Digestive Diseases and Sciences

, Volume 51, Issue 12, pp 2264–2269 | Cite as

Hepatic Venous Pressure Gradient in Cirrhosis: Correlation with the Size of Varices, Bleeding, Ascites, and Child's Status

  • M. Wadhawan
  • S. Dubey
  • B. C. Sharma
  • S. K. Sarin
  • S. K. Sarin
Original Article

Abstract

The hepatic venous pressure gradient (HVPG) clearly reflects portal pressure in cirrhotic portal hypertension. Its relation with variceal bleeding has been well studied. We undertook to study the relation of HVPG to variceal size, Child's status, and etiology of cirrhosis. Patients with cirrhotic portal hypertension with esophageal varices underwent HVPG measurement as part of a prospective evaluation. One hundred seventy-six cirrhotics with varices (M:F, 140:36; mean age, 42.6 ± 13.4 years), 104 with CLD related to viral etiology, 40 with alcoholic liver disease, 26 cryptogenic with cirrhosis, and 6 with miscellaneous causes of CLD underwent HVPG measurement. The mean HVPG was lower in patients with small varices (n = 77; 14.6 ± 5.9 mm Hg) than in patients with large varices (n = 99; 19.2 ± 6.6 mm Hg; P < 0.01). In patients with large varices, the mean HVPG in bleeders (n = 37) was higher than in nonbleeders (n = 62) (21.7 ± 7.2 vs 17.9 ± 6.2 mm Hg; P < 0.01). The mean HVPG was significantly higher in Child's B (n = 97; 17.4 ± 6.9 mm Hg) and C (n = 56; 19.0 ± 5.7 mm Hg) compared to Child's A cirrhotics (n = 23; 12.2 ± 5.9 mm Hg; P < 0.01), and Child's C compared to Child's B cirrhotics (P = 0.05). HVPG was higher in alcoholic compared to nonalcoholic cirrhotics (20.8 ± 7.3 vs 16.4 ± 6.3 mm Hg; P < 0.05), but this was not significant in multivariate analysis. The HVPG was comparable between hepatitis B- and hepatitis C virus-related cirrhotics (P = 0.8). Cirrhotics with ascites had a higher HVPG than those without ascites (18.5 ± 5.6 vs 16.6 ± 7.6 mm Hg; P = 0.02). In multivariate analysis, only Child's status, size of varices, and variceal bleed predicted higher HVPG. HVPG is higher in cirrhotics with large varices and a history of bleed. There is a good correlation between HVPG and large varices, bleeder status, and ascites. A higher HVPG reflects more severe liver disease. The etiology of liver disease did not influence the portal pressure.

Keywords

Portal pressure Wedged hepatic venous pressure Free hepatic venous pressure Variceal bleeding 

