-12	A new generation of NITs for liver fibrosis in patients with MASLD, including the FIB-9, FIB-11 and FIB-12, have been reported to have greater accuracy compared to recommended NITs	Complex formula. Potentially costly
Liguori et al[19], 2024	Digestive and Liver Disease	n = 289	ELF test	ELF has been demonstrated to perform as well as histology from a liver biopsy for the evaluation of fibrosis and prediction of clinical outcomes in patients with MASLD	Small sample size. Further validation in patients with MASH
Torres et al[17], 2023	Annals of Hepatology	n = 183 training cohort. n = 261 validation cohort	FIB-4, MASLD fibrosis score	The cut-off points chosen were 1505 (sensitivity 85%, specificity 86%) for FIB-4 and -0.835 (sensitivity 100%, specificity 70%) for MASLD fibrosis score, which demonstrated greater specificity compared to the cut-off points currently used	Subjective nature of the evaluation of alcohol consumption. Data may not be generalized to other settings. Single radiologist performed analysis
Mózes et al[18], 2022	Gut	n = 5735	FIB-4 plus LSM-VCTE	Algorithm combining FIB-4 and LSM-VCTE sequentially in patients with MASLD with lower cut-offs to exclude advanced fibrosis and a higher cut-off value to rule-in cirrhosis, which reduced the need for liver biopsies	Data may not be generalized to other regions. Large chronological period during which LSM-VCTE underwent significant changes

ALBI: Albumin-bilirubin; CACLD: Compensated advanced chronic liver disease; CSPH: Clinically significant portal hypertension; ELF: Enhanced liver fibrosis; FIB: Fibrosis; HbA1c: Hemoglobin A1c; HVPG: Hepatic venous pressure gradient; LSM: Liver stiffness measurement; MASLD: Metabolic dysfunction associated steatotic liver disease; MASH: Metabolic dysfunction-associated steatohepatitis; NITs: Noninvasive tests; NPV: Negative predictive value; SSM: Splenic stiffness measurement; TE: Transient elastography; T2DM: Type 2 diabetes mellitus; VCTE: Vibration controlled transient elastography; VNT: Varices needing treatment.

It is essential to note that studies suggest different cut-offs for NITs in identifying fibrosis stages in patients with MASLD-cACLD compared to those with non-MASLD-cACLD. In a study of patients with MASLD, the cut-off points notable for liver fibrosis were 1.505 (sensitivity 85%, specificity 86%) for the FIB-4 score and -0.835 (sensitivity = 100%, specificity = 70%) for the MASLD fibrosis score. With the new cut-off points, greater specificity for predicting liver fibrosis compared to the traditional cut-off points (1.3 and -1.45 respectively) was documented[17]. For defining advanced liver fibrosis, the usual cut-offs recommended for the FIB-4 score is 3.25 for viral hepatitis-related liver disease and 2.67 for MASLD (Figure 1)[5,21,22]. Mózes et al[18] reported an algorithm that combined FIB-4 and LSM-VCTE sequentially in patients with MASLD, using lower cut-offs to exclude advanced fibrosis and higher cut-off values to rule in cirrhosis, which reduced the need for liver biopsies. The enhanced liver fibrosis test has been documented to perform as well as histology from a liver biopsy for assessing fibrosis and predicting clinical outcomes in patients with MASLD[19]. A new generation of NITs for liver fibrosis in patients with MASLD, including the FIB-9, FIB-11, and FIB-12, have been reported to have greater accuracy than conventional NITs[20].

