Noninvasive multimodal management of portal hypertension: from early screening to precision clinical decision-making

Portal hypertension (PH) is a critical driver of morbidity and mortality in chronic liver disease. Although the hepatic venous pressure gradient (HVPG) remains the diagnostic gold standard, its invasiveness, high cost, and technical requirements limit its utility for routine longitudinal monitoring. Despite the proliferation of noninvasive tests (NITs), a significant research gap persists regarding their optimal integration into standardized clinical workflows and the transition from static diagnosis to dynamic, precision-based management. This review synthesizes current evidence on serum-based biomarkers [e.g., fibrosis-4 (FIB-4) index, von Willebrand factor-to-platelet ratio (VITRO) score], elastography [liver stiffness measurement (LSM), spleen stiffness measurement (SSM), and magnetic resonance elastography (MRE)], and emerging artificial intelligence (AI)-based imaging radiomics. We critically evaluate their diagnostic performance and propose a multimodal framework for the comprehensive management of PH. Evidence suggests that while traditional scores like FIB-4 are effective for initial screening, the VITRO score significantly reduces the diagnostic "grey zone" inherent in the Baveno VII criteria. SSM shows superior linear correlation with HVPG across higher pressure ranges, and MRE demonstrates the highest diagnostic reliability in obese populations. Furthermore, AI-based vascular geometry and radiomics models offer high precision for virtual HVPG estimation, though their clinical adoption remains hindered by a lack of physiological interpretability and cross-platform standardization. This review proposes a practical, multimodal management model that integrates these noninvasive tools into a cohesive clinical pathway encompassing screening, risk stratification, treatment surveillance, and prognostic assessment. We critically examine the prevailing challenges regarding cost-effectiveness, global accessibility, standardization, and disease-specific validation. This paradigm establishes a conceptual framework for virtual HVPG modeling and therapeutic simulation. It provides evidence-based guidance for implementing tiered management strategies across both primary and specialized healthcare settings, ultimately moving toward a personalized, precision-medicine approach to PH. Future research must prioritize etiology-specific validation and the development of "closed-loop" systems that link noninvasive markers directly to therapeutic response and clinical outcomes.