References

  1. 1.
    Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. (1985) Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 5:419–424PubMedGoogle Scholar
  2. 2.
    Viallet A, Marleau D, Huet M, Martin F, Farley A, Villeneuve JP, Lavoie P (1975) Hemodynamic evaluation of patients with intrahepatic portal hypertension. Relationship between bleeding varices and the portohepatic gradient. Gastroenterology 69:1297–1300PubMedGoogle Scholar
  3. 3.
    de Franchis R (2000) Updating consensus in portal hypertension. Report of the Baveno III consensus workshop on definitions, methodology and therapeutic strategies in portal hypertension. J Hepatol 33:846–852CrossRefPubMedGoogle Scholar
  4. 4.
    Casado M, Bosch J, Garcia-Pagan JC, et al. (1998) Clinical events following transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 114:1296–1303CrossRefPubMedGoogle Scholar
  5. 5.
    Groszmann RJ, Bosch J, Grace ND, et al. (1990) Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 99:1401–1407PubMedGoogle Scholar
  6. 6.
    Vorobioff J, Groszmann RJ, Picabea E, et al. (1996) Prognostic value of hepatic venous pressure gradient measurements in alcoholic cirrhosis: a 10-year prospective study. Gastroenterology 111:701–709CrossRefPubMedGoogle Scholar
  7. 7.
    Escorsell A, Bordas JM, Castaneda B, Llach J, Garcia-Pagan JC, Rodes J, Bosch J (2000) Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension. Hepatology 31:1061–1067CrossRefPubMedGoogle Scholar
  8. 8.
    Villanueva C, Minana J, Ortiz J, et al. (2001) Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding. N Engl J Med 345:647–655CrossRefPubMedGoogle Scholar
  9. 9.
    Rossle M, Siegerstetter V, Olschewski M, Ochs A, Berger E, Haag K (2001) How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with transjugular intrahepatic portosystemic shunts. Am J Gastroenterol 96:3379–3383PubMedGoogle Scholar
  10. 10.
    Moitinho E, Escorsell A. Bandi JC, et al. (1999) Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology 117:626–631CrossRefPubMedGoogle Scholar
  11. 11.
    Sanyal AJ, Genning C, Reddy KR, Wong F, Kowdley KV, Benner K, McCashland T, North American Study for the Treatment of Refractory Ascites Group (2003) The North American Study for the Treatment of Refractory Ascites. Gastroenterology 124:634–641CrossRefPubMedGoogle Scholar
  12. 12.
    The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices (1988) Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med 319:983–989CrossRefGoogle Scholar
  13. 13.
    Bellis L, Castellacci R, Montagnese F, Festuccia F, Corvisieri P, Puoti C (2003) Hepatic venous pressure gradient determination in patients with hepatitis C virus-related and alcoholic cirrhosis. Eur J Gastroenterol Hepatol 15:1085–1089CrossRefPubMedGoogle Scholar
  14. 14.
    Perello A, Escorsell A, Bru C, Gilabert R, Moitinho E, Garcia-Pagan JC, Bosch J (1999) Wedged hepatic venous pressure adequately reflects portal pressure in hepatitis C virus-related cirrhosis. Hepatology 30:1393–1397CrossRefPubMedGoogle Scholar
  15. 15.
    Valla D, Jiron MI, Poynard T, Lebrec D (1987) Failure of haemodynamic measurement to predict recurrent gastrointestinal bleeding incirrhotic patients receiving propranolol. J Hepatol 5:144–148CrossRefPubMedGoogle Scholar
  16. 16.
    Conn HO (1967) Ammonia tolerance in the diagnosis of esophageal varices: a comparison of the endoscopic, radiologic and biochemical techniques. J Lab Clin Med 70:442–451PubMedGoogle Scholar
  17. 17.
    Lay CS, Tsai YT, Teg C, et al. (1997) Endoscopic variceal prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices. Hepatology 25:1346–1350CrossRefPubMedGoogle Scholar
  18. 18.
    D'Amico G, Pagliaro L, Bosch J (1999) Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis 19:475–505PubMedCrossRefGoogle Scholar
  19. 19.
    Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, Cavallarin G, Bolognesi M, Donada C, Bellini B, Torboli P, Gatta A, Gruppo Triveneto per l'Ipertensione Portale (2004) A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 127:476–484CrossRefPubMedGoogle Scholar
  20. 20.
    Sarin SK, Sethi KK, Nanda R (1987) Measurement and correlation of wedged hepatic, intrahepatic, intrasplenic and intravariceal pressures in patients with cirrhosis of liver and non-cirrhotic portal fibrosis. Gut 28:260–266PubMedGoogle Scholar
  21. 21.
    Thalheimer U, Mela M, Patch D, Burroughs AK (2004) Targeting portal pressure measurements; a critical reappraisal. Hepatology 39:286–290CrossRefPubMedGoogle Scholar
  22. 22.
    Stanley AJ, Robinson I, Forrest EH, Jones AL, Hayes PC (1998) Hemodynamic parameters predicting variceal hemorrhage and survival in alcoholic cirrhosis. Q J Med 91:19–25Google Scholar
  23. 23.
    Abraldes JG, Tararitino I, Turnes J, Garcia-Pagan JC, Rodes J, Bosch J (2003) Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology 37:902–908CrossRefPubMedGoogle Scholar
  24. 24.
    Burroughs AK, Groszman R, Bosch J, Grace N, Garcia-Tsao G, Patch D, Garcia-Pogan JCV, Dagher L (2002) Assessment of therapeutic benefit of antiviral therapy in chronic hepatitis C is hepatic venous pressure gradient a better end-point? Gut 50:425–427CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • M. Wadhawan
    • 1
  • S. Dubey
    • 1
  • B. C. Sharma
    • 1
  • S. K. Sarin
    • 1
  • S. K. Sarin
    • 2
  1. 1.Department of GastroenterologyG. B. Pant HospitalNew DelhiIndia
  2. 2.Department of GastroenterologyNew DelhiIndia

Personalised recommendations