Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound

The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.