Invasive and NoninvasiveMethods to Diagnose PortalHypertension and EsophagealVarices

INTRODUCTION

The development of portal hypertension (PH) is a crucial event in the evolution ofcirrhosis and is defined by an increase in portal pressure above the normal range of1 to 5 mm Hg, as measured by the hepatic vein pressure gradient (HVPG). Whenthe HVPG increases further to 10 mm Hg, PH is defined as clinically significant.

a crucial turningthe development

of esophageal varices and hepatic decompensation. It is therefore important from

ence of esophagogastric varices are the measurement of the hepatic vein pressuregradient (HVPG) and esophagogastroduodenoscopy.

Several methods have been tested as potential surrogates of HVPG: none of them hasproven accurate enough to predict the numerical value of HVPG.

With all methods proposed as noninvasive tests to predict the presence of varices, acertain number of patients with varices will be missed, and a variable number of unnec-essary endoscopies will still be done.

If one decides to adopt a noninvasive method to replace HVPG measurement or esoph-agogastroduodenoscopy, the potential benefits in terms of cost saving, availability, andpatient acceptancemust be weighted against the potential risks of misdiagnosis and inap-propriate therapeutic decisions.The authors declare that they have no conflict of interest.Gastroenterology Unit, Department of Clinical and Biomedical Sciences, Luigi Sacco UniversityHospital, University of Milan, Via G. B. Grassi 74, Milan 20157, Italy* Corresponding author.E-mail address: roberto.defranchis@unimi.it

Clin Liver Dis 18 (2014) 293302The occurrence of clinically significant portal hypertension (CSPH) ispoint in the natural history of cirrhosis, because it opens the way toKEY POINTSRoberto de Franchis, MD*, Alessandra DellEra, MD, PhD

KEYWORDS

Portal hypertension Esophageal varices Hepatic vein pressure gradient Esophagogastroduodenoscopy Transient elastography

The reference standard methods to measure portal pressure and to diagnose the pres-http://dx.doi.org/10.1016/j.cld.2013.12.002 liver.theclinics.com1089-3261/14/$ see front matter 2014 Elsevier Inc. All rights reserved.

prehepatic PH (eg, portal vein thrombosis) HVPG is normal or slightly increased.36

de Franchis & DellEra294Accurate measurement of the HVPG is crucial, because inaccuracy can lead toinappropriate clinical decisions. Therefore, several guidelines have been publishedon how to measure HVPG properly.7,8

The required equipment to measure HVPG is composed of a recorder with the capa-bility of producing permanent tracings of pressure values (with an upper limit of about3040 mm Hg), a quartz pressure transducer that can detect even subtle changes invenous pressure, and an occlusion balloon catheter. When measuring the WHVP orthe FHVP, the operators should wait for stabilization of the venous pressure and allmeasurements should be repeated at least 3 times to check reproducibility. Completeocclusion of the hepatic vein by the inflated balloon and the absence of venovenousshunts distally to the balloon should be routinely checked, to avoid an underestimationof the WHVP; this is usually done by injecting 5 mL of contrast medium through the tipof the catheter. All pressure tracings should be recorded and printed so that they canbe reviewed by independent observers. HVPG must be measured as the differencebetween WHVPs and FHVPs: this prevents the measurement from being influencedby changes in intra-abdominal pressure (eg, for ascites) and by inadequate positioninga clinical standpoint to assess the presence of CSPH and of esophageal varices.Indeed, international guidelines1 state that, In centers where adequate resourcesand expertise are available, HVPG measurement should be routinely used for diag-nostic and therapeutic indications and that All cirrhotic patients should be screenedfor varices at diagnosis. The reference standard technique to assess the presenceand severity of PH is the measurement of HVPG, whereas esophagogastroduodeno-scopy (EGD) is the gold-standard method for the diagnosis of esophageal varices.Both these methods are costly and invasive and perceived as unpleasant, and in addi-tion, HVPGmeasurement is available in specialized centers only. For these reasons, inthe last 10 years, methods aimed at determining noninvasively the presence of CSPHand of esophageal varices have been increasingly investigated.In this article, the technique of HVPG measurement for the assessment of portal

pressure and of EGD for the diagnosis of varices is described; also the performanceof several methods that have been proposed as noninvasive alternatives to HVPGand EGD is analyzed.

