Hepatic sinusoidal obstruction syndrome and the search for a modifiable endothelial state

Pyrrolizidine alkaloid (PA) exposure, haematopoietic stem cell transplantation (HSCT), and repeated oxaliplatin treatment provide distinct contexts for sinusoidal endothelial injury, with differing mechanisms and courses. Oxaliplatin-associated abnormalities may resolve or persist. Illustrated features are conceptual, not validated clinical stages or a shared temporal sequence. Recognition varies by setting and age; the proposed gap remains unvalidated. Current biomarkers and imaging do not establish the reversibility of liver sinusoidal endothelial cell (LSEC) injury. Clinical care remains etiology-specific. Testing whether an endothelial profile can guide treatment selection requires endothelial-associated measures, independent vascular assessment, and prospective evidence of differential treatment benefit. No endothelial-state-based treatment threshold has been validated.