Endoscopic Ultrasound and Portal Hypertension

  • Oriol Sendino
  • Angels GinèsEmail author


Endoscopic ultrasound (EUS) is a valuable diagnostic and therapeutic tool in many gastrointestinal disorders. It is a useful technique to assess vascular abnormalities in patients with chronic liver disease and portal hypertension and allows for a noninvasive evaluation of the hemodynamic changes linked to this condition. EUS improves the detection of gastric varices and collateral veins and provides assessment of variceal recurrence, risk of rebleeding and response to therapy. Furthermore EUS may be of help in guiding endoscopic therapy of varices, such as EUS-guided sclerotherapy of esophageal collateral vessels and EUS-guided glue injection or coiling of gastric varices. In addition, the ability of EUS to access the portal vein (PV) enables a broad spectrum of diagnostic and therapeutic interventions in patients with portal hypertension which have been shown to be feasible in animal models and in small, preliminary human studies.


Endoscopic ultrasound Portal hypertension Cirrhosis Gastroesophageal varices Cyanoacrylate Portal vein 


  1. 1.
    Kitano S, Terblanche J, Kahn D, et al. Venous anatomy of the lower oesophagus in portal hypertension: practical implications. Br J Surg. 1986;73:525–31.CrossRefPubMedGoogle Scholar
  2. 2.
    Hashizume M, Kitano S, Sugimachi K, et al. Threedimensional view of the vascular structure of the lower esophagus in clinical portal hypertension. Hepatology. 1988;8:1482–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Irisawa A, Obara K, Sato Y, et al. EUS analysis of collateral veins inside and outside the esophageal wall in portal hypertension. Gastrointest Endosc. 1999;50:374–80.CrossRefPubMedGoogle Scholar
  4. 4.
    Parasher VK, Meroni E, Malesci A, et al. Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound. Gastrointest Endosc. 1998;48:588–92.CrossRefPubMedGoogle Scholar
  5. 5.
    Wiersema MJ, Chak A, Kopecky KK, et al. Duplex Doppler endosonography in the diagnosis of splenic vein, portal vein, and portosystemic shunt thrombosis. Gastrointest Endosc. 1995;42:19–26.CrossRefPubMedGoogle Scholar
  6. 6.
    Kakutani H, Hino S, Ikeda K, et al. Use of the curved linear-array echo endoscope to identify gastrorenal shunts in patients with gastric fundal varices. Endoscopy. 2004;36:710–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Avunduk C, Hampf F. Endoscopic ultrasound in the diagnosis of watermelon stomach. J Clin Gastroenterol. 1996;22:104–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Kassem AM, Salama ZA, Zakaria MS, et al. Endoscopic ultrasonography study of the azygos vein before and after endoscopic obliteration of esophagogastric varices by injection sclerotherapy. Endoscopy. 2000;32:630–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Nishida H, Giostra E, Spahr L, et al. Validation of color Doppler EUS for azygos blood flow measurement in patients with cirrhosis: application to the acute hemodynamic effects of somatostatin, octreotide, or placebo. Gastrointest Endosc. 2001;54:24–30.CrossRefPubMedGoogle Scholar
  10. 10.
    Lee YT, Sung JJY, Yung MY, et al. Use of color Doppler EUS in assessing azygos blood flow for patients with portal hypertension. Gastrointest Endosc. 1999;50:47–52.CrossRefPubMedGoogle Scholar
  11. 11.
    Faigel DO, Rosen HR, Sasaki A, et al. EUS in cirrhotic patients with and without prior variceal hemorrhage in comparison with noncirrhotic control subjects. Gastrointest Endosc. 2000;52:455–62.CrossRefPubMedGoogle Scholar
  12. 12.
    McKiernan PJ, Sharif K, Gupte GL. The role of endoscopic ultrasound for evaluating portal hypertension in children being assessed for intestinal transplantation. Transplantation. 2008;86:1470–3.CrossRefPubMedGoogle Scholar
  13. 13.
    Caletti G, Brocchi E, Baraldini M, et al. Assessment of portal hypertension by endoscopic ultrasonography. Gastrointest Endosc. 1990;36:S21–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Burtin P, Calès P, Oberti F, et al. Endoscopic ultrasonographic signs of portal hypertension in cirrhosis. Gastrointest Endosc. 1996;44:257–61.CrossRefPubMedGoogle Scholar
  15. 15.
    Boustiere C, Dumas O, Jouffre C, et al. Gastric endoscopic ultrasonography: a new approach to the diagnosis of portal hypertension in cirrhotic patients. Hepatology. 1991;14:85.Google Scholar
  16. 16.
    Liu JB, Miller LS, Feld RI, et al. Gastric and esophageal varices: 20-MHz transnasal endoluminal US. Radiology. 1993;187:363–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Suzuki T, Matsutani S, Umebara K, et al. EUS changes predictive for recurrence of esophageal varices in patients treated by combined endoscopic ligation and sclerotherapy. Gastrointest Endosc. 2000;52:611–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Choudhuri G, Dhiman RK, Agarwal DK. Endosonographic evaluation of the venous anatomy around the gastro-esophageal junction in patients with portal hypertension. Hepato-Gastroenterology. 1996;43:1250–5.PubMedGoogle Scholar
