Portal hypertension in the era of endo-hepatology: Emerging diagnostic and therapeutic roles of endoscopy and endoscopic ultrasound

Table 1 Endoscopic and endoscopic ultrasound guided techniques for the screening, diagnosis, risk stratification, and management of portal hypertension

Technique	Mechanism	Primary indications	Advantages	Clinical outcomes	Limitations	Key evidence
Screening and risk stratification
EGD	Direct visualization and grading of varices and mucosal features (size, red wale markings, cherry red spots)	Patients with compensated cirrhosis who do not meet Baveno VI/VII criteria for deferred screening; surveillance after variceal eradication	Identifies high-risk features that predict bleeding; guides prophylaxis and surveillance	Baveno VI criteria safely defer endoscopy with only 2.2% missed high-risk varices; Baveno VII avoids 56.7%-75.4% of EGDs	Cannot assess extramural collaterals or portal hemodynamics	AASLD 2024 practice guidance (Kaplan et al[9]); Baveno VII consensus 2022 (de Franchis et al[11])
Esophageal varices
EVL	Mechanical strangulation causing ischemia, necrosis, and fibrosis	First-line for acute esophageal variceal bleeding; primary prophylaxis when NSBBs contraindicated; secondary prophylaxis (with NSBBs)	High hemostasis rate; achieves long-term variceal obliteration; well-established	Hemostasis in majority of acute bleeding cases	PBUB in 5.5% (22.5% mortality); does not reduce portal pressure; requires repeated sessions	AASLD 2024 practice guidance (Kaplan et al[9]); ESGE 2022 guideline (Gralnek et al[29]); de Brito Nunes et al[31]
EIS	Chemical sclerosant injection causing thrombosis and fibrosis	Alternative when EVL not feasible	Useful in difficult visualization during active bleeding or scarred esophagus	Effective rescue therapy	Inferior to EVL for most patients	Li et al[43]
EUS-guided sclerotherapy	Ultrasound-directed sclerosant injection targeting perforating veins	Esophageal varices with persistent perforating veins; recurrence after conventional therapy	Targets feeder vessels not visible on standard endoscopy; shorter treatment times; less severe rebleeding	Significantly shorter treatment times and greater improvement in variceal bleeding with EUS guidance	Requires EUS expertise; limited data from small studies; multicenter trials needed	Dhiman et al[32]; Fang et al[33]
Self-expanding esophageal stent	Mechanical tamponade of bleeding varices	Refractory acute variceal hemorrhage as bridge to TIPS or definitive therapy	High immediate hemostasis; avoids balloon tamponade complications	Effective temporary bleeding control	Temporary bridge; stent migration; requires removal	AASLD 2024 practice guidance (Kaplan et al[9]); ESGE guideline 2022 (Gralnek et al[29])
Gastric varices
ECI	Cyanoacrylate polymerizes on blood contact embolizing the varix	First-line for acute gastric variceal bleeding; secondary prophylaxis of gastric varices; GOV1 (ECI or EVL)	Current endoscopic standard; high hemostasis rates; low embolization rate	87%-100% hemostasis in acute bleeding	Recurrence (34%); early rebleeding (16%); late rebleeding (39%); other adverse event rate (28%)	ESGE 2022 guideline (Gralnek et al[29]); AGA clinical practice update 2021 (Henry et al[29]); Hu et al[38]
EUS-guided coil + cyanoacrylate	EUS-guided coil scaffold for thrombus formation followed by cyanoacrylate to prevent embolization	Gastric varices (acute and prophylactic)	Doppler confirmation of hemostasis; precise targeting; lower recurrence than ECI alone	84% obliteration (vs 63% direct injection); 96%-98% hemostasis; recurrence 5%; > 95% obliteration in prophylaxis	Requires advanced EUS training; limited to specialized centers; pooled adverse event rate 14%; not suitable with complex vascular anatomy	Florencio de Mesquita et al[41]; Kouanda et al[42]
Portal hypertensive gastropathy
APC	Non-contact thermal coagulation via high-frequency current through argon gas	Bleeding from PHG	Non-contact; effective alone or synergistic with NSBBs	75.4% clinical success with one session for severe PHG	May require multiple sessions; not studied in hepatic encephalopathy, severe cardiovascular disease, chronic renal failure, hemodynamic instability, or active variceal/ulcer bleeding	Hanafy and El Hawary[58]
EUS-guided portal pressure measurement
EUS-PPG	Direct measurement of portal and hepatic vein pressures via needle with compact manometer	Risk stratification; suspected presinusoidal portal hypertension; discordant noninvasive data; concurrent with variceal screening	Direct measurement (vs indirect HVPG); no radiation/contrast; same-session with endoscopy and liver biopsy	100% technical success (pilot); HVPG correlation on r = 0.923	High-risk bleeding procedure per ASGE (caution with anticoagulation); requires advanced EUS training; not yet validated in large multicenter RCTs	Huang et al[68]; Choi et al[69]; Zhang et al[70]; Delphi consensus 2025 (Wang et al[73])
EUS-guided liver biopsy
EUS-LB	Core tissue sampling under EUS visualization	Fibrosis staging; concurrent portal pressure assessment; contraindication to percutaneous biopsy	Fibrosis staging when concurrent endoscopic procedure indicated; percutaneous biopsy contraindicated (ascites, obesity, coagulopathy)	83% combined adequate biopsy + reliable pressure gradient	High-risk bleeding procedure (ASGE/AGA); requires anticoagulant interruption; caution with platelets < 50000/μL; percutaneous remains first-line when sole indication is histology	Benmassaoud et al[74]; Arruda do Espirito Santo et al[75]
Emerging EUS-guided vascular interventions
EUS-guided SPSS obliteration	EUS-directed transgastric coil and glue injection to occlude SPSS	Refractory hepatic encephalopathy with SPSS ≥ 8 mm; MELD usually < 15	Transgastric access; can combine with variceal assessment and portal pressure measurement	Clinical improvement in 6/7 patients	Avoid in advanced liver disease, portal vein thrombosis, end-stage shunt syndrome; 43% long-term adverse event rate	Rathi et al[83]; ACG 2026 guideline on HE (Bajaj et al[81]); Wang et al[85]
Hybrid EUS-TIPS	EUS localizes portal vein to guide subsequent transjugular TIPS placement	Cavernous transformation of portal vein where conventional TIPS is technically difficult	Enables TIPS in otherwise technically impossible cases	All patients successful; no recurrent hemorrhage or ascites at mean 12-month follow-up	Adds procedural complexity (requires advanced endoscopy and IR); should not be used when standard transjugular access is feasible	Zhang et al[88]
EIPS	Self-expanding metal stent via EUS bridging hepatic and portal veins	Experimental; potential alternative to TIPS	Avoids transjugular access; concurrent portal pressure measurement possible	Successful creation in porcine models with confirmed portosystemic flow	Preclinical only; classified as experimental by AGA; no human trials	Buscaglia et al[87]; AGA clinical practice update 2023 (Ryou et al[39])

