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Case Report

EUS-guided Measurement of Portosystemic Pressure Gradients (PPG) Followed by EUS-liver Biopsy: The Emergence of the Field of Endo-Hepatology

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David Diehl, MD

@DavidDiehlMD

64-year-old woman was seen in the nutrition/bariatric medicine clinic for consideration of RYGB surgery. An ultrasound was done for routine pre-operative bariatric workup and the liver showed a heterogenous echotexture and slightly nodular contour. The radiologist felt that both findings raised the possibility of early cirrhosis. The FIBROSIS 4 score (calculated from a formula using age, AST, ALT, and platelet count) was calculated at 2.85, suggesting the potential for significant fibrosis. A FibroScan was done and showed a fibrosis score of 9.7 kPa, which would be interpreted as F2 fibrosis. Because of the worrisome ultrasound findings of possible cirrhosis, the elevated FIB-4 score, and the discordant FibroScan results, it was decided to pursue a liver biopsy as well as EUS-guided assessment of the portal pressure gradient. The patient underwent EGD and EUS in the endoscopy unit. The EGD did not demonstrate esophageal varices or portal gastropathy. The echotexture of the liver under EUS was homogenous, and not consistent with cirrhosis. To accomplish measurement of the portosystemic pressure gradient (PPG), a 25-gauge (G) needle connected to a manometer was used (EchoTip Insight portosystemic pressure gradient measurement system, Cook Medical, Bloomington IN). A small branch of the middle hepatic vein (HV) was identified in the left hepatic lobe, and its identity confirmed with Doppler (FIG 1). The 25G EUS needle was inserted into the vessel using a needle trajectory that went through liver parenchyma before reaching the vein (FIG 2). After the pressure stabilized, three pressure measurements were taken with 30-60 seconds between measurements. After this, the needle was removed, and the needle track monitored with Doppler imaging to confirm that there was no bleeding (FIG 3). Next, a small branch of the portal vein (PV) in the left lobe was identified by EUS and Doppler (FIG 4). The 25G needle was inserted into the PV through the liver parenchyma (FIG 5), and three PV pressure measurements were taken. The PPG is the difference between means of PV and HV pressure. In this case, the PPG was 2.3 mmHg (normal is less than 5 mmHg).

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