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Figure 4 - Nonalcoholic fatty liver disease and portal hypertension

Figure 4. Direct and indirect methods for the assessment of portal hypertension. A. Several minimally invasive or non-invasive approaches (indicated by white circles) have been developed to estimate portal venous pressure, including endoscopic visualization or imaging of portal-systemic collaterals by various methods based on abdominal sonography [28, 63, 64, 79], computer tomography [80] and multi-parametric MR imaging [81]; tissue stiffness assessment of the liver and spleen by vibrationcontrolled transient elastography or 2-dimensional (gradient-recalled echo) MR elastography [65, 82-84]; and analysis of mucosal vascular pattern and flow by confocal endomicroscopy [78]. Direct access methods (indicated by blue circles) include HVPG measurement, which is the reference technique for measuring portal hypertension, and the occasional opportunity to obtain intraoperative access to the portal vein [57, 85, 86]. EUS-guided portal and hepatic vein access is an emerging method to provide safe and direct measurement of portal pressure gradient (PPG) [87, 88]; B. Comparison of the classic hepatic venous pressure gradient (HVPG) method using indirect access through the hepatic vein to estimate PVP and endoscopic ultrasound (EUS)-guided assessment of through direct access of the portal vein and hepatic vein. To calculate HVPG, a balloon-tipped central vein catheter is inserted into a hepatic vein tributary where retrograde occlusion detects WHVP and keeping the catheter "free" in the hepatic vein detects FHVP [57, 85]. In cirrhotic patients, WHVP is almost identical to PVP and the pressure difference between wedged and free-floating catheter positions defines HVPG [89]. To calculate PPG, the portal and hepatic vein is accessed through insertion of a digital pressure detection device by EUS-guided technique to calculate the difference between PVP and FHVP [87, 88]. SMV: superior mesenteric vein; IMV: inferior mesenteric vein; PV: portal vein; HV: hepatic vein
Direct and indirect methods for the assessment of portal hypertension. A. Several minimally invasive or non-invasive approaches (indicated by white circles) have been developed to estimate portal venous pressure, including endoscopic visualization or imaging of portal-systemic collaterals by various methods based on abdominal sonography [28, 63, 64, 79], computer tomography [80] and multi-parametric MR imaging [81]; tissue stiffness assessment of the liver and spleen by vibrationcontrolled transient elastography or 2-dimensional (gradient-recalled echo) MR elastography [65, 82-84]; and analysis of mucosal vascular pattern and flow by confocal endomicroscopy [78]. Direct access methods (indicated by blue circles) include HVPG measurement, which is the reference technique for measuring portal hypertension, and the occasional opportunity to obtain intraoperative access to the portal vein [57, 85, 86]. EUS-guided portal and hepatic vein access is an emerging method to provide safe and direct measurement of portal pressure gradient (PPG) [87, 88]; B. Comparison of the classic hepatic venous pressure gradient (HVPG) method using indirect access through the hepatic vein to estimate PVP and endoscopic ultrasound (EUS)-guided assessment of through direct access of the portal vein and hepatic vein. To calculate HVPG, a balloon-tipped central vein catheter is inserted into a hepatic vein tributary where retrograde occlusion detects WHVP and keeping the catheter "free" in the hepatic vein detects FHVP [57, 85]. In cirrhotic patients, WHVP is almost identical to PVP and the pressure difference between wedged and free-floating catheter positions defines HVPG [89]. To calculate PPG, the portal and hepatic vein is accessed through insertion of a digital pressure detection device by EUS-guided technique to calculate the difference between PVP and FHVP [87, 88]. SMV: superior mesenteric vein; IMV: inferior mesenteric vein; PV: portal vein; HV: hepatic vein
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