  19. 19.
    Lee YT, Chan FK, Ching JY, et al. Diagnosis of gastroesophageal varices and portal collateral venous abnormalities by endosonography in cirrhotic patients. Endoscopy. 2002;34:391–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Konishi Y, Nakamura T, Kida H, et al. Catheter US probe EUS evaluation of gastric cardia and perigastric vascular structures to predict esophageal variceal recurrence. Gastrointest Endosc. 2002;55:197–203.CrossRefPubMedGoogle Scholar
  21. 21.
    Lo GH, Lai KH, Cheng JS, et al. Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy. Gastrointest Endosc. 1999;49:428–36.CrossRefPubMedGoogle Scholar
  22. 22.
    Pontes JM, Leitao MC, Portela FA, et al. Endoscopic ultrasonography in the treatment of esophageal varices by endoscopic sclerotherapy and band ligation: do we need it. Eur J Gastroenterol Hepatol. 1995;7:41–6.PubMedGoogle Scholar
  23. 23.
    Goenka MK, Kochhar R, Nagi B, et al. Rectosigmoid varices and other mucosal changes in patients with portal hypertension. Am J Gastroenterol. 1991;86:1185–9.PubMedGoogle Scholar
  24. 24.
    Wu CS, Chen CM, Chang KY. Endoscopic injection sclerotherapy of bleeding duodenal varices. J Gastroenterol Hepatol. 1995;19:481–3.CrossRefGoogle Scholar
  25. 25.
    Palazzo L, Hochain P, Helmer C, et al. Biliary varices on endoscopic ultrasonography: clinical presentation and outcome. Endoscopy. 2000;32:520–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Irisawa A, Saito A, Obara K, et al. Endoscopic recurrence of esophageal varices is associated with the specific EUS abnormalities: severe periesophageal collateral veins and large perforating veins. Gastrointest Endosc. 2001;53:77–84.CrossRefPubMedGoogle Scholar
  27. 27.
    Sato T, Yamazaki K, Toyota J, et al. Endoscopic ultrasonographic evaluation of hemodynamics related to variceal relapse in esophageal variceal patients. Hepatol Res. 2009;39:126–33.CrossRefPubMedGoogle Scholar
  28. 28.
    Dhiman RK, Choudhuri G, Saraswat VA, et al. Role of paraesophageal collateral and perforating veins on outcome of endoscopic sclerotherapy for esophageal varices: an endosonographic study. Gut. 1996;38:759–64.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Leung VK, Sung JJ, Ahuja AT, et al. Large paraesophageal varices on endosonography predict recurrence of esophageal varices rebleeding. Gastroenterology. 1997;112(6):1811.CrossRefPubMedGoogle Scholar
  30. 30.
    Hino S, Kakutani H, Ikeda K, et al. Hemodynamic analysis of esophageal varices using color Doppler endoscopic ultrasonography to predict recurrence after endoscopic treatment. Endoscopy. 2001;33:869–72.CrossRefPubMedGoogle Scholar
  31. 31.
    Kuramochi A, Imazu H, Kakutani H, et al. Color Doppler endoscopic ultrasonography in identifying groups at high-risk of recurrence of esophageal varices after endoscopic treatment. J Gastroenterol. 2007;42:219–24.CrossRefPubMedGoogle Scholar
  32. 32.
    Lee YT, Chan FK, Ng EK, et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc. 2000;52:168–74.CrossRefPubMedGoogle Scholar
  33. 33.
    Iwase H, Suga S, Morise K. Color Doppler endoscopic ultrasonography for the evaluation of gastric varices and endoscopic obliteration with cyanoacrylate glue. Gastrointest Endosc. 1995;41:150–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Lahoti S, Catalano M, Alcocer E, et al. Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler. Gastrointest Endosc. 2000;51(3):331.CrossRefPubMedGoogle Scholar
  35. 35.
    De Paulo GA, Ardengh JC, Nakao FS, et al. Treatment of esophageal varices: a randomized controlled trial comparing endoscopic sclerotherapy and EUSguided sclerotherapy of esophageal collateral veins. Gastrointest Endosc. 2006;63:396–402.CrossRefPubMedGoogle Scholar
  36. 36.
    Romero-Castro R, Pellicer-Bautista FJ, Jiménez-Saenz M, et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc. 2007;66:402–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Levy M, Wong Kee Song L, Kendrick M. EUS-guided coil embolization for refractory ectopic variceal bleeding. Gastrointest Endosc. 2008;67:572–4.CrossRefPubMedGoogle Scholar
  38. 38.
    Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc. 2013;78:711–21.CrossRefPubMedGoogle Scholar
  39. 39.
    Bhat YM, Weilert F, Fredrick RT, et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc. 2016;83(6):1164–72.CrossRefPubMedGoogle Scholar
  40. 40.
