Portal Pressure Gradient Measurement Research Articles

Endoscopic ultrasound-guided portal pressure gradient measurement: a systematic review and meta-analysis.

Endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPG) is a new modality where the portal pressure is measured by directly introducing a needle into the hepatic vein and portal vein. This is the first systematic review and meta-analysis to evaluate the efficacy and safety of EUS-PPG. A comprehensive literature search was performed to identify pertinent studies. The primary outcomes assessed were the technical and clinical success of EUS-PPG. Technical success was defined as successful introduction of the needle into the desired vessel, while clinical success was defined as the correlation of the stage of fibrosis on the liver biopsy to EUS-PPG, or concordance of HVPG and EUS-PPG. The secondary outcomes were pooled rates for total and individual adverse events related to EUS-PPG. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI). Eight cohort studies with a total of 178 patients were included in our analysis. The calculated pooled rates of technical success and clinical success were 94.6% (95%CI 88.5-97.6%; P=<0.001; I2=0) and 85.4% (95%CI 51.5-97.0%; P=0.042; I2=70), respectively. The rate of total adverse events was 10.9% (95%CI 6.5-17.7%; P=<0.001; I2=4), and 93.7% of them were mild, as defined by the American Society for Gastrointestinal Endoscopy. Abdominal pain (11%) was the most common adverse event, followed by bleeding (3.6%). There were no cases of perforation or death reported in our study. EUS-PPG is a safe and effective modality for diagnosing portal hypertension. Further randomized controlled trials are needed to validate our findings.

The safety and efficacy of endoscopic ultrasound-guided portal pressure gradient measurement with concomitant endoscopic ultrasound-guided liver biopsy: a systematic review

IntroductionPortal hypertension (PH) is a complication of advanced liver disease. Traditionally, PH has been quantified using hepatic venous pressure gradient (HVPG) through an indirect transjugular approach requiring ionizing radiation exposure. Endoscopic ultrasound-guided porto-systemic pressure gradient (EUS-PPG) measurement is an emerging alternative, minimally invasive technique that provides direct portal pressure measurement. The aim of this systematic review is to evaluate the safety and efficacy of EUS-PPG measurement and concomitant EUS-guided liver biopsy (EUS-LB) in patients with chronic liver disease.MethodsThe preferred reporting items for systematic reviews and meta-analyses method was used. A PubMed, Medline, Web of Science, Google Scholar, and CINAHL search for terms “endoscopic ultrasound,” “EUS,” and “portal pressure gradient” was used to identify qualifying studies. Eligible studies included those which were published before 2022, reporting outcomes of EUS-PPG measurement, simultaneous EUS-LB if applicable, and adverse events rate. Risk of bias was assessed by Egger’s test. Results were synthesized using I2 to test heterogeneity.ResultsFour published studies including 147 patients met inclusion criteria, with mean age 59.6 years, 59% male. Indications for EUS-PPG measurement were history of chronic liver disease or suspected cirrhosis, viral hepatitis, alcohol associated liver disease, hepatic sinusoidal obstruction or Budd Chiari syndrome. The pooled technical success rate of EUS-PPG measurements was 98.61% with 95% confidence interval of 95.20% - 99.82%. A 25-gauge needle was used in 92% (135/147) of patients. EUS-PPG measurement was performed through a transgastric approach in all 147 (100%) patients using a compact manometer with pressure transducer and non-compressible tubing. The mean PPG was 10.07 (range 6.44 – 13.70) mmHg. Ninety-five patients underwent simultaneous EUS-LB using 19G needle with wet suction technique. Technical success rate of EUS-LB was 100% and specimen was adequate in 99% (94/95) patients to establish histological diagnosis. There were no major life-threatening complications of the EUS-PPG procedure. Predominant adverse events were abdominal pain 6.1% (9/147) and sore throat 5.4% (8/147).ConclusionEUS-PPG measurement is safe and useful in providing an assessment of portal pressure in patients with chronic liver disease. Future studies are needed to evaluate whether there is consistent correlation between EUS-PPG measurements and histologic fibrosis stage by liver biopsy.

