Year 2025 / Volume 117 / Number 12
Letter
Challenging the gold standard: endohepatology for the diagnosis of presinusoidal portal hypertension

800-801

DOI: 10.17235/reed.2025.11480/2025

Sofia Bragança, Pooja Khonde, Stephen D. Zucker’s, Marvin Ryou,

Abstract
We report a 52-year-old patient referred for evaluation of abnormal liver tests, with extensive etiological workup negative. Abdominal CT and MRI revealed hypertrophy of the left hepatic lobe, nodular liver contours, and ascites (SAAG 1.7; total protein 1.8 g/dL). Upper endoscopy showed no stigmata of portal hypertension. A dual interventional radiology procedure was performed. Transjugular liver biopsy (LB) (18G) was non-diagnostic, and hepatic venous pressure gradient (HVPG) was normal (HVPG 3 mmHg; wedged hepatic venous pressure [WHVP] 13 mmHg; free hepatic venous pressure [FHRVP] 10 mmHg). Given suspicion of pre-sinusoidal portal hypertension, endoscopic ultrasound (EUS) was performed (Arietta 850, Fujifilm Healthcare, Tokyo, Japan). EUS showed blunting of the left lobe tip, irregular contours, and ascites. Endoscopic “palpation” revealed an indentation of 2.0 mm (abnormal). Shear-wave-elastography (SWE) of the left lobe was normal at 6.04 kPa, but other areas showed 10.5–11.1 kPa (abnormal). No splenomegaly, but the mean SWE was 31.9 kPa (abnormal). EUS-guided portal pressure gradient (EUS-PPG), measured with EchoTip Insight™ FNB needle (Cook Medical, USA), was elevated (PPG 8 mmHg; mean hepatic vein pressure 4.0 mmHg; mean portal vein pressure [PVP] 12.0 mmHg). Targeted EUS-guided biopsy of the left lobe (Acquire™ 19G FNB needle, Boston Scientific, USA) showed vague liver nodular transformation with alternating regenerative and atrophic hepatocytes, consistent with nodular regenerative hyperplasia (NRH). Due to refractory ascites, TIPS placement was proposed. Pre-TIPS evaluation showed mildly elevated HVPG (6 mmHg), while immediate post-TIPS assessment revealed elevated HVPG (HVPG 11 mmHg; PVP 20 mmHg; FHRVP 9 mmHg). Ascites was controlled with TIPS.
New comment
Comments
No comments for this article
References
1. Diehl DL. The four pillars of endohepatology. Journal of the Canadian Association of Gastroenterology. 2025; 8:56–61.
2. Bazarbashi AN, Al-Obaid L, Ryou M. Future Directions in EndoHepatology. Techniques and Innovations in Gastrointestinal Endoscopy. 2022; 24:98–107.
3. Diehl DL. Top tips regarding EUS-guided liver biopsy. Gastrointestinal Endoscopy. 2022; 95:368–71.
4. Bazarbashi AN, Ryou M. Portal pressure measurement: Have we come full circle? Gastrointestinal Endoscopy. 2021; 93: 573–6.
5. Choi AY, Chang KJ. Endoscopic Diagnosis of Portal Hypertension. Techniques and Innovations in Gastrointestinal Endoscopy. 2022; 24:167–75.
Related articles

Letter

Duodenal lymphangiomas: endoscopic ultrasound features

DOI: 10.17235/reed.2024.10338/2024

Letter

Transanal local excision for mucosal prolapse syndrome

DOI: 10.17235/reed.2023.10022/2023

Digestive Diseases Image

Imaging of pancreatic desmoid fibromatosis by endoscopic ultrasound

DOI: 10.17235/reed.2023.9792/2023

Letter

An unusual cause of liver lesions

DOI: 10.17235/reed.2023.9787/2023

Digestive Diseases Image

Endosonographic and ERCP findings in COVID-19 critical illness cholangiopathy

DOI: 10.17235/reed.2022.9218/2022

Letter

Angiosarcoma of the aorta diagnosed via endoscopic ultrasound

DOI: 10.17235/reed.2022.8879/2022

Digestive Diseases Image

Pancreatic lymphoma during pregnancy

DOI: 10.17235/reed.2022.8811/2022

Digestive Diseases Image

When needles are not enough, forceps delivers!

DOI: 10.17235/reed.2022.8697/2022

Letter

Unexpected diagnosis for nodular hepatic lesions

DOI: 10.17235/reed.2021.8230/2021

Letter

Lumen-apposing metal stent deployment failure

DOI: 10.17235/reed.2020.7060/2020

Letter

Sometimes things are what they seem

DOI: 10.17235/reed.2019.5911/2018

Letter

A giant abdominal collection: when things are not what they seem

DOI: 10.17235/reed.2018.5642/2018

Letter to the Editor

Late migration of a metal stent after EUS-drainage of a pancreatic pseudocyst abscess

DOI: 10.17235/reed.2018.5411/2017

Letter to the Editor

EUS-guided ethanol ablation therapy for gastric stromal tumors

DOI: 10.17235/reed.2017.5361/2017

Letter to the Editor

A rectal neuroendocrine neoplasm

DOI: 10.17235/reed.2017.4836/2017

Case Report

Glycogenic hepatopathy in young adults: a case series

DOI: 10.17235/reed.2016.3934/2015

Review

Endoscopic ampullectomy: a technical review

DOI: 10.17235/reed.2016.3867/2015

Case Report

Pelvic inflammatory myofibroblastic tumor mimicking a rectal cancer

DOI: 10.17235/reed.2015.3777/2015

Citation tools
Bragança S, Khonde P, Zucker’s S, Ryou M. Challenging the gold standard: endohepatology for the diagnosis of presinusoidal portal hypertension. 11480/2025


Download to a citation manager

Download the citation for this article by clicking on one of the following citation managers:

Metrics
This article has received 6 visits.
This article has been downloaded 1 times.

Statistics from Dimensions


Statistics from Plum Analytics

Publication history

Received: 08/07/2025

Accepted: 16/07/2025

Online First: 29/09/2025

Published: 12/12/2025

Article Online First time: 83 days

Article editing time: 157 days


Share
This article hasn't been rated yet.
Reader rating:
Valora este artículo:




Asociación Española de Ecografía Digestiva Sociedad Española de Endoscopia Digestiva Sociedad Española de Patología Digestiva
The Spanish Journal of Gastroenterology is the official organ of the Sociedad Española de Patología Digestiva, the Sociedad Española de Endoscopia Digestiva and the Asociación Española de Ecografía Digestiva
Cookie policy Privacy Policy Legal Notice © Copyright 2025 y Creative Commons. The Spanish Journal of Gastroenterology