doppler of the portal system 1
TRANSCRIPT
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Doppler of the portal system
Pathological findings
Dr. Muhammad Bin ZulfiqarPGR-II FCPS-II SIMS/SHL
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Portal Vein Thrombosis
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Causes of Portal vein Thrombosis
IDIOPATHIC : (mostly): ? neonatal sepsis
SECONDARY:
– (1) Cirrhosis+ portal hypertension (5%)
– (2) Malignancy:
– (3) Trauma:
– (4) Hypercoagulable state:
– (5) Intraperitoneal inflammatory process (portal vein phlebitis):
– (6) Budd-Chiari syndrome (20%)
– (7) Liver transplantation
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Portal vein thrombosis
• Sensitivity Equal to CT – Power Doppler increase Sen.
• False positive Very low portal flow
• Partial Gray scale better than color Doppler
• Indications Before hepatic surgery
Before porto-caval shunt
Before hepatic transplantation
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Classification of portal vein thrombosis
• Duration Acute
Chronic
• Severity Complete
Partial
• Causes Malignant
Non-malignant
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Diagnosis of malignant PV thrombosis
• Color Doppler US* PV > 23 mm in diameter
“AASLD” Arterial-like flow on Doppler
Increased serum α-FP
• FNA CT- or US-guided
• CEUS Contrast-Enhanced Ultrasound
* DeLeve L et al. AASLD practice guidelines: Vascular disorders of the liver.Hepatology 2009 ; 49 : 1729 – 1764.
AASLD: American association of study of liver disease.
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Portal vein thrombus in HCC
Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.
FNA of portal vein thrombus confirmed HCC
Gray-scale US image
Thrombus in PV & its branches
Color Doppler image
Vascularity within thrombusLow-resistance arterial waveform
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Malignant PV thrombosis / CEUS38 pts (15 benigns - 23 malignants) – Conclusive (37/38)
Dănilă M et al. Medical Ultrasonography 2011 ; 13 : 102 – 107.
Gray-scale US
Malignant PVT Arterial phase
Enhancement
Portal phase
Wash-out
Late phase
Wash-out
Contrast-Enhanced US
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Splenic vein thrombosisGastric cancer
Malignant thrombus tends to distend vein+ exhibitpulsatile flow, a bland thrombus does not!
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Superior mesenteric vein thrombosis
Pancreatic cancer
Sagittal view of pancreas & SMV
Thrombosed
SMV
Mass in
Pancreatic neck
Shunt between SMV
& systemic venous return
http://www.sonographers.ca
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Superior mesenteric vein thrombosis
Transverse image of SMA & SMV
http://www.ultrasoundcases.info
SMA
SMV
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Non-malignant PV thrombosis in cirrhosis
• Incidence 10 – 25%
• Pathophysiology Cirrhosis no longer hypocoagulable state
• Clinical findings Asymptomatic disease
Life-threatening condition
• Management Not addressed in any consensus publication
1st line treatment: warfarin or LMWH
2nd line treatment: thrombectomy, TIPS
Tsochatzis EA et al. Aliment Pharmacol Ther 2010; 31 : 366 – 374.
LMWH : Low molecular weight heparin, TIPS: Transjugular intrahepatic portosystemic shunts
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Acute thrombosis of portal vein
Complete thrombosis
http://www.sites.tufts.edu
Echogenic material visualized within portal vein.Increased diameter of portal vein.
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Partial thrombosis of portal vein
Echogenic material occluding lumen of PV by ≈ 50%
Sacerdoti D et al. J Ultrasound 2007 ; 10 : 12 – 21.
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Partial thrombosis of portal vein
Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.
Gray scale ultrasound
Partial echogenic thrombus
Color & pulsed Doppler
Complete filling of main PVobscuring the clot
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Portal vein pseudoclot – Augmentation
Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
Color Doppler US of main portal vein
At rest No detectable flow
Compression of lower abdomenAugmented portal venous flow
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Portal vein pseudoclot – Incorrect angle
Velocity: 24 cm/sec
Wall filter: medium
Angle 90°
Velocity: 7 cm/sec
Wall filter: medium
Angle < 60°
Radiol Clin N Am 2006 ; 44 : 805 – 835.
