Advances in the diagnosis and management of clinically significant portal hypertension in cirrhosis: A narrative review

Table 1 Classification of portal hypertension

Classification	Etiologies
Prehepatic	Portal vein thrombosis
	Splenic vein thrombosis
	Congenital venous abnormalities
Intrahepatic	Presinusoidal: Hepatoportal sclerosis; schistosomiasis; myeloproliferative diseases; sarcoidosis; early stage of primary biliary cholangitis; primary sclerosing cholangitis; congenital hepatic fibrosis; arsenic toxicity
	Sinusoidal: Cirrhosis; alcohol-associated hepatitis; nodular regenerative hyperplasia
	Postsinusoidal: Veno-occlusive disease
Posthepatic	Budd-Chiari
	Heart failure
	Pulmonary hypertension
	Constrictive pericarditis

Table 2 Comparison between hepatic vein pressure gradient and endoscopic ultrasound-guided portal pressure gradient

	HVPG	EUS-guided portal pressure gradient
Technique	Transjugular catheterization of the hepatic vein with a balloon-tipped catheter	Under EUS guidance, fine-needle puncture of the hepatic vein and the portal vein
Principle	HVPG = wedged hepatic venous pressure – free hepatic venous pressure	PPG = portal vein pressure – hepatic vein pressure
Sedation	Usually under minimal (low-dose midazolam) or no sedation	Usually under moderate to deep sedation
Advantages	Well-established as the gold standard for clinically significant portal hypertension assessment	Direct measurement of portal vein pressure. Alternative when HVPG is not accurate such as presinusoidal PH. Can be combined with endoscopic evaluation of varices
Limitations	Indirect measurement of portal vein pressure. May underestimate presinusoidal PH such as primary biliary cholangitis and metabolic dysfunction-associated steatotic liver disease. May be contraindicated in severe coagulopathy	Limited availability and expertise. Requires further validation. Moderate to deep sedation can cause hemodynamic variations and lead to inaccurate PPG measures

EUS: Endoscopic ultrasound; HVPG: Hepatic vein pressure gradient; PH: Portal hypertension; PPG: Portal pressure gradient.