Advances in Endohepatology.

Over the past decade, the number of endoscopic procedures relevant to patients with liver disease not only increased but also altered and expanded in terms of indications and applications. "Endohepatology" refers to the integration of advanced endoscopy within the practice of hepatology with endoscopic ultrasound as one of the main pillars. Current applications under the umbrella of endohepatology focus on advanced diagnostics and oncological, vascular, and metabolic interventions. These involve, among others, endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided coil and glue embolization of gastric varices. In addition to its conceptually attractive technical and innovative characteristics, endohepatology is also an appealing practical option for daily practice because it can be offered as a "one-stop clinic" intervention where comprehensive endoscopic diagnostic and/or therapeutic testing is performed in a single outpatient visit. In this review, we will discuss current trends and future developments within endohepatology and the remaining hurdles to overcome.

Endoscopic ultrasound-guided portal pressure gradient measurement: improving safety and overcoming technical difficulties.

Endoscopic ultrasound-guided portal pressure gradient measurement: improving safety and overcoming technical difficulties.

Endoscopic ultrasound-guided portal pressure gradient measurement in managing portal hypertension.

Portal hypertension (PH) is still a challenging clinical condition due to its silent manifestations in the early stage and needs to be measured accurately for early detection. Hepatic vein pressure gradient measurement has been considered as the gold standard measurement for PH; however, it needs special skill, experience, and high expertise. Recently, there has been an innovative development in using endoscopic ultrasound (EUS) for the diagnosis and management of liver diseases, including portal pressure measurement, which is commonly known as EUS-guided portal pressure gradient (EUS-PPG) measurement. EUS-PPG measurement can be performed concomitantly with EUS evaluation for deep esophageal varices, EUS-guided liver biopsy, and EUS-guided cyanoacrylate injection. However, there are still major issues, such as different etiologies of liver disease, procedural training, expertise, availability, and cost-effectiveness in several situations with regard to the standard management.

Endoscopic ultrasound-guided vascular interventions: An expanding paradigm.

Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Evolution of interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.

S1109 General vs Monitored Anesthesia Time: Is One Preferred for EUS-Guided Portal Pressure Gradient Measurements and Liver Biopsies?

Introduction: EUS-guided portal pressure gradient (PPG) measurement and EUS guided liver biopsies are well tolerated procedures under anesthesia, but it is unclear which anesthesia modality, monitored anesthesia care (MAC) or general anesthesia (GA), is superior for performing these cases. We aimed to describe our centers’ experiences and approach to EUS-guided PPG and liver biopsy from an anesthesia perspective and compared the two anesthesia modalities in terms of procedure duration, efficacy, and safety. Methods: This was a retrospective review of all consecutive patients who underwent EUS-guided PPG measurement and/or liver biopsies at a single tertiary center between June 2021 and May 2022. All procedures were done with an anesthesiologist attending and/or a resident/nurse. After initial experience with GA, our center largely switched to MAC for these cases. In the last 40 cases, 82% were done with MAC. Demographic data, scope time, anesthesia time, technical success rate, and adverse events post procedure for each patient were noted. Statistical analysis was performed using student t-testing. Results: We have a total of 73 patients who underwent EUS guided PPG measurement and/or liver biopsy, with 30 (54%) having undergone only PPG measurement. The mean age was 51, with 56 (77%) patients being female and mean BMI as 37. The clinical indication for most patients 60 (82%) in undergoing the EUS procedure was for evaluation of underlying NAFLD/NASH. No differences in basic demographics was found between the MAC and GA cohorts. The mean scope time for MAC vs GA was 38.2 ± 14.2 and 47.3 ± 14.5 minutes respectively for patients who underwent both EUS-PPG and liver biopsy. The timing of endoscopy was comparable between the two modalities (p=0.013). The mean anesthesia time for MAC vs GA was 57.1 ± 14.9 and 81.6 ± 14.9 minutes respectively, with MAC being shorter by 25 minutes (p= < 0.001). Similar comparisons were made for patients who underwent EUS-PPG alone. Technical success was 100% for all cases, and there was only one reported adverse event of a patient who reported transient shortness of breath post-extubation from GA who underwent EUS-PPG alone. This was resolved within a few hours with close monitoring. (Table) Conclusion: Our results show that MAC was superior in terms of anesthesia time as compared to GA. Both anesthesia modalities demonstrated excellent and comparable safety and efficacy. Table 1. - Procedure and Anesthesia time for EUS guided PPG measurement and Liver Biopsy Table a EUS guided PPG measurement (with liver biopsy) Mean Mac(n=20) GA (N=23) p value Procedure time (mins) 38.2 ± 14.2 47.3 ± 14.5 0.013 Anesthesia time (mins) 57.1 ± 14.9 81.6 ± 14.9 Table b EUS guided PPG measurement (without liver biopsy) Mean MAC (N=13) GA (N=17) p value Procedure time (mins) 37.7 ± 14.5 46.9 ± 14.5 0.011 Anesthesia time (mins) 58.1 ± 15.5 81.9 ± 15.5 < 0.001 Table c Mean intubation time with GA (n=23 )( with liver biopsy) 66.3 ± 14.6 Mean intubation time in minutes with GA (n= 17) ( without liver biopsy) 66 ± 15.3

