Noninvasive diagnosis of clinically significant portal hypertension: current evidence and future directions

INTRODUCTION: Clinically significant portal hypertension (CSPH) is related to poor prognosis and its early detection is crucial for timely clinical interventions, such as initiation of nonselective-beta-blockers. The hepatic vein pressure gradient remains the gold standard to diagnose CSPH; however, noninvasive tests (NITs) have been developed as valuable alternatives. In this review, we summarize the diagnostic performance and clinical utility of such techniques in patients with compensated advanced chronic liver disease (cACLD). AREAS COVERED: A comprehensive literature search was performed, focusing on imaging methods, including elastographic techniques, ultrasound (US)-, magnetic resonance (MR)- and computed tomography (CT)-based methods, as well as serum biomarkers for the assessment of CSPH. The diagnostic accuracy of these techniques for the detection of esophageal varices is also discussed. Evidence on the combined use of NITs, emerging predictive models and developments following the Baveno VII consensus is summarized. EXPERT OPINION: NITs, particularly liver and spleen stiffness measurement, have been validated for the diagnosis of CSPH. Baveno VII has incorporated these tools into its recommendations for the management of cACLD. Future research should focus on the establishment of etiology-specific cutoff values and the further validation of alternative methods, such as MR elastography, spleen stiffness measurement and contrast enhanced US.