INVASIVE METHODS TO DIAGNOSE PH AND ESOPHAGEAL VARICESMeasurement of HVPG

Since 1951,2 HVPGmeasurement has replaced more invasive methods to assess por-tal pressure, such as splenic pulp manometry and percutaneous transhepatic or trans-venous catheterization of the portal vein, which were used previously.HVPG measurement is performed under local anesthesia via the internal jugular or

femoral vein using a balloon catheter. The catheter is advanced into a hepatic vein,and HVPG is obtained by measuring the difference between the wedged (WHVP)and the free (FHVP) hepatic venous pressures. The WHVP is obtained by inflatingthe balloon, thus occluding the hepatic vein, while the FHVP is measured with thecatheter floating freely in the vein lumen. The occlusion of one hepatic vein stopsblood flow in the hepatic veins and in the sinusoids, equalizing the pressure in theoccluded position to the pressure in the sinusoids. In the normal liver the WHVP isslightly lower than the portal pressure but in cirrhosis of viral or alcoholic cause, theWHVP gives an accurate estimate of portal pressure.3,4 In cirrhosis, HVPG equals por-tal pressure, whereas in presinusoidal PH (eg, schistosomiasis, idiopathic PH) or inof the external zero reference point. The hepatic-atrial pressure gradient, suggested

flow5,11; in fact, the balloon allows measuring the pressure in a larger volume of the

Portal Hypertension and Esophageal Varices 295liver, and thus more reproducibly.1216

HVPGmeasurement is a safe procedure with 0 to 1%minor complications in a largeseries of patients.17,18 Nevertheless, the technique has limited applicability because itis available only in specialized centers and is regarded as unpleasant and potentiallydangerous by the patients or their physicians.19

Endoscopic Evaluation of Esophageal Varices

Upper gastrointestinal (GI) endoscopy is a suitable tool for screening because it iswidely available; in addition, because the risk of bleeding is related to the size of vari-ces and the presence of red signs,20 it can be estimated by endoscopy, and finally,besides esophageal varices, endoscopy can identify other potentially bleeding lesionsrelated to PH, such as gastric varices, portal hypertensive gastropathy, and gastricantral vascular ectasia.Upper GI endoscopy may be performed with or without light sedation and should

include a complete examination of the esophagus, stomach, and proximal duodenum,because portal-hypertension related lesions can be found in all 3 sites. The adoptionof simple rules will help improve the quality of the examination, increase the amount ofinformation obtained, and decrease interobserver variability: (1) the evaluation mustbe done at the end of the examination, on the way out, after removing as much airas possible from the stomach by suction; (2) the size of varices must be assessedwith the esophagus fully distended by air; (3) the worst finding present must berecorded; (4) a validated classification of esophageal varices must be used. Twowidely adopted classifications are that of the Japanese Research Society for PortalHypertension21 and that of the Italian Liver Cirrhosis Project.22 As stated in the intro-duction, international guidelines1 state that, All cirrhotic patients should be screenedfor varices at diagnosis. However, at a given point in time, a variable proportion of pa-tients will not have varices; in fact, the reported prevalence of esophageal varices isvariable,23 ranging in different series between 24% and 80%. Thus, screening allcirrhotic patients with upper GI endoscopy to detect the presence of varices impliesseveral unnecessary endoscopies, which increase the workload of endoscopy units.In addition, compliance with endoscopic screening recommendations may be subop-timal, because they require patients who are often totally asymptomatic to repeatedlyundergo a procedure that is perceived as unpleasant.24

NONINVASIVE METHODS PROPOSED FOR THE DIAGNOSIS OF BOTH PH ANDESOPHAGEAL VARICES

The search for a practical splanchnic sphygmomanometer is challenging becausethe ideal noninvasive method to diagnose PH should be safe, cheap, easy to perform,accurate, and reproducible. In addition, it should be able to give objective numericalresults in real-time and be predictive of significant hard endpoints, to allow prog-nostic stratification. As stated in the introduction, several methods have been exam-by some authors to reflect the variceal hemodynamics better, should not be usedbecause it has been shown9 that this parameter does not correlate with HVPG anddoes not provide the excellent prognostic information HVPG gives when used to eval-uate the response to drug therapy.The measurement of theWHVP should be done by inflating the balloon at the tip of a

balloon catheter in a large hepatic vein, as first described by Groszmann and col-leagues,10 and not by wedging the catheter in a small venule to block the bloodined in the hope of finding such a tool.

