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Portal hypertension

Guidelines

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 American Association for the Study of Liver Diseases (AASLD 2024,2021,2017,2014), the World Federation for Ultrasound in Medicine and Biology (WFUMB 2024), the European Association for the Study of the Liver (EASL 2023,2018,2010), the American College of Gastroenterology ...
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Screening and diagnosis

Diagnostic criteria, clinical findings: as per ESMO 2018 guidelines, diagnose clinically important portal hypertension based on the presence of esophageal varices and/or splenomegaly with blood platelet counts of 100×10⁹ cells/L.
B
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  • Diagnostic criteria (HPVG)

  • Diagnostic criteria (liver elastography)

  • Diagnostic criteria (spleen elastography)

  • Diagnostic criteria (laboratory tests)

Classification and risk stratification

Prognosis: as per AASLD 2024 guidelines, insufficient evidence to support the use of blood- or imaging-based noninvasive liver disease assessments to predict clinical outcomes in patients with chronic liver disease and clinically significant portal hypertension.
I

Diagnostic investigations

HVPG measurement, technical considerations: as per Baveno VII 2022 guidelines, 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.
A
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  • HVPG measurement (considerations in various etiologies)

  • HVPG measurement (pre- and post-TIPS)

  • Liver elastography

  • Spleen elastography

  • 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

Medical management

Management of the etiological factor: as per Baveno VII 2022 guidelines, 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.
A
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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

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.
B
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.
B

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  • Patients with pulmonary arterial hypertension

Follow-up and surveillance

Serial liver elastography: as per WFUMB 2024 guidelines, recognize that a stable decrease in vibration-controlled transient elastography liver stiffness measurement < 20 kPa after removal/suppression of the primary etiologic factor indicates a significantly decreased risk of liver-related event-driven portal hypertension that becomes negligible < 10 kPa.
B

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  • Surveillance for gastroesophageal varices