Commentary

Krishnan et al. report the comprehensive endoscopic management of a patient with morbid obesity and esophageal varices. An endoscopic ultrasound (EUS)-guided portal pressure gradient measurement (importantly, it was less than 5 mmHg) was done, followed by EUS-guided liver biopsy and endoscopic sleeve gastroplasty.

The best parameter for evaluating prognostic portal hypertension is the hepatic venous pressure gradient obtained by interventional radiology. However, this approach has drawbacks that limit its general use: it requires high radiation exposure levels; it is technically demanding; it is available at only a few centers; and provides a surrogate metric for the actual portal vein pressure. The EUS-guided portal pressure gradient measurement avoids these disadvantages, and, when appropriately indicated and performed by trained endosonographers, could provide this key information in daily clinical practice for the majority of patients with portal hypertension. This is especially so in the setting of morbid obesity where noninvasive tools to evaluate portal hypertension could not be properly assessed.

Endoscopic procedures are coming into pole position to provide real personalized “one-stop shop” care in routine clinical practice to patients with portal hypertension, especially in the current era of an obesity pandemic.

Publication History

Article published online:
26 October 2023