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.