de Franchis & DellEra296Laboratory Tests

Laboratory tests evaluating the degree of protein-synthetic function of the liver (albu-min, international normalized ratio, bilirubin) correlate with the HVPG and the presenceand grade of esophageal varices in patients with compensated as well as decompen-sated cirrhosis25; however, the correlation is not good enough to allow these tests tobe used for diagnosing PH or esophageal varices.

Abdominal Imaging (Ultrasound Scan, Magnetic Resonance Imaging, ComputedTomography)

Splenomegaly is a sensitive but nonspecific imaging sign of PH.25 Therefore, CSPHcan be only suspected if splenomegaly is identified by imaging techniques, but re-quires confirmation by other means. On the other hand, abdominal portosystemic col-laterals are specific signs of PH,26 and when they are observed on ultrasound scan(US), magnetic resonance imaging, or computed tomography (CT), a diagnosis ofCSPH can be made with confidence. The sensitivity of portosystemic collaterals, how-ever, is limited, because only 20% to 54% of compensated cirrhotic patients withCSPH show abdominal collaterals on imaging. Therefore, imaging techniques arenot accurate enough to be routinely used to diagnose or rule out PH.

Liver Stiffness Alone or in Combination

Liver stiffness (LS) is measured by means of transient elastography, an US techniquethat uses pulse-echo US acquisitions. The use of transient elastography in patientswith liver disease is based on the assumption that fibrosis results in increased stiffnessof the liver parenchyma. LS is measured in kilopascals. Transient elastography isattractive because it is noninvasive and measures stiffness in a volume of the liverthat is approximately 100 times bigger than that of liver biopsy and thus might beless prone than biopsy to sampling error. Because fibrosis is one of the major deter-minants of PH, assessing the relationship between LS and portal pressure makessense. LS has been shown to correlate strongly with portal pressure as measuredby the HVPG and may predict clinical decompensation in compensated cirrhoticpatients.27,28 However, when HVPG values exceed 10 to 12 mm Hg, which are thethreshold for CSPH and for the development of varices, portal pressure becomeslargely independent from stiffness/fibrosis. Accordingly, the ability of LS to predictthe presence and grade of esophageal varices in cirrhosis is insufficient.27

The combination of different noninvasive tests might provide complementary infor-mation, resulting in increaseddiagnostic value. In 2013,Berzigotti andcolleagues29 pro-posed 2models, the PH risk score and the variceal risk score (VRS). ThePH risk score iscalculated with the formula: [PH risk score 5 5.953 1 0.188 LS 1 1.583 sex(1: male; 0: female)1 26.705 spleen diameter/platelet count ratio]. The VRS is calcu-lated with the formula: [VRS 5 4.364 1 0.538 spleen diameter 0.049 plateletcount 0.44 LS1 0.001 (LS platelet count)]. In 117 patients with compensatedcirrhosis, the PH risk score and the VRS showed area under the receiver operatedcharacteristic of 0.935 and 0.909, respectively. If used to select patients to undergoendoscopic screening, the VRS would have spared 65% of endoscopies.

Spleen Stiffness

Because spleen congestion is a specific feature of PH, spleen stiffness (SS) might alsocorrelate with portal pressure. The performance of SS in diagnosing both CSPH andesophageal varices has been evaluated by transient elastography by Colecchia and

colleagues30: the correlation of SS with the HVPG and with the presence or absence

Portal Hypertension and Esophageal Varices 297of varices was evaluated in comparison with LS, the LSPS index, and the plateletcount/spleen diameter ratio (PSR). SS outperformed all other tests in both the assess-ment of CSPH and the presence of varices.

