Xie XY, Benmassaoud A. Advances in the diagnosis and management of clinically significant portal hypertension in cirrhosis: A narrative review. World J Hepatol 2025; 17(6): 104761 [DOI: 10.4254/wjh.v17.i6.104761]
Corresponding Author of This Article
Amine Benmassaoud, MD, Assistant Professor, Department of Gastroenterology and Hepatology, McGill University Health Centre, 1001 Decarie Blvd, Montreal H4A3J1, Quebec, Canada. amine.benmassaoud@mcgill.ca
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Jun 27, 2025; 17(6): 104761 Published online Jun 27, 2025. doi: 10.4254/wjh.v17.i6.104761
Advances in the diagnosis and management of clinically significant portal hypertension in cirrhosis: A narrative review
Xiao-Yu Xie, Amine Benmassaoud
Xiao-Yu Xie, Faculty of Medicine, University of Montreal, Montreal H3T1J4, Quebec, Canada
Amine Benmassaoud, Department of Gastroenterology and Hepatology, McGill University Health Centre, Montreal H4A3J1, Quebec, Canada
Author contributions: Xie XY conducted the literature review, drafted the original manuscript, and created the artwork; Benmassaoud A supervised and made critical revisions; Xie XY and Benmassaoud A both worked on the conception and the design of the study; all authors have read and approved the final manuscript.
Supported by Quebec Health Research Fund Clinician Research Scholars Junior 1, No. 350546.
Conflict-of-interest statement: Xie XY has no conflicts of interest to declare; Benmassaoud A has received fees for serving as a speaker for Cook Medical, and advisory board member for Jazz Pharmaceuticals.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Amine Benmassaoud, MD, Assistant Professor, Department of Gastroenterology and Hepatology, McGill University Health Centre, 1001 Decarie Blvd, Montreal H4A3J1, Quebec, Canada. amine.benmassaoud@mcgill.ca
Received: January 9, 2025 Revised: April 9, 2025 Accepted: May 18, 2025 Published online: June 27, 2025 Processing time: 167 Days and 15.6 Hours
Abstract
Clinically significant Portal hypertension (PH), defined by a hepatic venous pressure gradient (HVPG) greater than 10 mmHg, is a key predictor of decompensation events in cirrhosis, leading to variceal hemorrhage, ascites, and hepatic encephalopathy. This narrative review explores the pathophysiology of PH in cirrhosis, evaluates diagnostic methods for identifying clinically significant PH (CSPH), and discusses guideline-driven strategies to prevent initial and further decompensation. While HVPG remains the gold standard for diagnosing CSPH, non-invasive tools such as liver stiffness measurement and spleen stiffness measurement are increasingly used for initial risk stratification. The combined use of these tools reduces the proportion of patients in the diagnostic "grey zone". Endoscopic ultrasound-guided portal pressure gradient is an emerging diagnostic tool that requires further validation. Non-selective beta-blockers are the cornerstone of primary prophylaxis for decompensation, and their combination with endoscopic variceal ligation is the first-line therapy for secondary prophylaxis of recurrent esophageal variceal bleeding. Statins show promise in reducing PH and preventing decompensation while further studies are still needed. This review also discusses the indications for preemptive transjugular intrahepatic portosystemic shunt and its role in managing refractory ascites and variceal bleeding.
Core Tip: Portal hypertension (PH) is the main driver of morbidity and mortality in patients with cirrhosis. Over the last decade, there have been many critical developments in the diagnosis and management of this condition. The following review will provide the reader with a state-of-the-art appreciation of the most recent updates in the non-invasive and invasive diagnostic approaches, including the use of liver stiffness, spleen stiffness, and endoscopic ultrasound. A diagnostic algorithm is proposed to guide clinicians. We also discuss the role of pharmacological, endoscopic, and interventional therapeutic options to prevent and manage manifestations of PH.
