This ASG video tip is sponsored by Braintree, maker of the newly approved Souffleve and Soutab. So then we move on to portal pressure gradient. So we've heard about the different types of ways you can measure portal pressure gradient. You can measure it via EUS, which is hopefully what I'll convince you is the better way, or via IR, which is the hepatic venous pressure gradient. Now the way IR people measure it is they puncture the hepatic vein, and then they wedge their catheter towards the end to do a wedge hepatic measurement that is a surrogate for the portal pressure, portal pressure, venous pressure, and then they have a gradient. What is important that you understand is that when we look at this as a continuum with liver disease, you go from the non-cirrhotic compensated and the decompensated stages is that the more you become decompensated, the higher the pressure is, but you do have a pressure gradient that once it's more than five, that's clinically, it means that you have hypertension. Anywhere between five and 10, it's clinically insignificant, but it probably portends a worse outcome down the line. And so once you get anything above 10, you start having a high risk of varices. Anything above 16, you have variceal bleeding and ascites. So this is sort of what I just mentioned. Anything above 10 to 12, ascites and varices. The severity of portal pressure gradient, meaning if it's above 16, you have a high risk of death, but if you decrease it by 20%, then you decrease the risk of variceal bleeding. Obviously, the risk of hepatocellular carcinoma is higher. It goes up if the pressures are above 10 and the disease progression also increases by up to four years. So you can get, you're more likely to see decompensation if your pressure gradient is greater than 10. So our aim is to reduce the pressure no matter how, and if weight loss is the way, and you'll hear about obesity later on, then that's great. So the limitations of the transjugular approach is obviously, it's cumbersome, it needs contrast, it needs radiation exposure, but it's also not accurate for patients with obesity. And I'll show you a couple of studies as we're trying to. So when we think of causes of portal hypertension, you have presinusoidal causes, sinusoidal causes, and postsinusoidal causes. When IR is trying to measure the portal pressure, the portal pressure, and it's doing a wedge pressure, you're inaccurately going to measure the pressures in presinusoidal causes such as for instance, sarcoidosis, portal vein thrombosis, primary biliary cirrhosis, etc. And so you're going to get a falsely normal pressure or a lower pressure than normal. So there are these groups of patients that you're not going to accurately predict whether or not they have portal pressure, an elevated portal pressure. And so this is a study that looked at this with, is pressure measurement via IR not as reliable in NASH patients? And what they did was they looked at liver biopsy patients that were collected at one and two years, and follow up, 90% of those patients had an episode where they decompensated, they became decompensated, either via ascites, bleeding, or death. And of those, about 14% of those patients had a normal pressure gradient as measured via IR. They took this a step further back in 2021, where they compared the wedge pressure with the accurate portal pressure gradient in patients with NASH and compared them with patients with alcohol or viral hepatitis. And what it showed is that there was a disagreement. So in the patients with the NASH group, in about 37% of patients, the pressure was measured as normal or low, when in fact that wasn't, it was an actual underestimation. And so you're four times more likely to have an inaccurate pressure in patients with NASH, sort of another reason why you should really be doing portal pressures. And so this is one of the first studies that was published out there, looking at 28 patients with suspected cirrhosis, and they classified them as high or low. And what the study showed was that in patients with high versus low cirrhosis, you can see that the pressure gradients were different. And so here is the high risk versus low risk cirrhosis. And then the next graph shows the high versus low risk of varices, and you can see that the portal pressure gradient was significantly different. And this is the evidence or absence of portal hypertensive gastropathy. Again, the portal pressure gradient was significantly different between the two groups. Sorry, I think I speak faster than the mouse. So this is our data with 24 comers of all patients with liver biopsies and portal pressure gradients at Cordell. And what you can see here is that we correlated really nicely, that the portal pressure correlated with both the FIB4 and the FibroScan, sort of showing that it's a good surrogate for this. And this year at DDW, both Marvin and I were part of a group that prospectively looked at measurements of portal pressure gradients and liver biopsies. And this is sort of the main summary of this is that it's easy, it's simple, everyone can do it, very low side effect profile. So how do we move on this clinically? So we know and we've shown that if you lose weight, your hepatic steatosis index improves, and that means your fibrosis improves, the NASH score also improves with weight loss. This was done with an endoscopic sleeve gastroplasty, and we published this a few years ago. The Brigham group looked at this with a different placation device and looked at the fibrosis scores measured with a portal pressure gradient and also liver biopsy. And what they showed is that with weight loss, the NFS score, the FIB4, all these non-invasive scores also improved at the 6 to 12 month mark. But again, also the hepatic venous pressure improved, the portal venous pressure improved, and the portal pressure gradient also improved, sort of suggesting a good correlation that when you lose weight, you're going to get improvement in NASH, but you're also going to get improvement in portal pressure gradients. So how do we tie this in all together? At Cornell, and I know at a lot of other places, we have a multidisciplinary clinic for NAFLD and patients with obesity, where they have an integrated approach, they see an on-site GI hepatologist, they get a fibro scan, they get an in-body scan. If they see me, they'll get a liver biopsy and portal pressure gradients, and maybe some procedure for weight loss, or they get medications. So it's important to see that we can all tie it in together in that one-stop shop. If I can play this video, but Marvin might be able to show it a little bit later, but we'll show this. This is a patient that came in with obesity, so had a fibro scan measurement done, and it showed F3 and S3. So we then go in and do an endoscopy, and the endoscopy looks for any evidence of varices, portal hypertensive gastropathy, to see if we can treat it. I don't know if you can advance the video to the sort of dots, those are the most important parts of the video. But what it basically does show is that you can do the shear wave elastography, which we did. And here, the shear wave elastography showed a KPA of 14, which is similar to what the patient had on a fibro scan. And then we go in and do the hepatic venous pressure gradient and portal pressure gradient with the Cooke 25-gauge needle, and this is obviously a proprietary needle. It's all in sort of a one-step shop here. In the next few images, you can see us accessing both the portal pressure and the portal vein and the hepatic vein. And you could use Doppler flow to sort of know which vein you're in. And so the sinusoidal approach shows you that you're in the hepatic vein. And then the portal vein, you can see sort of more of a halo around it, so you know you're in the portal vein. And then after that, you can do a liver biopsy with sort of a modified suction technique, either pull through, wet suction, whatever you prefer, but it has to be a core needle. And hopefully with that, you get good core. And so this is sort of the summary to show you that you can stop the video. You can get everything all in one stop shop with these patients. Can you move on to the next slide, please? So one-stop shop, you can also assess, which we haven't really talked about because there's very little data, response to beta blockers, response to antiviral agents, and maybe even assess the risk post-hepatectomy for liver failure. There's so many indications for portal pressure gradient and liver biopsy and where we can access them as endoscopists here and not hepatologists in these patients. And so the evolution is to use portal pressure gradient in these patients. You know that hepatic venous gradient is not accurate in patients with NASH, and they may get underestimated. You should be able to do a one-stop shop, talk to your hepatologist. Multiple studies are forthcoming, but we need to collaborate with our hepatologists. Thank you very much. ♪♪♪

portal pressure gradient

liver disease

EUS

IR

portal hypertension