NONINVASIVE METHODS PROPOSED FOR THE DIAGNOSIS OF ESOPHAGEAL VARICESPSR

The PSR is calculated by dividing the platelet number per cubic millimeter by themaximum spleen bipolar diameter in millimeters as estimated by abdominal US.The ratio is higher in patients without than in those with varices. In the original study,using a cutoff value of 909 of the PSR, the AUROC was 0.981, corresponding to pos-itive and negative predictive values for the presence of varices of 96% and 100%,respectively (LR1 5 14.3; LR 5 0.1). Recently, a meta-analysis of 20 studies evalu-ating the performance of the PSR for the diagnosis of varices has been published.31

The global performance of the PSR across studies was good (Hierarchical SummaryROC curve: 0.95), but there was statistically significant heterogeneity, and wide vari-ability of the performance of PSR across studies. Therefore, the universal use of thePSR for diagnosing or ruling out varices cannot be recommended yet.

Liver Stiffness Platelet Spleen Index

In 2010, Kim and colleagues32 proposed a new index, the Liver Stiffness PlateletSpleen index (LSPS, 5 LS spleen diameter/platelet count) for the diagnosis of vari-ces. The LSPS performed very well, with an AUROC of 0.954. The authors proposedan algorithm whereby patients with LSPS less than 3.5 should not undergo endos-copy; patients with an LSPS between 3.5 and 5.5 should be screened by EGD for vari-ces, and patients with LSPS greater than 5.5 should undergo EGD or start empirictreatment. This method needs external validation.

Spleen Stiffness

The correlation of SS with the presence and size of varices was evaluated by tran-sient elastography by Sharma and colleagues33 and compared with LS, LSPS, andthe PSR. Again, SS outperformed all other tests, and the authors suggested thatcombining SS1LS gave the best prediction of the presence of varices. SS canalso be measured by acoustic radiation force impulse imaging (ARFI). ARFI is basedon the measurement of the velocity of shear waves generated by mechanical excite-ment of liver tissue by ultrasonic impulses. ARFI is incorporated into conventional USmachines and can be performed during a standard US examination. At variance withtransient elastography, the region of interest whereby stiffness is measured is cho-sen under visual control in B-mode. These technical features and the physical prin-ciple of ARFI allow overcoming some of the limitations of transient elastography,such as the frequent technical failures in measuring SS, and in assessing LS in obeseor ascitic patients. ARFI is expressed in meters per second. In a study by Takumaand colleagues,34 ARFI measurement of SS outperformed LS and platelet count inthe prediction of varices, with an AUROC of 0.933. However, a recent meta-analysis of 12 studies that compared the accuracy of SS with that of EGD in the diag-nosis of esophageal varices35 concluded that the accuracy of SS in diagnosingesophageal varices is limited, and this precludes its widespread use in clinical prac-tice, at this time.

Videocapsule Endoscopy

Videocapsule endoscopy (VCE), originally developed for the study of the small

bowel, has become suitable for the esophagus with the development of a video

discriminating between patients with and without CSPH. Nevertheless, none of the

de Franchis & DellEra298proposed noninvasive alternatives to HVPG measurement is accurate enough to pre-dict the numerical value of HVPG.As far as the second question is concerned, it has been shown that LS is not

currently capable of providing accurate information on the hemodynamic responseto b-blockers (eg, LS changes do not correlate with HVPG changes during therapy).40

Whether SS will perform better than LS remains to be ascertained.

Presence and Grade of Esophageal Varices

In deciding whichmethod (if any) to adopt to select patients for EGD screening for vari-ces, the following questions must be answered:

a. How many endoscopies would be spared by this method?b. How many patients with varices would be missed?c. How many unnecessary endoscopies would still be done?

Table 1 shows the answers to these questions for the various methods proposed.In addition, one also must keep in mind that most studies were performed in patients

with a high pretest probability of esophageal varices, not reflecting the clinical sce-nario of screening, that some of the methods proposed are not validated yet, andthat, whatever the method, the number of endoscopies spared will have to beweighted against a proportion of missed varices and of residual unnecessary endos-capsule specifically designed to image this organ. The largest study that evaluatedVCE for the screening and surveillance of esophageal varices36 included 288 pa-tients, of whom 62.5% had esophageal varices. The study had a noninferioritydesign, the assumption being that the difference (1SEM) between VCE and EGD,which was used as the gold standard, would be less than 10%. Although VCE per-formed well (positive predictive value 92%; negative predictive value 77%, LR1 7;LR 0.18), the study failed to meet the assumption, because there was a 16% dif-ference in sensitivity in favor of EGD.

