We report our experience on EUS-guided portal pressure gradient measurement (EUS-PPGm). 

 Prospective study of patients referred for EUS-PPGm. A 25G dedicated needle was used. A 19G FNA needle was used for EUS-guided bilobar liver biopsy (EUS-BLB). 

EUS-PPGm was performed in 72 patients. Indications: Assessment of MASLD in morbid obese patients: 43. Portal hypertension (PH): 26. Evaluation for curative therapy in hepatocellular carcinoma (HCC): 3. Additional procedures were performed in the same endoscopic session: Fifty-three (74%) EUS-BLB, 3 band ligation for esophageal varices and 1 EUS-guided coil therapy for gastric varices. EUS-PPGm was obtained in 65/72 patients (90%). In 12/43 morbid obese patients (28%) the EUS-PPGM was >6 mmHg without varices nor fibrosis on EUS-BLB. In morbid obese patients, there was a statistically significant difference in the S3 score of steatosis in the group of portal hypertension (33%) in comparison with the no portal hypertension group (4%). Patients were treated accordingly with the results of EUS-PPGm. In 7 cases (10%) EUS-PPGm was not obtained. For rapid breathing movements (1 case) and for non-reliable pressure measurements (6 cases). In one case the 25G needle passed in close proximity to the hepatic artery. We experienced difficulty in punction the hepatic and the portal vein in one and two cases, respectively. In one case the 25G needle failed to transverse the liver capsule. Mean time to obtain EUS-PPGm 23±2 minutes for EUS-BLB 16±2 minutes and for combined EUS-PPGm plus EUS-BLB 44±2 minutes. Three adverse events were observed: 1 mild epigastric pain, 1 self-limited bleeding from the cardias and 1 atrial fibrillation.

EUS-PPGm, even combined with EUS-BLB, seems safe, providing relevant clinical information. A notewhorty proportion of morbid obese patients were precociously diagnosed of portal hypertension in early reversible stages without liver fibrosis on EUS-BLB.