The Moment HVPG Changed our Mind: Role of Liver Hemodynamics in Vascular Liver Disease

Portosinusoidal vascular liver disorder (PSVD) is an uncommon cause of clinically significant portal hypertension that can be misdiagnosed as cirrhosis, leading to delayed management. We report a case in which low liver stiffness, portal hypertension manifestations, and hemodynamic assessment reoriented the diagnosis. A 61-year-old man previously diagnosed with MetALD and prior oxaliplatin-based chemotherapy presented in 2017 with variceal upper gastrointestinal bleeding. Although imaging suggested cirrhosis with portal vein thrombosis, liver stiffness was low (LSM 7.7 kPa) and HVPG was 9 mmHg. Inconsistencies in the diagnostic work up led us to perform a liver biopsy, which showed portal abnormalities with focal sinusoidal dilatation and no fibrosis. Even when other potential causes of liver disease are present, in the absence of a liver biopsy, the underlying aetiology cannot be assumed to be the driver of portal hypertension; in this setting, liver elastography together with invasive hepatic hemodynamic measurements can help reorient the diagnosis toward PSVD and guide management.