CT Esophagography

The use of single-detector and multidetector CT scanning has been evaluated as ascreening modality for esophageal varices in 3 studies.3739 In all 3 studies the perfor-mance of CT esophagography was compared with that of EGD, which served as thegold standard. When considering all varices, across studies, CT esophagography hadsensitivity ranging between of 64% and 93%, and specificity between 76% and96.6%, respectively. For the detection of large varices, sensitivity ranged between56% and 92%, and specificity between 84% and 92%. In the study giving the best re-sults, air was insufflated into the esophagus (mean volume 1300 mL) via a catheterpassed through the mouth.

WHAT DO THE CLINICIANS REALLY NEED TO KNOW?Diagnosis of PH

Two crucial questions need to be answered to decide whether a noninvasive methodcan be used to replace HVPG measurement:

a. Is this method good enough to rule in or rule out CSPH?b. Can this method be used to monitor the effect of drug therapy on portal pressure?

Concerning the first question, LS measurement has been shown to perform well incopies. All the above facts should be considered in making the decision.

Table 1Trade-offs of different methods proposed for selecting patients for the endoscopic screening of esophageal varices

Method VCE PSR LS LSPS SS VRS ARFI

Author de Franchis et al36 Ying et al31 Colecchia et al30 Kim et al32 Sharma et al33 Berzigotti et al29 Takuma et al34

No. of patients 288 3063 100 280 174 117 340

With varices, n (%) 181 (63) 1905 (62) 53 (53) 124 (44) 124 (71) 37 (32) 132 (39)

Endoscopies spared, n (%) 123 (43) 1088 (36) 29 (29) 157 (56) 45 (26) 76 (65) 144 (42)

Varices missed, n (%) 29 (16) 115 (6) 2 (4) 15 (12) 7 (6) 7 (23) 2 (1.5)

Unnecessary EGD, n (%) 13 (8) 185 (16) 20 (42) 14 (9) 12 (24) 11 (16) 66 (32)

Porta

lHyp

erte

nsio

nandEsophagealVarice

s299

de Franchis & DellEra300SUMMARY

In summary, although HVPGmeasurement and EGD, the reference standard methodsto diagnose the presence and grade of PH and esophageal varices, have some draw-backs, in that they are invasive, costly, and perceived as unpleasant by patients, noneof the alternative noninvasive methods to replace them has been proven to be goodenough so far.As far as the evaluation of PH is concerned, LS measurement can distinguish be-

tween patients with and without CSPH; however, it is not suitable to detecttreatment-related changes in HVPG, and thus, it cannot be used to guide therapy.SS is also good in diagnosing CSPH, but its performance in evaluating treatment-related HVPG changes has not been assessed.Concerning the diagnosis and grading of esophageal varices, the PSR has given

variable results, the LSPS and SS, measured either by transient elastography orARFI, showed overall good performances, but these methods need external valida-tion. VCE is inferior to EGD, whereas CT esophagography has given variable results,and in addition, there is the concern of radiation exposure.At any rate, if one decides to adopt a noninvasive method to replace HVPG mea-

surement or EGD, the potential benefits in terms of cost-saving, availability, and pa-tient acceptance must be weighted against the potential risks of misdiagnosis andinappropriate therapeutic decisions.

REFERENCES

1. de Franchis R, Baveno V Faculty. Revising consensus in portal hypertension.Report of the Baveno V consensus workshop on methodology of diagnosis andtherapy in portal hypertension. J Hepatol 2010;53:7628.

2. Myers J, Taylor W. An estimation of portal venous pressure by occlusive catheter-ization of a hepatic venule. J Clin Invest 1951;30:6623.

3. Perello A, Escorsell A, Bru C, et al. Wedged hepatic venous pressure adequatelyreflects portal pressure in hepatitis C virus-related cirrhosis. Hepatology 1999;30:13937.

