Commentary on “Portal Hypertension‐Noninvasive Multiparametric Ultrasound Based Criteria and Measurements”

Hepatic venous pressure gradient (HVPG) measurement is the gold standard measurement for diagnosing portal hypertension (PH), a critical complication of liver cirrhosis. However, HVPG is an invasive and highly specialized technique. Noninvasive measurements would be extremely valuable to assess portal venous pressure [1]. It is therefore with interest that Möller et al. [2] report noninvasive multiparametric ultrasound-based criteria and measurements for evaluating PH comprehensively. This review emphasized the clinical utility of noninvasive multiparametric ultrasound-based techniques, including B-mode ultrasound, color Doppler imaging and measurement, contrast-enhanced ultrasound, endoscopic ultrasound, and elastography in assessing severity of PH and in predicting complications of PH. The paper highlighted the importance of liver and spleen stiffness measurements, along with Doppler measurements, for predicting complications of PH, such as esophageal varices. The authors proposed an algorithm for routine assessment and emphasized the need of further research to validate these techniques in clinical practice. This review aligned with and expanded upon prior studies on elastography [3] and hepatic steatosis [4] by contextualizing multiparametric ultrasound features within the evolving landscape of noninvasive PH assessment. The Key findings highlighted the diagnostic value of portal vein diameter, flow velocity, collateral detection, and liver and spleen stiffness measurements obtained via transient elastography (e.g., FibroScan) and acoustic radiation force impulse imaging. The integration of elastography with platelet count (e.g., Baveno VII criteria) effectively stratifies the risks of variceal bleeding, reducing the need for unnecessary endoscopies. By advocating for the standardization of elastography protocols and hybrid algorithms, this review served as a bridge between previous studies in elastography and the Baveno VII consensus. While this review focused on structural and hemodynamic vascular assessment via ultrasound, its ultrasound-based framework aligned with Vasomics' goal of holistic vascular profiling [5], thereby advancing noninvasive, multidimensional approaches to optimize clinical management of patients with PH [6]. Future advancements in contrast-enhanced techniques show promise for refining noninvasive portal vein pressure estimation and personalized therapeutic strategies [2]. Harmonic imaging plays an essential role in contrast-enhanced ultrasound. Due to the significant acoustic impedance difference between the liquid and air, the microbubbles strongly reflect the acoustic pulse. Microbubble expansion depends on the pressure of the surrounding medium, typically blood, due to their strict intravascular distribution after intravenous injection. Therefore, characterizing the nonlinear responses of microbubbles enables the estimation of blood pressure. In the subharmonic-aided pressure estimation (SHAPE) technique, insonation occurs at double the microbubble resonance frequency, while signal recording is performed at half this frequency [7]. The publications provided proof that the SHAPE gradient could estimate portal venous pressure in patients with liver cirrhosis [7-9]. Furthermore, it proposes future synergies with contrast-enhanced ultrasound and subharmonic pressure estimation to enhance noninvasive portal hypertension monitoring in metabolically complex populations. In conclusion, despite variability in Doppler data and technical limitations, the review advocated for the use of standardized algorithms that combine morphological, hemodynamic, and elastography parameters to optimize PH management. Yi Dong: conceptualization and writing. The author has nothing to report. The author has nothing to report. Prof. Yi Dong is a member of the Portal Hypertension & Cirrhosis editorial board and therefore excluded from the peer review process and all editorial decisions related to the publication of this manuscript. The author has nothing to report.