Endoscopic ultrasound-guided portal pressure gradient measurement.

Endoscopic ultrasound-guided portal pressure gradient measurement.

Endoscopic ultrasound-guided portal pressure gradient with liver biopsy: 6years of endo-hepatology in practice.

The portal pressure gradient (PPG) is a useful predictor of portal hypertension (PH) related complications. We previously showed the feasibility and safety of endoscopic ultrasound guided PPG measurement (EUS-PPG). Now EUS-guided liver biopsy (EUS-bx) has been shown to be a safe and effective alternative to percutaneous or Interventional Radiology-guided liver biopsy for the diagnosis of chronic liver disease (CLD). We aimed to evaluate the correlation between PPG and clinical markers of PH, and assess the feasibility and safety of concomitant, single session EUS-PPG and EUS-bx. This was a retrospective study of patients undergoing EUS-PPG for CLD at a single tertiary endoscopy center between February 2014 and March 2020. EUS-PPG was performed using a 25-gauge needle and compact manometer. Data analysis was performed with SAS version 9.4. Eighty-three patients underwent EUS-PPG with 100% technical success. The mean PPG was 7.06mmHg (SD 6.09, range 0-27.3). PPG was higher in patients with (vs without) clinical features of cirrhosis (9.46 vs 3.61mmHg, P<0.0001), esophageal or gastric varices (13.88 vs 4.34mmHg, P<0.0001), and thrombocytopenia (9.25 vs 4.71mmHg, P=0.0022). In the 71 patients (85.5%) who underwent EUS-bx, 70 (98.6%) specimens were deemed adequate by the pathologist for histologic diagnosis. There were no early or late major adverse events. EUS-PPG correlates well with clinical markers of PH. EUS-bx can be performed safely during the same session as EUS-PPG, providing a comprehensive endoscopic evaluation of the patient with CLD.

Endoscopic Ultrasound-Guided Portal Pressure Gradient Measurement, Is It Ready for Prime Time?