Figure 1 Noninvasive diagnosis of metabolic dysfunction-associated steatotic liver disease. ¹If the fibrosis-4 (FIB-4) score is < 1.3 or FibroScan liver stiffness measurement (LSM) is < 8 kPa, patients can be followed in the primary care setting and reassessed periodically. Patients without prediabetes/type 2 diabetes mellitus (T2DM) and 1 metabolic risk factor have a low risk for disease progression and can be reassessed every 2–3 years. Patients with prediabetes/T2DM or 2 or more metabolic risk factors are at higher risk for disease progression, and more frequent FIB-4 monitoring (e.g., every 1–2 years) should be considered. Direct referral to gastroenterology or hepatology should be considered in those with aminotransferases persistently (> 6 months) above normal to exclude other causes of liver disease or when FIB-4 score > 2.67. ²Patients at all stages of metabolic dysfunction-associated steatotic liver disease (MASLD) should be counseled on lifestyle modifications, and those with F2 and F3 fibrosis (or FibroScan LSM 10-19.9 kPa) should be considered for treatment with resmetirom. Hepatic steatosis is defined as one of these: (1) > 5% macrovesicular steatosis on liver biopsy; (2) Magnetic resonance elastography-proton density fat fraction > 5.5%; and (3) FibroScan controlled attenuation parameter > 288 dB/minute. Cardiometabolic risk factors (at least one of these along with hepatic steatosis defines MASLD with: (1) Body mass index 25 kg/m² or waist circumference > 94 cm/> 80 cm (male/female); (2) Fasting serum glucose ≥ 100 mg/dL or hemoglobin A1c ≥ 5.7% or on treatment for T2DM; (3) Blood pressure ≥ 130/85 mmHg or on treatment with antihypertensive drugs; (4) Plasma triglyceride ≥ 150 mg/dL or on lipid-lowering treatment; and (5) Plasma high-density lipoprotein ≥ 40 mg/dL (50 mg/dL in females) or on lipid-lowering treatment). ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; FIB-4: Fibrosis-4; GI: Gastroenterology; LSM: Liver stiffness measurement; MASLD: Metabolic dysfunction associated steatotic liver disease; MRE-PDFF: Magnetic resonance elastography-proton density fat fraction; VCTE: Vibration controlled transient elastography.

Several NITs have been described for MASLD-related cACLD, including versions of the Baveno criteria and FIB-4 scores, models incorporating liver and spleen stiffness measurements, platelet counts, and other novel tests. However, further studies are warranted to explore these NITs in large cohorts of patients with MASLD.

BAVENO VII CRITERIA AND VIRAL HEPATITIS

There are limited studies on the validation of the Baveno VII criteria in patients with viral hepatitis-related cACLD. In a study by Jachs et al[23] of 51 patients with hepatitis D virus-related cACLD, the standalone Baveno VII criteria and composite Baveno VII criteria, including the Baveno VII-VITRO and Baveno VII-SSM algorithms, were demonstrated to diagnose CSPH with high accuracy. Investigators noted that the composite Baveno VII criteria will help to refine and reduce the intermediate zone with the standalone Baveno VII criteria[23]. Zhang et al[24] revealed that the Baveno VII criteria demonstrated excellent performance using the SSM using a 50 Hz and a 100 Hz probe in ruling out high-risk varices (HRV) in patients with HBV-related cirrhosis. Kim et al[25] reported that the CHESS-ALARM score reliably predicted hepatic decompensation in patients with HBV-associated cirrhosis and performed similarly to other VCTE-based models.

The Baveno VII consensus also proposed criteria to define recompensation in decompensated cirrhosis, which is often associated with well-controlled disease or removal of the underlying etiology of cirrhosis[4]. In a study of patients with cirrhosis due to curable etiologies (alcohol, HBV, and HCV) by Tonon et al[26], the Baveno VII criteria for recompensation of decompensated cirrhosis were validated. The criteria identified cirrhotic patients with a good prognosis, but only < 10% of patients achieved recompensation in this cohort. The Baveno criteria seems to be helpful in predicting CSPH in patients with viral hepatitis-related cACLD, although further studies are warranted on this topic.

BAVENO VII CRITERIA AND HEPATOCELLULAR CARCINOMA

Patients with advanced hepatocellular carcinoma (HCC) are at an increased risk of variceal hemorrhage. A study by Wu et al[27] demonstrated that the Baveno VII criteria may be used as a noninvasive risk stratification tool for variceal bleeding and hepatic decompensation in patients with HCC. A prospective cohort study concluded that the Baveno VII criteria are valid for identifying patients who require screening endoscopy for VNT in patients with different Barcelona Clinic Liver Cancer stages of HCC undergoing curative hepatectomy[28]. Further studies are warranted to investigate the role of the Baveno criteria in patients with HCC.