4. Thalheimer U, Leandro G, Samonakis DN, et al. Assessment of the agreementbetween wedge hepatic vein pressure and portal vein pressure in cirrhotic pa-tients. Dig Liver Dis 2005;37:6018.

5. Viallet A, Joly JG, Marleau D, et al. Comparison of free portal venous pressureand wedged hepatic venous pressure in patients with cirrhosis of the liver.Gastroenterology 1970;59:3725.

6. Boyer TD, Triger DR, Horisawa M, et al. Direct transhepatic measurement of por-tal vein pressure using a thin needle. Comparison with wedged hepatic vein pres-sure. Gastroenterology 1977;72:5849.

7. Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: any-thing worth doing should be done right. Hepatology 2004;39:2802.

8. Bosch J, Garcia-Pagan JC, Berzigotti A, et al. Measurement of portal pressure andits role in themanagement of chronic liver disease. Semin Liver Dis 2006;26:34862.

9. La Mura V, Abraldes JG, Berzigotti A, et al. Right atrial pressure is not adequateto calculate portal pressure gradient in cirrhosis: a clinicalhemodynamic corre-lation study. Hepatology 2010;51:210816.

10. Groszmann RJ, Glickman M, Blei AT, et al. Wedged and free hepatic venouspressure measured with a balloon catheter. Gastroenterology 1979;76:2538.

11. Reynolds TB, Ito S, Iwatsuki S. Measurement of portal pressure and its clinical

application. Am J Med 1970;49:64957.

Portal Hypertension and Esophageal Varices 30112. Garcia-Tsao G, Groszmann RJ, Fisher RL, et al. Portal pressure, presence ofgastroesophageal varices and variceal bleeding. Hepatology 1985;5:41924.

13. Butzow GH, Novak D. Clinical value of hepatic vein catheterization. Improvedpracability by balloon catheter technique. Gastrointest Radiol 1977;2:15361.

14. Koyama K, Ito K, Asanuma Y, et al. Hepatic venography in portal hypertension byballoon catheter. Tohoku J Exp Med 1983;139:34954.

15. Zipprich A, Winkler M, Seufferlein T, et al. Comparison of balloon vs. straight cath-eter for the measurement of portal hypertension. Aliment Pharmacol Ther 2010;32:13516.

16. Montagnese S, Cavasin L, Vezzaro R, et al. Variability of the hepatic venous pres-sure gradient (HVPG) within the cirrhotic liver: an issue or a technical issue? Hep-atology 2009;50(Suppl 1):444A.

17. Bosch J, Abraldes JG, Groszmann R. Current management of portal hyperten-sion. J Hepatol 2003;38(Suppl 1):S5468.

18. Thabut D, Moreau R, Lebrec D. Noninvasive assessment of portal hypertension inpatients with cirrhosis. Hepatology 2011;53:68394.

19. DellEra A, Cubero Sotela J, Fabris FM, et al. Primary prophylaxis of varicealbleeding in cirrhotic patients: a cohort study. Dig Liver Dis 2008;40:93643.

20. North Italian Endoscopic Club for the Study and Treatment of Esophageal Vari-ces. Prediction of the first variceal hemorrhage in patients with cirrhosis of theliver and esophageal varices. A prospective multicenter study. N Engl J Med1988;319:9839.

21. The general rules for recording endoscopic findings on esophageal varices. JpnJ Surg 1980;10:847.

22. Italian Liver Cirrhosis Project. Reliability of endoscopy in the assessment of vari-ceal features. J Hepatol 1987;4:938.

23. Pascal JP, Cale`s P, Desmorat H. Natural history of oesophageal varices. review no:22. In: Bosch J, Rode`s J, editors. Recent advances in the pathophysiology andtreatment of portal hypertension. Rome (Italy): Serono Symposia; 1989. p. 12742.

24. Hapke RZ, Benner KG, Rosen HR, et al. Prevention of first variceal hemorrhage asurvey of community practice patterns [abstract]. Hepatology 1997;26(Pt 1):A30.

25. Berzigotti A, Gilabert R, Abraldes JG, et al. Noninvasive prediction of clinicallysignificant portal hypertension and esophageal varices in patients with compen-sated liver cirrhosis. Am J Gastroenterol 2008;103:115967.