Portal hypertension is a serious complication of advanced liver disease. Portal pressure gradient measurement accurately determines severity of portal hypertension, prognosis, and guides medical therapy. Conventionally, interventional radiology-guided hepatic venous portal gradient measures portal pressure gradient indirectly using specialized balloon catheter. Recent advances in endoscopy have paved the novel method of endoscopic ultrasound-guided direct portal pressure gradient measurement to evaluate portal hypertension with equivalent safety in both animal models and humans studies. With the expansion of Endo-Hepatology practice, a concept of “one stop shop” is becoming more popular which is a comprehensive endoscopic approach in the evaluation of chronic liver disease. During the same endoscopic procedure, patients could be evaluated for esophageal or gastric varices, portal hypertensive gastropathy, EUS-guided elastography, EUS-guided portal pressure measurement and EUS-guided liver biopsy when suspecting advanced liver disease or diagnosis remains uncertain. This article focuses on the overview of portal hypertension and EUS-guided interventions such as EUS-guided portal pressure measurement, EUS-guided elastography and EUS-guided liver biopsy in the evaluation of individuals with advanced liver disease.

Endoscopic Ultrasound-guided Portal Pressure Gradient Measurement Is Technically Successful and Safe Without Deep Sedation: A Proof-of-Concept Case Series

The hepatic venous pressure gradient (HVPG), which is the difference between the wedged (WHVP) and free hepatic vein pressures (FHVP), is the gold standard to evaluate portal hypertension in patients with cirrhosis 1 Bosch J Abraldes JG Berzigotti A et al. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol. 2009; 6: 573-582 Crossref PubMed Scopus (436) Google Scholar . Unfortunately, there currently exists a gap in the evaluation of patients with pre-sinusoidal portal hypertension, where HVPG is known to underestimate portal pressure. Endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPG) has recently brought back the possibility of safely obtaining direct portal vein pressure (PVP) and represents a long-awaited less-invasive diagnostic tool for patients with suspected pre-sinusoidal portal hypertension.

S2005 Effects of Endoscopic Gastric Plication on Portal Pressure Gradient in a Patient With Non-Alcoholic Steatohepatitis Cirrhosis

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide with the prevalence approaching 90% in patients with obesity. Nonalcoholic steatohepatitis (NASH) is an aggressive form of NAFLD with an increased risk of cirrhosis. The treatment for NASH is limited to lifestyle modification. Case Description/Methods: Our patient was a 68-year-old woman with obesity and compensated NASH cirrhosis. She underwent an attempted Roux-en-Y gastric bypass, which was aborted due to cirrhosis. Transient elastography suggested cirrhosis with liver stiffness of 17 kPa. This case represents the convergence of endobariatrics and endohepatology. Specifically, we demonstrate the use of endoscopic gastric plication (EGP) to treat obesity and NASH in a patient with cirrhosis, as well as the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement to monitor its changes following EGP. Prior to EGP, she underwent EUS-guided PPG measurement. Specifically, a transgastric transhepatic puncture with a 25-gauge fine needle aspiration needle into the hepatic vein was achieved. The manometer and needle were flushed with heparinized saline solution. The manometer reading rose and plateaued. The process was repeated at least two more times and the average manometer number represented hepatic venous pressure (HVP). The needle was slowly withdrawn under Doppler. Subsequently, the portal vein was punctured, and the same steps repeated to measure the portal vein pressure (PVP). In this case, the average HVP and PVP were 17 mmHg and 28.5 mmHg. Therefore, her PPG prior to EGP was 11.5 mmHg. The patient then underwent an EGP procedure. The first set of plications was placed in the distal gastric body perpendicular to the length of the stomach to reduce its width. The second and third sets of plications were placed longitudinally to shorten the gastric length. The last set of plications was then placed at the proximal gastric body to further reduce its width. At 9 months, her weight decreased from 279 to 255 pounds, representing an 8.6% weight loss. Her liver stiffness decreased from 17 to 7.6 kPa, suggesting regression from stage 4 to stage 2 fibrosis. A follow-up PPG showed a PPG of 8 mmHg, representing a 30% reduction. Discussion: This case demonstrates the safety and efficacy profile of EGP for the treatment of compensated NASH cirrhosis with improvement in liver fibrosis and PPG. Watch video at https://bit.ly/3i0axL1.

Effects of endoscopic gastric plication on portal pressure gradient in a patient with nonalcoholic steatohepatitis cirrhosis.

