EUS Guided Portal-systemic Pressure Gradient Measurement
EUS Guided Portal-systemic Pressure Gradient Measurement
Portal hypertension is characterised by an increased portal pressure gradient (PPG), that is
 the difference in pressure between the portal vein and the inferior vena cava (IVC). Portal
 hypertension is a consequence of cirrhosis resulting from chronic hepatitis. Patients with
 portal hypertension are at risk of developing complications including oesophageal or gastric
 varices, variceal bleeding, ascites, spontaneous bacterial peritonitis, hepatic
 encephalopathy and mortality.

 Albeit its clinical significance, direct measurement of portal venous pressure to document
 portal hypertension has traditionally been difficult. The portal vein pressure can be
 measured by transhepatic or transvenous methods but the procedure carries a risk of
 intra-peritoneal bleeding. Furthermore, the IVC pressure measurement requires further
 transjugular catheterisation. Hence, the technique is rarely used. Currently, the gold
 standard in measurement of portal hypertension is via measurement hepatic venous pressure
 gradient (HVPG). The HVPG has been shown to correlate with risk of clinical decompensation,
 development of varices, hepatocellular carcinoma, variceal bleeding, spontaneous bacterial
 peritonitis and mortality. Nevertheless, the technique has a low acceptance rate amongst
 patients and it may not be available even in tertiary medical centres.

 Recently, the use of EUS-guided approach for measurement of portal pressure gradient (PPGM)
 has been shown to be feasible. The technical success rate was 100% and no adverse events were
 reported. Measurements obtained with the EUS approach was shown to correlate excellently with
 clinical parameters of portal hypertension including presence of varices, portal hypertensive
 gastropathy and thrombocytopenia. Furthermore, the procedure could be performed at the same
 time of screening oesophagogastroduodenoscopy (OGD), that is frequently required for variceal
 screening in this group of patients. Hence, the aim of the current study is to investigate
 the feasibility of EUS-PPGM and correlate the risk of developing complications with the PPGM
 in patients that are suffering from chronic hepatitis.
Currently, the gold standard in measurement of portal hypertension is via measurement hepatic
 venous pressure gradient (HVPG). The HVPG has been shown to correlate with risk of clinical
 decompensation, development of varices, hepatocellular carcinoma, variceal bleeding,
 spontaneous bacterial peritonitis and mortality. The technique involves ultrasound guided
 puncture of the internal jugular vein, followed by passage of a balloon catheter from through
 the right atrium, IVC and right hepatic vein. The free hepatic vein venous pressure is then
 measured followed by the wedge balloon venous pressure. The HVPG is then calculated by
 subtracting the free hepatic venous pressure from the wedge balloon venous pressure. When
 HVPG is >10mmHg, the risk of developing varices is increased. If >12mmHg, then risk of
 variceal bleeding is increased. Mortality risk is increased when HVPG is >16-20mmHg.
 Nevertheless, the technique is technically difficult and it may not be available even in
 tertiary medical centres [8]. Furthermore, it requires the use of ionic contrast and also has
 a low acceptance rate amongst patients.

 The aim of the current study is to investigate the feasibility of EUS-PPGM using the novel
 device and correlate the risk of developing complications with the PPGM in patients that are
 suffering from chronic hepatitis.

 Recently, the use of EUS-guided approach for measurement of portal pressure gradient (PPGM)
 has been shown to be feasible. PPGM by the EUS approach was found to have excellent accuracy
 and strong correlation with pressure values obtained by the criterion standard transjugular
 wedged and free hepatic venous pressure measurements by interventional radiology in an animal
 model. Furthermore, in a pilot study involving 29 patients. The technical success rate was
 100% and no adverse events were reported. Measurements obtained with the EUS approach was
 shown to correlate excellently with clinical parameters of portal hypertension including
 presence of varices, portal hypertensive gastropathy and thrombocytopenia. Furthermore, the
 procedure could be performed at the same time of screening oesophagogastroduodenoscopy (OGD),
 that is frequently required for variceal screening in this group of patients. However,
 whether the technique could reproduce results similar to HVPG in humans is uncertain.
Inclusion Criteria:

 -  Suffering from chronic hepatitis induced cirrhosis

 -  Informed consent available

 Exclusion Criteria:

 -  Medical

 -  Child-Pugh Class C

 -  Uncorrected platelet count <50,000

 -  INR > 1.5 (natural)

 -  Anatomical

 -  Previous transjugular intrahepatic or surgical portosystemic shunt

 -  Portal vein thrombosis

 -  Anatomic alterations of the hepatic vasculature that prevent access to the portal vein
 or intrahepatic portion of the hepatic veins (identified at screening and/or during
 the endoscopic procedure).

 -  Previous history of spontaneous bacterial peritonitis within the previous three months

 -  Portopulmonary hypertension

 -  Cardiac decompensation

 -  Endoscopically Confirmed Exclusion Criteria

 -  Evidence of active GI bleeding (identified at screening and/or during the endoscopic
 procedure)

 -  If the volume of ascites in the path of the needle prevents apposition of the
 gastrointestinal tract and liver.

 -  Presence of gastric or duodenal ulcers, dieulafoy's lesion or cancers.