This table summarizes established and emerging endoscopic and endoscopic ultrasound based techniques used in the diagnosis and management of portal hypertension, including their mechanisms, primary indications, reported efficacy, and key limitations. AASLD: American Association for the Study of Liver Diseases; AGA: American Gastroenterological Association; APC: Argon plasma coagulation; ASGE: American Society for Gastrointestinal Endoscopy; ECI: Endoscopic cyanoacrylate injection; EGD: Esophagogastroduodenoscopy; EIPS: Endoscopic intrahepatic portosystemic shunt; EIS: Endoscopic injection sclerotherapy; ESGE: European Society of Gastrointestinal Endoscopy; EUS: Endoscopic ultrasound; EUS-LB: Endoscopic ultrasound-guided liver biopsy; EUS-PPG: Endoscopic ultrasound-guided portal pressure gradient measurement; EVL: Endoscopic variceal ligation; GOV1: Gastroesophageal varices type 1; HE: Hepatic encephalopathy; HVPG: Hepatic venous pressure gradient; MELD: Model for end-stage liver disease; NSBB: Nonselective β-blocker; PHG: Portal hypertensive gastropathy; PBUB: Post-banding ulcer bleeding; SPSS: Spontaneous portosystemic shunt; TIPS: Transjugular intrahepatic portosystemic shunt; RCTs: Randomized controlled trials.