Diagnosing Portal Hypertension on Ultrasound

Key Ultrasound Findings for Portal Hypertension Diagnosis

The presence of portosystemic collaterals is 100% specific for clinically significant portal hypertension (CSPH) 1, 2
Flow reversal within the portal system is 100% specific for CSPH 1
Splenomegaly is sensitive for portal hypertension, but nonspecific when used alone, and is valuable when combined with other parameters 1, 2
Reduced portal vein velocity can be measured with Doppler, but shows high variability 1
The congestion index of the portal vein, a combination of portal vein diameter and velocity, is a useful parameter 1

The American College of Radiology recommends a first-line assessment looking for portosystemic collaterals and flow reversal in the portal system, which if present, confirms CSPH with 100% specificity 1, 2, 3
If these signs are absent, the evaluation should continue, as recommended by the American College of Radiology 4
The measurement of spleen size and portal vein parameters, such as portal vein diameter and flow velocity, can be used in the third-line assessment, as suggested by the Hepatology society 1, 2

The European Association for the Study of the Liver recommends liver stiffness measurement (LSM) by transient elastography (TE) with a cut-off of >20-25 kPa to diagnose CSPH in patients with compensated advanced chronic liver disease (cACLD) 3, 5
The combined parameters, such as the LSPS score (liver stiffness × spleen size/platelet count), can improve the accuracy of CSPH diagnosis, with a score >2.06 having 90% specificity 1, 3

The American Association for the Study of Liver Diseases recommends interpreting ultrasound findings alongside laboratory parameters, such as platelet count and Child-Pugh score, and clinical signs of portal hypertension, such as spider nevi and visible abdominal collaterals 1, 3
The Hepatology society suggests that hepatic venous pressure gradient (HVPG) remains the gold standard for measuring portal pressure, with CSPH defined as HVPG ≥10 mmHg 1