P2825 - Endoscopic Ultrasound-Guided Portal Pressure Gradient Measurement Accurately and Safely Streamlines Patient Care

Sanjeevani Tomar, MD¹, Torfay S.. Roman, MD², Thomas J.. Ward, MD¹, Ayman Koteish, MD², Abdul Mohammed, MD¹, Deepanshu Jain, MD¹, Mustafa Arain, MD¹, Dennis Yang, MD¹, Kambiz Kadkhodayan, MD¹, Muhammad K. Hasan, MD¹, Natalie Cosgrove, MD^1
1AdventHealth, Orlando, FL; ²AdventHealth Transplant Institute, AdventHealth, Orlando, FL

Introduction: Percutaneous hepatic venous pressure gradient (HVPG) measures portal pressure indirectly, which is a limitation in certain clinical situations. A new endoscopic ultrasound (EUS)-guided approach facilitates direct portal vein and portal pressure gradient (PPG) measurement, with values shown in studies to correlate significantly with HVPG. Potential benefits include a more accurate determination of portal pressure, and the ability to perform endoscopic procedures concurrently. We present a case in which EUS-PPG measurement streamlined patient care and accurately identified significant portal hypertension.

Case Description/Methods: A 64-year-old female was referred to us for endoscopic mucosal resection of large gastric polyps. Endoscopy showed grade II esophageal varices (Figure A). She was told previously she had a “fatty liver” but denied a history of known cirrhosis. CT revealed a cirrhotic-appearing liver, splenomegaly, gastric and peritoneal varices. After hepatology assessment, she underwent EUS-guided liver biopsy and EUS-PPG along with endoscopic band ligation of varices, which had red wale marks. A PPG of 18 mmHg (consistent with clinically significant portal hypertension and suggestive of increased bleeding risk) was measured with a 25-gauge needle (Cook EchoTip Insight) under EUS guidance (Figure B). Liver biopsy results indicated steatohepatitis nonalcoholic fatty liver disease with activity score of 3/8 and stage 4 fibrosis. Despite serial banding, her esophageal varices continued to worsen, increasing to grade III with red wale signs. Considering her low MELD score (9), high PPG, worsening esophageal varices, and ectopic varices, a multidisciplinary decision was made to place a TIPS, after discussion of the risk/benefits with the patient. While the pre-TIPS HVPG was 10 mmHg, direct portal pressure measured during TIPS placement gave a PPG of 20 mmHg; this discrepancy was later attributed to a hepatic venovenous shunt. The gradient post TIPS placement was 5 mmHg.

Discussion: EUS-guided PPG measurement is safe and accurate for evaluating portal hypertension. While the HVPG value was falsely low in this patient (10 vs 20 mmHg), EUS-PPG accurately determined the high portal pressure and was consistent with the direct PPG obtained by interventional radiology during TIPS placement (18 vs 20 mmHg). The accurate measurement of high portal pressures helped further solidify the increased risk of bleeding, while the performance of endoscopic banding during EUS-PPG helped streamline her care.



Disclosures:


Sanjeevani Tomar, MD¹, Torfay S.. Roman, MD², Thomas J.. Ward, MD¹, Ayman Koteish, MD², Abdul Mohammed, MD¹, Deepanshu Jain, MD¹, Mustafa Arain, MD¹, Dennis Yang, MD¹, Kambiz Kadkhodayan, MD¹, Muhammad K. Hasan, MD¹, Natalie Cosgrove, MD¹. P2825 - Endoscopic Ultrasound-Guided Portal Pressure Gradient Measurement Accurately and Safely Streamlines Patient Care, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.