26. Vilgrain V, Lebrec D, Menu Y, et al. Comparison between ultrasonographic signsand the degree of portal hypertension in patients with cirrhosis. Gastrointest Ra-diol 1990;15:21822.

27. Castera L, Pinzani M, Bosch J. Non-invasive evaluation of portal hypertension us-ing transient elastography. J Hepatol 2012;56:696703.

28. Robic MA, Procopet B, Metivier S, et al. Liver stiffness accurately predicts portalhypertension related complications in patients with chronic liver disease: a pro-spective study. J Hepatol 2011;55:101724.

29. Berzigotti A, Selio S, Arena U, et al. Elastography, spleen size and platelet countidentify portal hypertension in patients with compensated cirrhosis. Gastroenter-ology 2013;1044:10211.

30. Colecchia A, Montrone L, Scaioli E, et al. Measurement of spleen stiffness to eval-uate portal hypertension and presence of esophageal varices in patients withHCV-related cirrhosis. Gastroenterology 2012;143:64654.

31. Ying L, Lin X, Xie ZL, et al. Performance of platelet count/spleen diameter ratio fordiagnosis of esophageal varices in cirrhosis: a meta-analysis. Dig Dis Sci 2012;

57:167281.

32. Kim BK, Han KH, Park JU, et al. A liver stiffness measurement-based, noninva-sive prediction model for high risk esophageal varices in B-viral liver cirrhosis.Am J Gastroenterol 2010;105:138290.

33. Sharma P, Kirnake V, Tyagi P, et al. Spleen stiffness in patients with cirrhosis inpredicting esophageal varices. Am J Gastroenterol 2013;108:11017.

34. Takuma Y, Nouso K, Morimoto Y, et al. Measurement of spleen stiffness by acous-tic radiation force impulse imaging identifies cirrhotic patients with esophagealvarices. Gastroenterology 2013;144:92101.

35. Singh S, Eaton JE, Murad MH, et al. Accuracy of spleen stiffness measurement indetection of esophageal varices in patients with chronic liver disease: systematicreview and meta-analysis. Clin Gastroenterol Hepatol 2013. http://dx.doi.org/10.1016/j.cgh.2013.09.013.

36. de Franchis R, Eisen GM, Laine L, et al. Oesophageal capsule endoscopy forscreening and surveillance of oesophageal varices in patients with portal hyper-tension. Hepatology 2008;47:1595603.

37. Kim YJ, Raman SS, Yu NC, et al. Esophageal varices in cirrhotic patients: evalu-ation with liver CT. AJR Am J Roentgenol 2007;188:13944.

38. Kim SH, Kim YJ, Lee JM, et al. Oesophageal varices in patients with cirrhosis:multidetector CT esophagography comparison with endoscopy. Radiology2007;242:75968.

39. Perri RE, Chiorean MV, Fidler JL, et al. A prospective evaluation of computerizedtomographic (CT) scanning as a screening modality for esophageal varices.Hepatology 2008;47:158794.

de Franchis & DellEra30240. Reiberger T, Ferlitsch A, Payer BA, et al. Non-selective b-blockers improve thecorrelation of liver stiffness and portal pressure in advanced cirrhosis.J Gastroenterol 2012;47:5618.

Invasive and Noninvasive Methods to Diagnose Portal Hypertension and Esophageal VaricesKey pointsIntroductionInvasive methods to diagnose PH and esophageal varicesMeasurement of HVPGEndoscopic Evaluation of Esophageal Varices

Noninvasive methods proposed for the diagnosis of both PH and esophageal varicesLaboratory TestsAbdominal Imaging (Ultrasound Scan, Magnetic Resonance Imaging, Computed Tomography)Liver Stiffness Alone or in CombinationSpleen Stiffness

Noninvasive methods proposed for the diagnosis of esophageal varicesPSRLiver Stiffness Platelet Spleen IndexSpleen StiffnessVideocapsule EndoscopyCT Esophagography

What do the clinicians really need to know?Diagnosis of PHPresence and Grade of Esophageal Varices

SummaryReferences