Imaging assessment and interventional management of paediatric portal hypertension: an update

Portal hypertension in children presents distinct etiologies, clinical manifestations, and management strategies compared with adults, making accurate imaging evaluation essential across the diagnostic and therapeutic pathway. Ultrasound remains the first-line modality, providing real-time assessment of vascular anatomy, haemodynamics, splenic involvement, and portosystemic collaterals. Colour Doppler ultrasound and pulsed-wave Doppler ultrasound, along with systematic scanning protocols, enable early identification of portal vein obstruction, cavernous transformation, and hepatofugal flow patterns. Elastography techniques, particularly spleen stiffness measurement, provide valuable non-invasive biomarkers of clinically significant portal hypertension and variceal risk and complement conventional imaging. When ultrasound findings are inconclusive, contrast-enhanced ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) offer detailed vascular mapping, characterisation of parenchymal changes, and preoperative evaluation. MRI-especially dynamic contrast-enhanced sequences, magnetic resonance cholangiopancreatography (MRCP), and magnetic resonance elastography-provides comprehensive anatomical and functional assessment without ionising radiation. Interventional and surgical procedures, including portal vein recanalisation, Meso-Rex bypass, and transjugular intrahepatic portosystemic shunts, require precise imaging both before and after treatment. Long-term surveillance relies on multimodal imaging to detect stenosis, thrombosis, or flow-related complications and to guide timely reintervention. With continuous advances in elastography, high-resolution CT, and MRI-based haemodynamic techniques, imaging plays an expanding role in the tailored management of paediatric portal hypertension, supporting early diagnosis, therapeutic decision-making, and structured follow-up.