Endoscopic ultrasound-guided portal pressure gradient assessment of acute hemodynamic response to intravenous propranolol

The development of portal hypertension is a critical hallmark in chronic liver diseases. The hepatic venous pressure gradient (HVPG) is the gold-standard method to diagnose and quantify portal hypertension and the hemodynamic response to drug therapy. An acute hemodynamic response to intravenous propranolol assessed with the HVPG predicts adverse liver-related events [1]. However, the HVPG is not recommended in routine clinical care due to its drawbacks [2]. Non-invasive tests (NITs) are used in daily clinical practice to stratify the risk of clinically significant portal hypertension [2]. Nevertheless, NITs are not recommended for assessing hemodynamic changes in portal hypertension [2]. Moreover, there is a gray-zone where patients affected with metabolic associated liver diseases, obesity or mixed etiologies could be misclassified by NITs [3]. The endoscopic ultrasound-guided portal pressure gradient measurement (EUS-PPGm) has been accurately compared to the HVPG and can directly obtain the real portal vein pressure [4].

We determine the acute hemodynamic response to intravenous propranolol with EUS-PPGm in a case of a series of four patients ([Table 1]). The procedure was performed as previously reported, taking into account several tips and tricks to avoid non-reliable results [5].

Table 1 Data and results.

Patient	Age	Sex	Etiology	Child-Pugh	MELD	Liver stiffness (kPa)	Platelets (g/L)	EUS-PPGm before iv ropranolol	EUS-PPGm after iv propranolol
Abbreviation: EUS-PPGm, endoscopic ultrasound-guided portal pressure gradient measurement.
1	60	Male	Alcohol	B8	12	75	164.000	3 mmHg	Not indicated
2	67	Female	Alcohol	A5	8	19	108.000	3.75 mmHg	Not indicated
3	60	Male	Metabolic	A5	7	29	170.000	10.5 mmHg	4.75 mmHg (55% reduction)
4	65	Female	Alcohol	B9	11	26,5	147.000	10 mmHg	2 mmHg (80% reduction)

Following baseline EUS-PPGm, 0.15 mg/kg of body weight, propranolol was administered intravenously by continuous infusion in 10 minutes. The second EUS-PPGm was repeated 15 minutes later targeting the same vessels with the same angle of the needle and position of the echoendoscope as in the baseline EUS-PPGm procedure ([Video 1]).

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EUS-guided portal pressure gradient assessment of the acute hemodynamic response to intravenous propranolol.Video 1

A significant reduction of PPG in two patients ([Fig. 1]), treated with intravenous propranolol, was observed (10.5 mmHg to 4.75 mmHg [55%] and 10 mmHg to 2 mmHg [80%], respectively). In the other two patients, the first EUS-PPGm was normal. So, a second EUS-PPG measurement was not performed avoiding further unnecessary therapy with beta-blockers. No adverse events were observed.

Fig. 1 EUS-guided assessment of the portal pressure gradient after intravenous administration of propranolol. EUS, endoscopic ultrasound.

EUS-PPGm can assess acute hemodynamic changes after intravenous administration of propranolol.

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Contributorsʼ Statement

Rafael Romero-Castro: Conceptualization, Formal analysis, Investigation, Methodology, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing. Enrique Silva-Albarellos: Conceptualization, Formal analysis, Investigation, Methodology, Resources. Lourdes Grandes-Santamaria: Conceptualization, Formal analysis, Investigation, Methodology, Resources. Isabel Carmona-Soria: Conceptualization, Investigation, Methodology, Resources. Victoria Alejandra Jimenez-Garcia: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Manuel Rodriguez-Tellez: Conceptualization, Investigation, Methodology, Supervision. Ángel Caunedo-Álvarez: Conceptualization, Investigation, Methodology, Resources, Supervision, Validation.

Conflict of Interest

Rafael Romero-Castro is a consultant to Cook Medical and has received speaker’s honorary fees from Cook Medical. The rest of the authors report no conflicts of interest.

Acknowledgement

The authors are indebted to the nurses team of the Endoscopy Unit for their outstanding expertise and support.

• References

• 1 Hofer BS, Simbrunner B, Bauer DJM. et al. Acute hemodynamic response to propranolol predicts bleeding and nonbleeding decompensation in patients with cirrhosis. Hepatol Commun 2022; 6: 2569-2580
• 2 de Franchis R, Bosch J, Garcia-Tsao G. et al. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022; 76: 959-974
• 3 Mendizabal M, Cançado GGL, Albillos A. Evolving portal hypertension through Baveno VII recommendations. Ann Hepatol 2024; 29: 101180
• 4 Sun X, Ni HB, Xue J. et al. Bibliometric-analysis visualization and review of non-invasive methods for monitoring and managing the portal hypertension. Front Med (Lausanne) 2022; 9: 960316
• 5 Romero-Castro R, Carmona-Soria I, Jiménez-García VA. et al. Endoscopic ultrasound-guided portal pressure gradient measurement: improving safety and overcoming technical difficulties. Endoscopy 2023; 55 (Suppl. 01) E878-E880

Publication History

Article published online:
13 January 2026