Endoscopic ultrasound guided portal pressure gradient: safety aspects, clinical relevance and technical issues to improve the procedure

Abstract

Introduction and Objectives: Endoscopic ultrasound guided portal pressure gradient measurement (EUS-PPGm) would provide useful clinical information in patients with liver diseases. However, there is yet scarcely data on the clinical relevance of this EUS-guided procedure.We report our experience on EUS-PPGm focus on safety, clinical relevant findings, technical drawbacks and how to overcome them, aiming to make this procedure more safe, accurate and available. Materials and Patients: EUS-PPGm was performed with a therapeutic echoendoscope and a dedicated 25G needle in 30 consecutive patients. Assessment of NAFLD 25; idiopathic portal hypertension 3; evaluation for curative therapy in hepatocellular carcinoma (HCC) 2. EUS-guided bilobar liver biopsies (EUS-BLB) were also immediately performed in 26 patients (87%) with a 19G needle Results: EUS-PPGm was obtained in 25/30 patients (83%) being >5 mmHg in 10/22 NALFD patients (45%) without endoscopic and/or ultrasonographic signs of portal hypertension neither liver fibrosis on EUS-BLB. Mean time to obtain EUS-PPGm was 21±2 minutes.EUS-PPGm was not obtained in 5 cases. In 4 cases for excesive use of the elevator and up&down wheel and bending of the needle. In another case for exacerbating breathing movements. The hepatic and portal vein were difficult to punction in one and two cases, respectively having to transverse the vessels and reposition the needle.A self-limited bleeding from the cardias and a mild epigastric pain 2 day after a combined procedure were observed without other adverse events one month later. Conclusions: EUS-guided PPGm, even when combined with EUS-BLB, seems safe providing useful clinical information. Almost half of patients affected with NAFLD have portal hypertension diagnosed precociously in reversible stages providing a useful tool in precision Medicine, especially in the setting of obesity pandemic. There are technical aspects related to the needle and the position of the echoendoscope that should be known to improve the safety, accuracy and availibility of this procedure.