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Chronic portal vein thrombosisPortal cavernoma
Parikh et al. Am J Med 2010 ; 123 : 111 – 119.
Hepatopetal collaterals around thrombosed portal vein
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Portal cavernoma
Gray-scale ultrasound Color & pulsed Doppler
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Tchelepi H et al. Ultrasound Clin 2007 ; 2 : 415 – 422.
Transverse color US of stomach
Multiple dilated gastric varices
P-S collaterals / Isolated gastric varices
Collaterals via short gastric veinsIsolated gastric varicesHepatopetal flow in LGV
Splenic vein thrombosis
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P-S collaterals / Transcapsular collateralsChronic PVT due to necrotizing pancreatitis or surgery
Seeger M et al. Radiology 2010 ; 257 : 568 – 578.
Transcapuslar collateralfrom SB varices to PVs
Color Doppler image
Submucosal varicesin small-bowel loop
US image
Ectopic intestinal varices& transcapsular collaterals
Schematic diagram
SB: small bowel
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Intestinal infarction
• Ascites
• Thinning of intestinal wall
• Lack of mucosal enhancement of thickened wall
• Development of multi-organ failure
Intestinal infarction is likely
Surgical exploration should be considered
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Ultrasound in ischemic bowel
Thickening of small bowel wall
Loss of layering structure of wall
Chen MJ et al. J Med Ultrasound 2006 ; 14 : 79 – 85.
Thickening of small bowel wall
Bright flecks within the wall
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Portal vein gas
Acute transmural mesenteric infarction
Tritou I et al. J Clin Ultrasound 2011 (in press). Wiesner W et al. Radiology 2003 ; 226 : 635 – 650.
Intrahepatic PV gas in periphery of both lobes
CECT scan
Tiny echogenic foci in liver parenchyma
Gray-scale US
Vertical bidirectionalspikes on PV waveform
Duplex of MPV
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Portal cholangiopathy
• Definition Biliary & GB abnormalities in EHPVO
• Frequency 70 – 100% (symptomatic or not)
• Mechanism Mechanical extrinsic compression
Biliary ischemic injury
• Manifestation Majority asymptomatic
RUQ quadrant pain
Cholestasis & cholangitis
Secondary biliary cirrhosis
• Management Directed to symptomatic patients only
Besa C et al. Abdom Imaging 2011 .(EHPVO: Extra hepatic portal vein obstruction)
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Portal cholangiopathyBiliary & GB wall abnormalities in EHPVO
Gallbladder varices
producing wall thickening
Cavernoma of portal vein
Associated with dilated bile ducts
Besa C et al. Abdom Imaging 2011.
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Budd Chiari syndrome
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Causes of Budd Chiari Syndrome
PregnancyPills (birth control pills)Platelets (thrombocytosis)Paroxysmal nocturnal hemoglobinureaPolycythemia rubra vera
Systemic Behcet syndrome, inflammatory bowel disease
Dahnert p 706
Thrombosis“5Ps”
Causes Disease
Idiopathic 60%
NonThrombotic
Compression or invasion of IVCMembranous obstruction/IVC diaphragmRight atrial causes
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Diagnosis of BCS
AASLD practice guidelines*
• Doppler US Most effective & reliable diagnostic mean
Experienced examiner aware of dg suspicion
• MRI or CT Confirmatory study
Experienced Doppler examiner not available
• Liver biopsy Diagnosis not done by non-invasive imaging
• Venography When diagnosis remains uncertain
* DeLeve L et al. AASLD practice guidelines: Vascular disorders of the liverHepatology May 2009 ; 49 : 1729 – 1764.
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Doppler US in BCS
• One/ more major hepatic veins reduced in size to <3 mm/
filled with thrombus/ not visualized
• Stenosis of hepatic veins
• Communicating intrahepatic venous collaterals
• Decreased/ absent/reversed blood flow in hepatic veins
• Flat flow/ loss of cardiac modulation in hepatic veins
• Demodulated portal venous flow = disappearance of
portal vein velocity variations with breathing
continued
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Doppler US in BCS
• Slow flow (<11 cm/sec)/hepatofugal flow in portal vein
• portal vein congestion index >0.1
• Portal vein thrombosis (20%)
• Compression of IVC by enlarged liver/caudate lobe
• Sluggish/ reversed/ absent blood flow within IVC
• Hepatic artery resistive index >0.75
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Doppler US in BCS
* DeLeve L et al. AASLD practice guidelines. Hepatology 2009 ; 49 : 1729 – 1764.