BAVENO VII CRITERIA AND PRIMARY BILIARY CHOLANGITIS

Ding et al[29] demonstrated in a study of 672 patients that LSM can be used to monitor disease progression and predict prognosis in patients with primary biliary cholangitis (PBC). Additional studies are warranted to validate the Baveno VII criteria in patients with PBC.

OTHER NITS TO IDENTIFY CSPH

In a systematic review and meta-analysis of 17 studies, algorithms combining Baveno VII criteria and SSM demonstrated good correlation with CSPH. The combined algorithm decreased the proportion of patients in the intermediate zone for CSPH[30]. In a study of 118 patients with cACLD by He et al[31], the Baveno VII criteria had similar performance compared to two-dimensional shear wave (2D-SWE) for ruling in CSPH, but not ruling out CSPH. Muzica et al[32] demonstrated that SSM through 2D-SWE may be a non-invasive tool for predicting esophageal varices in cACLD. A prospective study of 185 patients with cACLD concluded that SSM > 50 kPa, using the spleen-dedicated probe, is sufficient for identifying CSPH in patients with cACLD[33]. Kwape et al[34] reported the diagnostic accuracy of different noninvasive methods for detecting esophageal varices in a study of 50 patients with compensated cirrhosis. SSM and spleen stiffness-spleen size-platelet ratio score had the highest diagnostic accuracy, followed by PSR and liver stiffness-spleen size-platelet ratio. The liver stiffness-spleen stiffness-platelet ratio score, a novel composite score with good diagnostic accuracy for predicting esophageal varices, was also proposed[34]. Liu et al[35] documented in a study of 171 cirrhotic patients that SSM, using a 100 Hz frequency probe, had high accuracy in predicting HRV with a low missed HRV rate of 2.5%. LSM and noninvasive scores have been extensively discussed in the setting of treatment for MASLD with new medications such as resmetirom[21].

A prospective cross-sectional study of 199 patients documented the chronological changes in lymphatic vessels, the cisterna chyli, and the terminal thoracic duct in relation to liver disease progression, using computed tomography and ultrasonography. The study revealed that both the cisterna chyli and the terminal thoracic duct were narrowed as a terminal feature in chronic liver disease after an earlier phase of dilation. There was a significant correlation (r = 0.724) between the cisterna chyli diameter and the HVPG in patients who could not be classified for the presence of CSPH according to the Baveno VII criteria[36]. A study of 309 patients with porto-sinusoidal vascular disorder (PSVD) demonstrated that SSM-VCTE ≤ 40 kPa combined with bilirubin < 1 mg/dL identified patients with PSVD and portal hypertension. The study reported that SSM-VCTE ≤ 40 kPa combined with bilirubin < 1 mg/dL could spare 21% of screening endoscopies, with a 5% miss rate for HRV[37].

The Baveno criteria has not been explored exclusively in patients with alcohol-related cACLD, which could be due to the possibility of LSM being confounded by alcohol-associated hepatitis in these patients. However, most of the studies of Baveno criteria on patients with cACLD from different etiologies included patients with alcohol-related liver disease. Additional studies, such as randomized controlled trials, are warranted to compare and validate NITs in patients with MASLD as well as other chronic liver diseases.

CONCLUSION

The Baveno VII criteria are a promising, noninvasive tool for the identification of CSPH in patients with cACLD due to various conditions, including viral hepatitis, alcohol, PBC, as well as HCC. Even though the initial studies raised concerns about the diagnostic accuracy of the criteria in patients with MASLD-cACLD, the most recent studies reveal similar diagnostic performance of the Baveno VII criteria in patients with cACLD from all etiologies. Composite Baveno VII criteria, which incorporate SSM and novel noninvasive markers like von Willebrand factor-platelet count ratio, are promising, and the composite scores seem to improve the diagnostic accuracy of Baveno VII criteria. Some of these novel markers are still investigational and require additional studies to prove their clinical utility. The other new noninvasive scores which do not incorporate the Baveno criteria are also promising, and future studies will define their role in the diagnostic algorithms.