Measurement of Portal Pressure and its Application in the Clinical Setting

Jonathan D. Pierce; Anthony M. Esparaz; Raza Malik

doi:10.1055/s-0038-1629893

Digestive Disease Interventions, Table of Contents

Digestive Disease Interventions 2017; 01(04): 241-247
DOI: 10.1055/s-0038-1629893

Review Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA

Measurement of Portal Pressure and its Application in the Clinical Setting

Jonathan D. Pierce

¹George Washington University School of Medicine and Health Sciences, Washington, District of Columbia

,

Anthony M. Esparaz

²Division of Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

,

Raza Malik

³Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts

› Author Affiliations

Abstract

Portal hypertension is a severe, yet common sequela of patients with chronic liver disease and is responsible for many of the complications seen in this population. Measurement of the hepatic venous pressure gradient (HVPG) is the current gold standard technique for identifying and evaluating the severity of portal hypertension. Any increase in HVPG to ≥10 mm Hg is considered clinically significant portal hypertension. Above this threshold, complications of portal hypertension begin to manifest. In addition to assessing portal hypertension, various HVPG thresholds have been shown to have strong prognostic value for risk of complications and therapeutic failure, as well as survival in patients with chronic liver disease. These clinical applications include quantification of disease progression and regression in chronic viral hepatitis, acute alcoholic hepatitis, and hepatocellular carcinoma. Other applications include preoperative evaluation of liver resection and transplantation in patients with cirrhosis and hepatocellular carcinoma, assessment of response to therapy for portal hypertension, and identification of the need for transjugular intrahepatic portosystemic shunt (TIPS) revision.

Keywords

portal hypertension - hepatic venous pressure gradient - variceal hemorrhage - portal pressure - cirrhosis