Video 1Endoscopic gastric plication (EGP) to treat obesity and nonalcoholic steatohepatitis (NASH) in a patient with compensated cirrhosis, as well as the application of EUS-guided portal pressure gradient (EUS-PPG) measurement to monitor changes in PPG after EGP.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy—which revolves around glue injection, endovascular coil placement/embolization, and combination of both—has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

"One stop" liver-focused endoscopy: EUS-guided portal pressure gradient measurement technique.

Referral for abnormal liver chemistry is one of the most frequently encountered reasons for visits to gastroenterologists and hepatologists, particularly given the versatility and vulnerability of the liver.1Kwo P.Y. Cohen S.M. Lim J.K. ACG clinical guideline: evaluation of abnormal liver chemistries.Am J Gastroenterol. 2017; 112: 18-35Crossref PubMed Scopus (395) Google Scholar Here, we present a 40-year-old man with class III obesity, essential hypertension, and hyperlipidemia who was referred for further diagnostic workup of his abnormal liver chemistry. Despite periods of significant weight loss, his liver transaminases had remained elevated over the prior 10 years (alanine aminotransferase 20-93 U/L, aspartate aminotransferase 20-71 U/L). Diagnostic workup included an abdominal ultrasound with evidence of hepatic steatosis and transient elastography (Fibroscan) that demonstrated a liver stiffness of 12.8 kPa, S3 (marked steatosis), and F3 (severe fibrosis). After reviewing the risks, benefits, and alternatives, the decision was made to perform an EGD to evaluate for stigmata of portal hypertension and an EUS to obtain a liver biopsy specimen and portal pressure gradient (PPG) measurements. The patient was intubated and remained in the supine position for the entirety of the procedure (Video 1, available online at www.VideoGIE.org). Initially, an EGD was performed, with no endoscopic evidence of varices or stigmata of portal hypertension. Next, the EUS examination was performed. The left lobe of the liver appeared diffusely hyperechoic, suggestive of steatosis. Real-time elastography was then performed on the left and right lobes of the liver to assess liver stiffness. The region of interest was positioned over the hepatic parenchyma, and an average of 10 measurements was obtained from each lobe of the liver. Mean liver stiffness was 11.5 kPa. The EchoTip Insight Portosystemic Pressure Gradient Measurement System (Cook Medical, Bloomington, Ind, USA) then was set up, involving a 25-gauge FNA needle, noncompressible tubing, a compact digital manometer, and heparinized saline solution. The middle hepatic vein was first identified and punctured using a transgastric approach. Once the needle tip was seen within the vessel, approximately 1 to 2 mL of heparinized saline solution was used to flush the needle. The pressure reading on the manometer was obtained and recorded once stable. This process was repeated a total of 3 times, including repeat flushes of heparinized saline solution to obtain the mean hepatic vein pressure measurement. Next, the umbilical portion of the left portal vein was identified, and using the aforementioned approach, the process was repeated 3 times to obtain the mean portal vein pressure measurement. The PPG was calculated by subtracting the mean hepatic vein pressure (16.4 mm Hg) from the mean portal vein pressure (23.4), which measured 7 mm Hg (consistent with preclinical portal hypertension). Last, EUS-guided liver biopsy was performed. Using a 19-gauge EUS–fine needle biopsy needle primed with heparin, we performed a transgastric puncture to obtain a sample from the left lobe of the liver. This process was then repeated using a transduodenal approach to obtain tissue from the right lobe of the liver. Liver core was then expressed onto a slide and sent to surgical pathology. The patient was discharged home after endoscopy without any adverse events. Surgical pathology from the liver biopsy revealed mild steatohepatitis with stage 0-1/4 fibrosis (Fig. 1). On outpatient follow-up, the patient was started on a stricter diet and exercise regimen for weight loss. EUS-guided applications have been increasing over the past decade; today, both endoscopy and echoendoscopy offer tremendous diagnostic information to help guide management in the workup of liver disease.2Samarasena J. Chang K.J. Endo-hepatology: a new paradigm.Endosc Ultrasound. 2018; 7: 219-222Crossref PubMed Scopus (6) Google Scholar In particular, EUS-guided liver biopsy has emerged as a safe and minimally invasive approach and an alternative to a percutaneous technique and now can be paired with EUS-guided real-time elastography and PPG measurement.3Huang J.Y. Samarasena J.B. Tsujino T. et al.EUS-guided portal pressure gradient measurement with a simple novel device: a human pilot study.Gastrointest Endosc. 2017; 85: 996-1001Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,4Shah A. Martinez I.C. Valentin N. et al.Efficacy and safety of endoscopic ultrasound-guided liver biopsies in parenchymal liver diseases: a systematic review and meta-analysis.Am J Gastroenterol. 2018; 113: S565-S566Crossref Google Scholar Here, we demonstrate the safety and technique of EUS-guided PPG measurement in the diagnostic workup of abnormal liver tests. Dr Sharaiha is a consultant for Boston Scientific and Apollo Endosurgery (terminated). All other authors disclosed no financial relationships. https://www.videogie.org/cms/asset/91a9cbf3-9569-4652-812c-a82edde33120/mmc1.mp4Loading ... Download .mp4 (65.17 MB) Help with .mp4 files Video 1“One stop” liver-focused endoscopy: EUS-guided portal pressure gradient measurement technique.

