Hypertension in the large vein that brings blood from the intestines to the liver is the main driver of cirrhosis. But when hepatologists need to know if the pressure in a patient’s hepatic portal vein is too high, they’ve mainly had to rely on indirect measurement methods.

Physicians eschew direct measurement of portal pressure due to its invasiveness. Instead, they determine the pressure of two nearby veins and use the gradient to estimate portal pressure. Typically done by threading a guide wire through a vein in the neck, this method is also fairly invasive.

Johns Hopkins gastroenterologist and endoscopist Olaya Brewer Gutierrez says it’s time for some direct answers. She recently performed Maryland’s first endoscopic ultrasound (EUS) measurement of a patient’s portosystemic pressure gradient, and she hopes it’s the first of many.

“When liver doctors need to know whether a patient is at risk for cirrhosis or cancer, we can now use EUS to see for ourselves,” she says.

The Johns Hopkins therapeutic endoscopy team uses a new, tiny manometer connected to a small needle that provides a real-time, direct reading of the hepatic portal vein pressure — the most effective way to determine a patient’s risk for a host of dangerous liver diseases.

Brewer Gutierrez says Maryland’s first EUS measurement of hepatic portal vein pressure spared a patient from having a double transplant. “The patient was in end-stage kidney disease,” she says, “and also had been diagnosed somewhere else with cirrhosis.”

In the workup before a kidney and liver transplant, Brewer Gutierrez used EUS to find that the patient’s portal pressure was normal. “It was less than 5 millimeters of mercury,” she says, explaining that a manometer reading between 5 and 10 millimeters indicates subclinical portal hypertension.

While the patient was sedated in the endoscopy suite, Brewer Gutierrez looked for other signs of liver disease. “We didn’t find any lesions or nodules,” she says. “No esophageal varices. Nothing. We were happy to tell the transplant team that the patient only needed a kidney transplant. The liver was fine.”