Endoscopic ultrasound portal pressure gradient: possible discrepancies in metabolic dysfunction-associated steatotic liver disease-related portal pressure measurements

We read with great interest the article “Correlation of endoscopic ultrasound-guided portal pressure gradient measurements with hepatic venous pressure gradient: a prospective study” by Martinez-Moreno et al. [1]. The study provides novel insights into the potential of the endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) as an alternative to hepatic venous portal gradient (HVPG) for measuring portal pressure in cirrhotic patients, demonstrating a strong correlation (intraclass correlation coefficient of 0.82) between EUS-PPG and HVPG. However, significant discrepancies (≥5 mmHg) were found in four subjects, 75% of whom had metabolic dysfunction-associated steatotic liver disease (MASLD). In other words, almost half of MASLD patients exhibited notable portal pressure discrepancies between the two techniques.

Previous studies have demonstrated a presinusoidal component of portal pressure in MASLD, attributed to sinusoidal structural and functional disturbances secondary to fatty liver features [2]. This presinusoidal pressure develops also in precirrhotic stages, potentially increasing portal hypertension, and is not fully captured by noninvasive tests or portal hemodynamics, as HVPG mainly reflects sinusoidal and post-sinusoidal pressures [3] [4]. Importantly, similarly to Martinez-Moreno et al., another study measuring portal pressure through direct portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement found greater disagreement with HPVG measurements in patients with MASLD compared with those with hepatitis C virus [5].

These findings suggest that direct portal pressure measurements should be considered as an alternative to HVPG in patients without MASLD, given their excellent concordance. Further research is needed to assess the ability of portal hemodynamics, particularly EUS-PPG, to accurately capture presinusoidal portal pressure in MASLD. This approach would enhance the reliability of portal pressure assessments, facilitating the interpretation of results by elucidating the clinical significance of discrepancies between measurements. Consequently, it would refine the liver decompensation risk prediction and improve the management of MASLD patients.

Publication History

Article published online:
26 February 2025

• References

• 1 Martinez-Moreno B, Martínez Martínez J, Herrera I. et al. Correlation of EUS-guided portal pressure gradient measurements with hepatic venous pressure gradient: a prospective study. Endoscopy 2024;
• 2 Barberá A, Raurell I, García-Lezana T. et al. Steatosis as main determinant of portal hypertension through a restriction of hepatic sinusoidal area in a dietary rat nash model. Liver Int 2020; 40: 2732-2743
• 3 Baffy G, Bosch J. Overlooked subclinical portal hypertension in non-cirrhotic NAFLD: is it real and how to measure it?. J Hepatol 2022; 76: 458-463
• 4 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
• 5 Ferrusquía-Acosta J, Bassegoda O, Turco L. et al. Agreement between wedged hepatic venous pressure and portal pressure in non-alcoholic steatohepatitis-related cirrhosis. J Hepatol 2021; 74: 811-818