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Portal hypertension

Key sources
The following summarized guidelines for the evaluation and management of portal hypertension are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2023; 2018; 2010), the Baveno VII Consensus Workshop (Baveno VII 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2022), the European Society of Cardiology (ESC/ERS 2022), the American College of Gastroenterology (ACG 2022; 2016), the American Association for the Study of Liver Diseases (AASLD 2021; 2017; 2014), the British Association for the Study of the Liver (BASL/BSG 2021), the Advancing Liver Therapeutic Approaches Consortium (ALTA 2021), the World Society of Emergency Surgery (WSES/AAST 2021), the Society of Critical Care Medicine (SCCM 2020), the European Society of Medical Oncology (ESMO 2018), the European Society for Vascular Surgery (ESVS 2017), the International Liver Transplantation Society (ILTS 2016), the British Society of Gastroenterology (BSG 2015), the American Society for Gastrointestinal Endoscopy (ASGE 2014), and the American College of Gastroenterology (ACG/AASLD 2007).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria, clinical findings, ESMO: diagnose clinically important portal hypertension based on the presence of esophageal varices and/or splenomegaly with blood platelet counts of 100×10⁹ cells/L.
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  • Diagnostic criteria (HPVG)

  • Diagnostic criteria (liver elastography)

  • Diagnostic criteria (spleen elastography)

2.Classification and risk stratification

Prognosis: recognize that the presence of clinically significant portal hypertension, determined either by hepatic venous pressure gradient ≥ 10 mmHg or by clinical manifestations of portal hypertension, is associated with a higher risk of decompensation and mortality in patients with cirrhosis undergoing liver resection for HCC.
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3.Diagnostic investigations

HVPG measurement, technical considerations: prefer using an end-hole, compliant balloon occlusion catheter over a conventional straight catheter to reduce the random error of wedged hepatic vein pressure measurements.
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  • HVPG measurement (considerations in various etiologies)

  • HVPG measurement (pre- and post-TIPS)

  • Evaluation of variceal hemorrhage

  • Evaluation of ascites (initial evaluation)

  • Evaluation of ascites (diagnostic paracentesis)

  • Evaluation of SBP

  • Evaluation of hepatopulmonary syndrome

  • Evaluation of portopulmonary hypertension

  • Evaluation for pulmonary hypertension

  • Evaluation for mesenteric vein thrombosis

4.Medical management

Management of the etiological factor: remove/suppress the primary etiological factor to meaningfully decrease the hepatic venous pressure gradient in most patients and substantially reduce the risk of hepatic decompensation, including:
achieve sustained virological response in patients with HCV infection
suppress HBV in the absence of HDV coinfection
achieve long-term abstinence from alcohol in patients with ALD
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  • Primary prevention of gastroesophageal varices

  • Primary prevention of variceal hemorrhage

  • Secondary prevention of variceal hemorrhage

  • Management of portal hypertensive gastropathy

  • Management of variceal hemorrhage (vasoactive agents)

  • Management of variceal hemorrhage (intravenous fluids)

  • Management of variceal hemorrhage (antibiotic prophylaxis)

  • Management of variceal hemorrhage (blood product transfusion)

  • Management of variceal hemorrhage (endoscopic variceal ligation)

  • Management of variceal hemorrhage (endoscopic sclerotherapy)

  • Management of variceal hemorrhage (TIPS)

  • Management of variceal hemorrhage (balloon-occluded retrograde transvenous obliteration)

  • Management of variceal hemorrhage (balloon tamponade)

  • Management of variceal hemorrhage (Sengstaken-Blakemore tube)

  • Management of variceal hemorrhage (management of gastric hemorrhage)

  • Management of variceal hemorrhage (management of anorectal hemorrhage)

  • Management of ascites (salt restriction)

  • Management of ascites (diuretics)

  • Management of ascites (IV albumin)

  • Management of ascites (correction of hyponatremia)

  • Management of ascites (therapeutic paracentesis)

  • Management of ascites (TIPS)

  • Management of ascites (implantable peritoneal pump)

  • Management of ascites (liver transplantation)

  • Prevention of SBP (primary prevention)

  • Prevention of SBP (secondary prevention)

  • Management of SBP (IV albumin)

  • Management of SBP (antibiotic therapy)

  • Management of hepatorenal syndrome (pharmacotherapy)

  • Management of hepatorenal syndrome (RRT)

  • Management of hepatorenal syndrome (TIPS)

  • Management of hepatorenal syndrome (therapeutic paracentesis)

  • Management of hepatopulmonary syndrome

  • Management of portopulmonary hypertension

  • Antithrombotic therapy

  • Statin therapy

5.Specific circumstances

Pregnant patients
As per EASL 2023 guidelines:
Provide pre-pregnancy counseling and calculate risk scores to characterize the risk profile and determine the likelihood of complications before pregnancy.
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Obtain a screening endoscopy within 1 year before conception to assess for the presence of clinically significant varices and for primary prophylaxis to be instituted as appropriate in patients with known portal hypertension.
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  • Patients with pulmonary arterial hypertension

6.Follow-up and surveillance

Serial liver elastography: repeat an index liver stiffness measurement ≥ 10 kPa in fasting conditions as soon as feasible or complement with an established serum marker of fibrosis (FIB-4 ≥ 2.67, enhance liver fibrosis test ≥ 9.8, FibroTest ≥ 0.58 for alcohol-related/viral liver disease, FibroTest ≥ 0.48 for NAFLD) since transient elastography can lead to false-positive results.
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  • Surveillance for gastroesophageal varices