Endoscopic ultrasound in the management of complications related to cirrhosis- recent evidence

Table 2 Summarized version of the endoscopic ultrasound-guided portal pressure gradient measurement technique proposed by Laleman et al[2]

General technical steps in performing EUS-guided portal pressure gradient measurement
Survey liver on EUS for potential focal lesions and blunting of liver edge, liver echotexture, gastric varices, and flow in portal and splenic veins
EUS-shear wave elastography then used over left lobe of liver, spleen and then right lobe of liver from duodenum
Best vessel chosen and pulse wave doppler used to confirm. Listen for continuous hum of the portal vein
Typically, middle hepatic vein and left portal vein chosen
Pressure gauge and 25-gauge needle device primed with saline or heparinized saline, manometer placed at phlebostatic axis (4th intercostal space, approximately at level of R atrium)
Needle is then guided through parenchyma to vessel. Enter hepatic vein 2 cm from inferior vena cava convergence
Flush needle with saline, then watch pressure gauge rise until reaches steady state for 1 minute
Measurement repeated until 3 consecutive pressures are close together
Average is the mean hepatic vein pressure
Withdraw needle and apply doppler to ensure there is no hemorrhage
Repeat for portal vein

EUS: Endoscopic ultrasound.