Full Text

References

References
1 Bosch J, Abraldes JG, Berzigotti A, García-Pagan JC. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol 2009; 6 (10) 573-582
2 Abraldes JG, Sarlieve P, Tandon P. Measurement of portal pressure. Clin Liver Dis 2014; 18 (Issue 4): 779-792
3 Leung JC, Loong TC, Pang J, Wei JL, Wong VW. Invasive and non-invasive assessment of portal hypertension. Hepatol Int 2017; ( e-pub ahead of print)
4 Suk KT. Hepatic venous pressure gradient: clinical use in chronic liver disease. Clin Mol Hepatol 2014; 20 (01) 6-14
5 Sanyal AJ, Bosch J, Blei A, Arroyo V. Portal hypertension and its complications. Gastroenterology 2008; 134 (06) 1715-1728
6 Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right. Hepatology 2004; 39 (02) 280-282
7 Perelló A, Escorsell A, Bru C. , et al. Wedged hepatic venous pressure adequately reflects portal pressure in hepatitis C virus-related cirrhosis. Hepatology 1999; 30 (06) 1393-1397
8 Boyer TD, Triger DR, Horisawa M, Redeker AG, Reynolds TB. Direct transhepatic measurement of portal vein pressure using a thin needle. Comparison with wedged hepatic vein pressure. Gastroenterology 1977; 72 (4 Pt 1): 584-589
9 Pomier-Layrargues G, Kusielewicz D, Willems B. , et al. Presinusoidal portal hypertension in non-alcoholic cirrhosis. Hepatology 1985; 5 (03) 415-418
10 Lin HC, Tsai YT, Lee FY. , et al. Comparison between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related cirrhosis. J Hepatol 1989; 9 (03) 326-330
11 Thalheimer U, Leandro G, Samonakis DN, Triantos CK, Patch D, Burroughs AK. Assessment of the agreement between wedge hepatic vein pressure and portal vein pressure in cirrhotic patients. Dig Liver Dis 2005; 37 (08) 601-608
12 Steinlauf AF, Garcia-Tsao G, Zakko MF, Dickey K, Gupta T, Groszmann RJ. Low-dose midazolam sedation: an option for patients undergoing serial hepatic venous pressure measurements. Hepatology 1999; 29 (04) 1070-1073
13 La Mura V, Abraldes JG, Berzigotti A. , et al. Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical-hemodynamic correlation study. Hepatology 2010; 51 (06) 2108-2116
14 Maleux G, Willems E, Fieuws S. , et al. Prospective study comparing different indirect methods to measure portal pressure. J Vasc Interv Radiol 2011; 22 (11) 1553-1558
15 Zipprich A, Winkler M, Seufferlein T, Dollinger MM. Comparison of balloon vs. straight catheter for the measurement of portal hypertension. Aliment Pharmacol Ther 2010; 32 (11-12): 1351-1356
16 Thabut D, Moreau R, Lebrec D. Noninvasive assessment of portal hypertension in patients with cirrhosis. Hepatology 2011; 53 (02) 683-694
17 McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348 (12) 1123-1133
18 Valla DC, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. J Hepatol 2000; 32 (05) 865-871
19 Gluud C, Brok J, Gong Y, Koretz RL. Hepatology may have problems with putative surrogate outcome measures. J Hepatol 2007; 46 (04) 734-742
20 Procopet B, Berzigotti A. Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterol Rep (Oxf) 2017; 5 (02) 79-89
21 Silva-Junior G, Baiges A, Turon F. , et al. The prognostic value of hepatic venous pressure gradient in patients with cirrhosis is highly dependent on the accuracy of the technique. Hepatology 2015; 62 (05) 1584-1592
22 Berzigotti A, Seijo S, Reverter E, Bosch J. Assessing portal hypertension in liver diseases. Expert Rev Gastroenterol Hepatol 2013; 7 (02) 141-155
23 Burroughs AK, Groszmann R, Bosch J. , et al. Assessment of therapeutic benefit of antiviral therapy in chronic hepatitis C: is hepatic venous pressure gradient a better end point?. Gut 2002; 50 (03) 425-427
24 Kumar M, Kumar A, Hissar S. , et al. Hepatic venous pressure gradient as a predictor of fibrosis in chronic liver disease because of hepatitis B virus. Liver Int 2008; 28 (05) 690-698
25 Vincent JK, Stark C, Shields JT, Bhave AD, Morris CS. Hepatic venous pressure gradient correlates with advanced hepatic fibrosis: a retrospective review. Abdom Radiol (NY) 2017; 42 (11) 2609-2614
26 Rincon D, Ripoll C, Lo Iacono O. , et al. Antiviral therapy decreases hepatic venous pressure gradient in patients with chronic hepatitis C and advanced fibrosis. Am J Gastroenterol 2006; 101 (10) 2269-2274
27 Roberts S, Gordon A, McLean C. , et al. Effect of sustained viral response on hepatic venous pressure gradient in hepatitis C-related cirrhosis. Clin Gastroenterol Hepatol 2007; 5 (08) 932-937
28 Reiberger T, Rutter K, Ferlitsch A. , et al. Portal pressure predicts outcome and safety of antiviral therapy in cirrhotic patients with hepatitis C virus infection. Clin Gastroenterol Hepatol 2011; 9 (07) 602-8.e1
29 Afdhal N, Everson GT, Calleja JL. , et al. Effect of viral suppression on hepatic venous pressure gradient in hepatitis C with cirrhosis and portal hypertension. J Viral Hepat 2017; 24 (10) 823-831
30 Rehm J, Samokhvalov AV, Shield KD. Global burden of alcoholic liver diseases. J Hepatol 2013; 59 (01) 160-168
31 Poynard T, Degott C, Munoz C, Lebrec D. Relationship between degree of portal hypertension and liver histologic lesions in patients with alcoholic cirrhosis. Effect of acute alcoholic hepatitis on portal hypertension. Dig Dis Sci 1987; 32 (04) 337-343
32 Sen S, Mookerjee RP, Cheshire LM, Davies NA, Williams R, Jalan R. Albumin dialysis reduces portal pressure acutely in patients with severe alcoholic hepatitis. J Hepatol 2005; 43 (01) 142-148