    So H, Park do H, Jung K, Ko HK. Successful endoscopic ultrasound-guided coil embolization for severe duodenal bleeding. Am J Gastroenterol. 2016;111:925.CrossRefPubMedGoogle Scholar
  41. 41.
    Sharma M, Somasundaram A. Massive lower GI bleed from an endoscopically inevident rectal varices: diagnosis and management by EUS (with videos). Gastrointest Endosc. 2010;72:1106–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Weilert F, Shah JN, Marson FP, et al. EUS-guided coil and glue for bleeding rectal varix. Gastrointest Endosc. 2012;76:915–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Tsynman DN, DeCross AJ, Maliakkal B, et al. Novel use of EUS to successfully treat bleeding parastomal varices with N-butyl-2-cyanoacrylate. Gastrointest Endosc. 2014;79:1007–8. discussion 1008CrossRefPubMedGoogle Scholar
  44. 44.
    Lai L, Poneros J, Santilli J. EUS-guided portal vein catheterization and pressure measurement in an animal model: a pilot study of feasibility. Gastrointest Endosc. 2004;59:280–3.CrossRefPubMedGoogle Scholar
  45. 45.
    Giday S, Clarke J, Buscaglia J, et al. EUS-guided portal vein catheterization: a promising novel approach for portal angiography and portal vein pressure measurements. Gastrointest Endosc. 2008;67:338–42.CrossRefPubMedGoogle Scholar
  46. 46.
    Schulman AR, Thompson CC, Ryou M. EUS-guided portal pressure measurement using a digital pressure wire with real-time remote display: a novel, minimally invasive technique for direct measurement in an animal model. Gastrointest Endosc. 2016;83:817–20.CrossRefPubMedGoogle Scholar
  47. 47.
    Huang JY, Samarasena JB, Tsujino T, et al. EUS-guided portal pressure gradient measurement with a novel 25-gauge needle device versus standard transjugular approach: a comparison animal study. Gastrointest Endosc. 2016;84:358–62.CrossRefPubMedGoogle Scholar
  48. 48.
    Fujii-Lau LL, Leise MD, Kamath PS, et al. Endoscopic ultrasonography-guided portal-systemic pressure gradient measurement. Endoscopy 2014;46(S01):E654–E656.Google Scholar
  49. 49.
    Huang JY, Samarasena JB, Tsujino T, et al. EUS-guided portal pressure gradient measurement with a simple novel device: a human pilot study. Gastrointest Endosc.Epub 2016 Sep 29Google Scholar
  50. 50.
    Buscaglia JM, Dray X, Shin EJ, et al. A new alternative for a transjugular intrahepatic portosystemic shunt: EUS-guided creation of an intrahepatic portosystemic shunt (with video). Gastrointest Endosc. 2009;69:941–7.CrossRefPubMedGoogle Scholar
  51. 51.
    Schulman AR, Ryou M, Aihara H, et al. EUS-guided intrahepatic portosystemic shunt with direct portal pressure measurements: a novel alternative to transjugular intrahepatic portosystemic shunting. Gastrointest Endosc. 2017;85:243–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Binmoeller KF, Shah JN. EUS-guided transgastric intrahepatic portosystemic shunt using the axios stent [abstract]. Gastrointest Endosc. 2011;73:AB167.Google Scholar
  53. 53.
    Lai R, Stephens V, Bardales R. Diagnosis and staging of hepatocellular carcinoma by EUS-FNA of a portal vein thrombus. Gastrointest Endosc. 2004;59:574–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Michael H, Lenza C, Gupta M, et al. Endoscopic ultrasound-guided fineneedle aspiration of a portal vein thrombus to aid in the diagnosis and staging of hepatocellular carcinoma. Gastroenterol Hepatol. 2011;7:124–9.Google Scholar
  55. 55.
    Storch I, Gomez C, Contreras F, et al. Hepatocellular carcinoma (HCC) with portal vein invasion, masquerading as pancreatic mass, diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Dig Dis Sci. 2007;52:789–91.CrossRefPubMedGoogle Scholar
  56. 56.
    Kayar Y, Turkdogan KA, Baysal B, Unver N, et al. EUS-guided FNA of a portal vein thrombus in hepatocellular carcinoma. Pan Afr Med J. 2015;21:86.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Vazquez-Sequeiros E, Olcina JRF. Endoscopic ultrasound guided vascular access and therapy: a promising indication. World J Gastrointest Endosc. 2010;2:198–202.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Matthes K, Sahani D, Holalkere NS, et al. Feasibility of endoscopic ultrasound-guided portal vein embolization with Enteryx. Acta Gastroenterol Belg. 2005;68:412–5.PubMedGoogle Scholar
  59. 59.
    Faigel D, Lake D, Landreth T, et al. Endoscopic ultrasonography-guided portal injection chemotherapy for hepatic metastases. Endosc Ultrasound. 2014;3(Supp 1):S1.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Catenacci DVT, Chapman CG, Xu P, et al. Acquisition of portal venous circulating tumor cells from patients with pancreaticobiliary cancers by endoscopic ultrasound. Gastroenterology. 2015;149:1794–803.e4.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Endoscopy Unit, Hospital ClínicIDIBAPS, CIBERehdBarcelonaSpain

Personalised recommendations