Andrés Cárdenas

Background/Objectives: Variceal size and red wale marks determine hemorrhage risk and guide management in portal hypertension, so a reproducible classification is essential. The most widely used systems are Calès, Japanese Research Society for Portal Hypertension (JRSPH), and American Association for the Study of Liver Diseases (AASLD). We aimed to determine intra- and inter-observer concordance for variceal size using the mentioned classifications, and propose a simplified binary classification system based on the complete disappearance of the variceal relief during air insufflation. Methods: Descriptive cross-sectional study, using videos of esophagogastroduodenoscopy from pediatric and adult patients with esophageal varices, which were evaluated twice by three expert endoscopists. Cohen’s Kappa was used to assess agreement between two measurements, and Fleiss’s Kappa to evaluate the agreement of all three observers. Because some patients contributed more than one recording, confidence intervals were obtained by bootstrap resampling at the patient level. Results: A total of 78 videos were evaluated (58 adult, 20 pediatric). Intra-observer concordance for variceal size classification systems was: Calès κ = 0.41, JRSPH κ = 0.40, AASLD κ = 0.50, and new classification κ = 0.47. Inter-observer agreement was: Calès κ = 0.39, JRSPH κ = 0.24, AASLD κ = 0.31, and new classification κ = 0.47. Conclusions: Agreement for the commonly used variceal size classifications ranged from fair to moderate. Our proposed insufflation-based classification was the only system to achieve moderate agreement both within and between observers, offering a simpler criterion aligned with the treat-versus-observe decision. It should be regarded as a promising proposal rather than a validated tool: prospective multicenter validation against variceal bleeding outcomes is required before clinical use.

Portal hypertension is the principal driver of decompensation in advanced chronic liver disease, yet in metabolic dysfunction‐associated steatotic liver disease (MASLD) it deviates from the classical sinusoidal paradigm. Growing evidence points to a mixed sinusoidal–presinusoidal phenotype in which the hepatic venous pressure gradient (HVPG) may underestimate true portal pressure, and in which decompensation and varices can occur at lower HVPG values than in viral cirrhosis. This biology is compounded by a diagnostic gap: non‐invasive tests such as liver stiffness by vibration‐controlled transient elastography, FIB‐4, ANTICIPATE‐NASH, spleen stiffness and the NICER model, are degraded by obesity through technical limitations and altered diagnostic thresholds, even when test discrimination is preserved. Moreover, no non‐invasive rule‐in for clinically significant portal hypertension reaches a 90% positive predictive value in obese MASLD, leaving a clinically meaningful grey zone. Endohepatology addresses these diagnostic limitations by providing complementary hemodynamic, elastographic, and histological information. Within a single sedated session, EUS‐guided shear‐wave elastography and EUS‐guided liver biopsy can adjudicate F2–F3 fibrosis when treatment eligibility is uncertain; EUS‐guided portal pressure gradient measurement can provide a direct gradient when HVPG or non‐invasive tests are discordant with the clinical phenotype; and EUS‐based vascular assessment can characterize collateral and variceal anatomy. The same platform extends to therapy, including EUS‐guided gastric variceal obliteration and pre‐bariatric risk stratification. Current evidence is largely early‐phase and requires prospective validation. Rather than replacing established tools, endohepatology offers an integrated pathway tailored to the diagnostic and therapeutic problems most characteristic of MASLD.

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Percutaneous liver procedures are frequently performed in patients with abnormal coagulation tests. Current guidelines suggest prophylactic transfusion is not mandatory in all patients with liver disease or cirrhosis, depending on the risk of bleeding. This study aims to describe the incidence and risk of major bleeding after percutaneous liver procedure in patients with and without cirrhosis. This retrospective study includes patients who underwent percutaneous liver biopsy and radiofrequency and microwave ablation of liver lesions at 3 centers in Spain. A transfusion protocol was considered for platelet counts 1.5. The primary outcome was major bleeding. A total of 1797 patients were included in the study, with 316 having cirrhosis (18%) and 1481 without cirrhosis (82%). Among the patients with cirrhosis, 80 were classified as Child A, and percutaneous liver biopsy was the most frequent procedure (86%). Fourteen patients (0.8%) experienced major bleeding, with 0.4% occurring in radiofrequency and microwave ablation and 0.8% in percutaneous liver biopsy. Bleeding occurred in 0.6% of patients with cirrhosis compared to 0.8% in those without (p = ns). No clinical or procedural variables were associated with bleeding. Twenty-five patients (1.4%) had an international normalized ratio >1.5, and 22 patients (1.2%) had a platelet count 1.5 were transfused with fresh frozen plasma, and 72% (16/22) of those with platelet counts <50,000 received platelet transfusion. Patients with cirrhosis were more frequently transfused (5.9% vs. 1.5%). None of the patients who met the criteria for transfusion experienced major bleeding, regardless of whether they received a transfusion, and none of the patients who had a major bleeding episode met the transfusion criteria. In this cohort, major bleeding after percutaneous liver procedure occurred in <1% of patients, making it a low-risk procedure for patients with and without cirrhosis. Although not uniformly adopted, the current transfusion protocol still led to unnecessary blood product administration.

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