33 Rincon D, Lo Iacono O, Ripoll C. , et al. Prognostic value of hepatic venous pressure gradient for in-hospital mortality of patients with severe acute alcoholic hepatitis. Aliment Pharmacol Ther 2007; 25 (07) 841-848
34 Altamirano J, Miquel R, Katoonizadeh A. , et al. A histologic scoring system for prognosis of patients with alcoholic hepatitis. Gastroenterology 2014; 146 (05) 1231-9.e1 , 6
35 Ripoll C, Bañares R, Rincón D. , et al. Influence of hepatic venous pressure gradient on the prediction of survival of patients with cirrhosis in the MELD Era. Hepatology 2005; 42 (04) 793-801
36 Kim TY, Lee JG, Sohn JH. , et al. Hepatic venous pressure gradient predicts long-term mortality in patients with decompensated cirrhosis. Yonsei Med J 2016; 57 (01) 138-145
37 Blasco A, Forns X, Carrión JA. , et al. Hepatic venous pressure gradient identifies patients at risk of severe hepatitis C recurrence after liver transplantation. Hepatology 2006; 43 (03) 492-499
38 Samonakis DN, Cholongitas E, Thalheimer U. , et al. Hepatic venous pressure gradient to assess fibrosis and its progression after liver transplantation for HCV cirrhosis. Liver Transpl 2007; 13 (09) 1305-1311
39 Carrión JA, Navasa M, García-Retortillo M. , et al. Efficacy of antiviral therapy on hepatitis C recurrence after liver transplantation: a randomized controlled study. Gastroenterology 2007; 132 (05) 1746-1756
40 Ripoll C, Groszmann RJ, Garcia-Tsao G. , et al; Portal Hypertension Collaborative Group. Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis. J Hepatol 2009; 50 (05) 923-928
41 Forner A, Bruix J. East meets the West--portal pressure predicts outcome of surgical resection for hepatocellular carcinoma. Nat Clin Pract Gastroenterol Hepatol 2009; 6 (01) 14-15
42 Qi X, Zhang X, Li Z. , et al. HVPG signature: a prognostic and predictive tool in hepatocellular carcinoma. Oncotarget 2016; 7 (38) 62789-62796
43 European Association For The Study Of The Liver; European Organisation For Research And Treatment Of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 56 (04) 908-943
44 Bruix J, Sherman M. ; American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53 (03) 1020-1022
45 Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology 1999; 30 (06) 1434-1440
46 Bruix J, Castells A, Bosch J. , et al. Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure. Gastroenterology 1996; 111 (04) 1018-1022
47 He W, Zeng Q, Zheng Y. , et al. The role of clinically significant portal hypertension in hepatic resection for hepatocellular carcinoma patients: a propensity score matching analysis. BMC Cancer 2015; 15: 263
48 Cucchetti A, Cescon M, Golfieri R. , et al. Hepatic venous pressure gradient in the preoperative assessment of patients with resectable hepatocellular carcinoma. J Hepatol 2016; 64 (01) 79-86
49 Zhong JH, Li LQ. Portal hypertension should not be a contraindication of hepatic resection to treat hepatocellular carcinoma with compensated cirrhosis. Hepatology 2015; 62 (03) 977-978
50 Yang T, Lau WY, Zhang H, Wu M, Shen F. Should surgery be carried out in patients with hepatocellular carcinoma with portal hypertension?. Hepatology 2015; 62 (03) 976
51 Zhong JH, Li H, Xiao N. , et al. Hepatic resection is safe and effective for patients with hepatocellular carcinoma and portal hypertension. PLoS One 2014; 9 (09) e108755
52 Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985; 5 (03) 419-424
53 Casado M, Bosch J, García-Pagán JC. , et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998; 114 (06) 1296-1303
54 Addley J, Tham TC, Cash WJ. Use of portal pressure studies in the management of variceal haemorrhage. World J Gastrointest Endosc 2012; 4 (07) 281-289
55 Groszmann RJ, Bosch J, Grace ND. , et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990; 99 (05) 1401-1407
56 Feu F, García-Pagán JC, Bosch J. , et al. Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis. Lancet 1995; 346 (8982): 1056-1059
57 Abraldes JG, Tarantino I, Turnes J, Garcia-Pagan JC, Rodés J, Bosch J. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology 2003; 37 (04) 902-908
58 Abraldes JG, Villanueva C, Bañares R. , et al; Spanish Cooperative Group for Portal Hypertension and Variceal Bleeding. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 2008; 48 (02) 229-236
59 Albillos A, Bañares R, González M. , et al. Value of the hepatic venous pressure gradient to monitor drug therapy for portal hypertension: a meta-analysis. Am J Gastroenterol 2007; 102 (05) 1116-1126
60 D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology 2006; 131 (05) 1611-1624
61 Villanueva C, Aracil C, Colomo A. , et al. Acute hemodynamic response to beta-blockers and prediction of long-term outcome in primary prophylaxis of variceal bleeding. Gastroenterology 2009; 137 (01) 119-128
62 Bureau C, Péron JM, Alric L. , et al. “A La Carte” treatment of portal hypertension: Adapting medical therapy to hemodynamic response for the prevention of bleeding. Hepatology 2002; 36 (06) 1361-1366
63 Burroughs AK, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis. Scand J Gastroenterol 2002; 37 (03) 249-252
64 Garcia-Tsao G. Transjugular intrahepatic portosystemic shunt in the management of refractory ascites. Semin Intervent Radiol 2005; 22 (04) 278-286
65 Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. ; Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46 (03) 922-938
66 Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65 (01) 310-335
67 de Franchis R. ; Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752