EUS-guided portal pressure gradient measurement in patients with acute or subacute portal hypertension

EUS-guided portal pressure gradient (EUS-PPG) measurement is a novel method to evaluate portal hypertension severity. In this study, we determined the consistency between EUS-PPG and hepatic venous pressure gradient (HVPG) measurements in patients with acute or subacute portal hypertension. Twelve patients were prospectively enrolled. EUS-PPG measurements were performed using a 22-gauge FNA needle and a central venous pressure measurement monitor. The HVPG measurements were performed using the transjugular approach. If an HVPG measurement was not attainable and the patient underwent transjugular intrahepatic portosystemic shunt (TIPS) treatment, a PPG was recorded as a reference standard during the procedure. We assessed the feasibility and safety of EUS-PPG and calculated the correlation between the 2 measurements. EUS-PPG measurements were successful in 11 patients (91.7%). Subsequent HVPG measurements failed in 2 patients with Budd-Chiari syndrome (hepatic vein occlusion subtype), 1 of whom underwent TIPS treatment to obtain transjugular PPG data. A small shunt was found during 1 HVPG measurement that introduced inaccuracy. Nine patients were included in the statistical analysis. Mean EUS-PPG and HVPG/PPG (transjugular) were 18.07 ± 4.32mm Hg and 18.82 ± 3.43mm Hg, respectively. Pearson's correlation coefficient between the 2 methods was .923 (P< .001). EUS-PPG measurement using a 22-gauge FNA needle was a safe and accurate method to evaluate portal hypertension and has the potential to supplement the measurement of HVPG in liver diseases. (Clinical trial registration number: ChiCTR1800017317.).

665 EUS-GUIDED PORTAL PRESSURE GRADIENT MEASUREMENT SAFELY PERFORMED WITH EUS-GUIDED LIVER BIOPSY: ENDOHEPATOLOGY IN PRACTICE

