Diagnosis of Portal Hypertension

Abstract

Chronic liver disease (CLD) imposes a major global health burden, with portal hypertension (PH) and its complications driven by complex pathophysiological mechanisms. Understanding these processes is essential for effective therapy. The hepatic venous pressure gradient (HVPG) is the gold standard for assessing portal hypertension, providing key diagnostic, prognostic, and therapeutic guidance-particularly in distinguishing its type and monitoring response to treatments such as non-selective beta-blockers. While non-invasive tests like elastography and serum biomarkers are valuable for screening and follow-up, they cannot fully replace HVPG when precise measurement is needed. HVPG contains not only prognostic information but also helps to decide if pharmacological therapy is indicated and to monitor therapeutic effects with reductions correlating with improved outcomes. In this review, we highlight the comprehensive management of patients with PH and the indications for measurement of HVPG.

Keywords: alcoholic liver disease; cirrhosis; hepatic venous pressure gradient; measurement of portal pressure; metabolic dysfunction-associated steatotic liver disease; non-invasive tests.

Figure 1

According to the law of Ohm the hepatic venous pressure gradient (HVPG) equals the hepatic vascular resistance (HVR) multiplied by the hepatic blood flow (HBF). Increased HVR is due to structural and dynamic changes and HBF increases because of hemodynamic changes.

Figure 2

Types of portal hypertension (PH): Prehepatic PH is often caused by portal vein thrombosis or tumor-related thrombosis. Intrahepatic PH is divided into presinusoidal PH, for example, caused by sarcoidosis or schistosomiasis, and post-sinusoidal PH caused by cirrhosis of all causes. Posthepatic PH is most often associated with the Budd–Chiari syndrome or right-sided heart failure.

Figure 3

The hepatic venous pressure gradient (HVPG) can be measured by the femoral venous or the transjugular venous route during a liver vein catheterization. The hepatic venous pressure gradient (HVPG) is measured as the difference between the wedged hepatic venous pressure (WHVP) and the free hepatic venous pressure (FHVP). WHVP is achieved by a balloon occlusion with, for example, a Swan-Ganz catheter approximately measuring the portal venous pressure.

Figure 4

A liver vein catheterization through the femoral route with measurement of the wedged hepatic venous pressure (WHVP) with balloon occlusion and use of contrast dye (A) and the free hepatic venous pressure (B). Below the pressure measurement, where the hepatic venous pressure gradient (HVPG) is calculated as the difference between WHVP (high level curve) and the FHVP (low level curve). Panel (C) shows a transjugular biopsy.