The portal pressure gradient (PPG) is useful to predict the development of complications of portal hypertension (PH). Recently, we showed the feasibility and safety of a simple novel technique for Endoscopic ultrasound (EUS) guided PPG measurement (PPGM) in a pilot study. EUS-guided liver biopsy (EUS-LB) has been shown to be a safe and effective alternative to percutaneously or Interventional Radiology performed liver biopsy for the diagnosis of liver disease. We aimed to assess feasibility and safety of concomitant EUS-guided PPGM with EUS-LB in a single session. Secondarily, we aimed to evaluate the correlation between PPG and clinical markers of PH in an expanded clinical series. This was a retrospective study of EUS-PPGM at single tertiary endoscopy center that enrolled 76 consecutive patients suspected of liver cirrhosis between February 2014 and October 2019. Technical success rate of EUS-PPGM was 100% without any severe adverse events. PPG ranged from 0 to 27.3 mm Hg. There was excellent correlation between PPG and clinical parameters of PH including the presence of clinical features of cirrhosis (11.12 vs 3.55 mmHg, p < 0.001), varices (14.01 vs 4.7 mmHg, p <0.001), portal hypertensive gastropathy (16.37 vs 5.87 mmHg, p < 0.001), and thrombocytopenia (11.1 vs 4.51 mmHg, p < 0.01). Platelet count also had a moderate negative correlation with PPG (R = –0.579). EUS-guided liver biopsies were performed in 61 patients (80.2%). All biopsies were deemed adequate for achieving histologic diagnosis by our pathologists. There were no early or late major adverse events. This series is the largest on EUS guided portal pressure measurement to date. EUS-guided PPG measurement using a 25-gauge needle and compact manometer correlates well with clinical markers of portal hypertension and appears safe in this study with an expanded selection of patients. EUS-LB can be performed safely at the same session as EUS-PPGM further adding value to the endoscopic evaluation of the patient with liver disease.

Endoscopic ultrasound-guided portal pressure gradient measurement: a pilot animal study

Objective To evaluate the feasibility and safety of endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) measurement in the normal porcine model. Methods Four pigs, 2 male and 2 female, aged 8-12 months, weighing 20-30 kg were selected in the experiment. Under general anesthesia and EUS guidance, a 22 G fine needle connected to electrocardiograph monitor with a central vein pressure manometer was used to puncture and measure pressures in the portal vein (PV) and hepatic vein (HV) or inferior vena cava (IVC). Pressures were measured three times for each vessel and the mean pressure was recorded. The PPG was recorded as the difference between the PV pressure and HV or IVC pressure. Vital signs during and after the procedure and operation-related complications were monitored. Results EUS-PPG measurement was successful in all targeted vessels. The PV pressure, HV or IVC pressure, and PPG was 11.0±1.0 mmHg(1 mmHg=0.133 kPa), 7.3±1.1 mmHg and 3.8±0.9 mmHg, respectively. No adverse event occurred. Conclusion EUS-PPG measurement has a high successful rate and reliable accuracy and safety reflecting the portal vein pressure. Key words: Endosonography; Hypertension, portal; Portal pressure gradient; Hepatic venous pressure gradient

EUS-guided portal pressure gradient measurement with a simple novel device: a human pilot study

Background and AimsPortal hypertension is a serious adverse event of liver cirrhosis. Recently, we developed a simple novel technique for EUS-guided portal pressure gradient (PPG) measurement (PPGM). Our animal studies showed excellent correlation between EUS-PPGM and interventional radiology-acquired PPGM. In this video we demonstrate the results of the first human pilot study of EUS-PPGM in patients with liver disease.MethodsEUS-PPGM was performed by experienced endosonographers using a linear echoendoscope, a 25-gauge FNA needle, and a novel compact manometer. The portal vein and hepatic vein (or inferior vena cava) were targeted by use of a transgastric or transduodenal approach. Feasibility was defined as successful PPGM in each patient. Safety was based on adverse events captured in a postprocedural interview.ResultsTwenty-eight patients underwent EUS-PPGM with 100% technical success and no adverse events. PPG ranged from 1.5 to 19 mm Hg and had excellent correlation with clinical parameters of portal hypertension, including the presence of varices (P = .0002), PH gastropathy (P = .007), and thrombocytopenia (P = .036).ConclusionThis novel technique of EUS-PPGM using a 25-gauge needle and compact manometer is feasible and appears safe. Given the availability of EUS and the simplicity of the manometry setup, EUS-guided PPG may represent a promising breakthrough for procuring indispensable information in the management of patients with liver disease.