Obstructed HV Presence of solid endoluminal materialHyperechoic cord replacing normal veinReversed flow in large hepatic veinDilatation of vein upstream to obstacle
HV collaterals Sipder web in vicinity of HV ostiaSubcapsular or HV to intercostal or HV veins Caudate lobe hypertrophy with dilated veins
IVC Web – Thrombosis – Inversion of flow
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BCS / Solid endoluminal material in HV
Solid endoluminal material in middle & left hepatic veins
Narrowing at distal end of middle hepatic vein as it joins IVC
Chaubal N et al. J Ultrasound Med 2006 ; 25 : 373 – 379.
Transverse subcostal image
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Budd-Chiari syndrome
Hepatic veins transformed to fibrotic cords
“Hepatic vein star”
Boozari B et al. J Hepatol 2008 ; 49 : 572 – 580.
Hyperechoic cord
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BCS / Reversed flow in large HV
Inverted flow in right hepatic vein
Normal flow in middle hepatic vein
Right intercostal view
Bargalló X et al. Am J Roentgenol 2006 ; 187 : W33 – W42.
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BCS / Reversed flow in HV upstream to obstacle
Solid endo-luminal material in distal part of MHV
Reverse flow in proximal part of MHV
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BCS / Sipder web in vicinity of HV ostia
Vilgrain V. Eur Radiol 2001 ; 11 : 1563 – 1577.Segev D L. Liver Transpl 2007 ; 13 : 1285 – 1294.
Gray-scale US
Small interwoven veins near IVC
Hepatic venogram
Typical “spider web” pattern
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BCS / Large subcapsular vein
Large tortuous subcapsular vein draining into IVC
Bargalló X et al. Am J Roentgenol 2006 ; 187 : W33 – W42.
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BCS / HV draining into another HV
Occluded RHV draining through collateral vessel into MHV
Flow away & toward transducer in same vessel
“Bicolored hepatic vein”
Bargalló X et al. Am J Roentgenol 2006 ; 187 : W33 – W42.
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BCS / Collateral from HV to caudate lobe vein
Brancatelli G et al. Am J Roentgenol 2007 ; 188 : W168 – W176.
Transverse Doppler US at level of caudate lobe
Lack of flow in distal portion of MHV
Collateral from MHV to caudate lobe vein
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BCS / Suggestive intra-hepatic collateral
Erden A. Eur J Radiol 2007 ; 61 : 44 – 56.
Undulated course “h-shaped”
Hockey-stick Curvilinear Curved
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BCS / Caudate lobe hypertrophy
Erden A. Eur J Radiol 2007 ; 61 : 44 – 56.
Sagittal gray-scale US
Enlarged caudate lobe
Antero-posterior diameter: 7.6 cm
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BCS / Dilated caudate lobe vein
75% of cases
Bargalló X et al. Am J Roentgenol 2003 ; 181 : 1641 – 1645.
Mildly dilated caudate vein
7 mm
Largely dilated caudate vein
21 mm
Caudate vein (≥ 3 mm) suggests diagnosis
Except for cardiac failure
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BCS / Membranous obstruction of IVC
Kandpal H et al. RadioGraphics 2008 ; 28 : 669 – 689.
30-year-old woman, abdominal pain & distention of 3 y duration
Ostial HV narrowingMultiple IH collaterals
Tapered IVC occlusionat cavo-atrial junction
Reversed flow in IVCLoss of cardiac pulsations
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Budd-Chiari syndrome & liver hydatid diseaseRetrospective study of 13 patients with HDL & BCS
Yilmaz C et al. Radiol Oncol 2009 ; 43 : 225 – 232.
Heterogeneous mass representing degenerated & collapsed membranes
Large subcapsular vein draining into suprahepatic IVC
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BCS / IVC thrombosis Behçet disease – Secondary BCS
Sagittal image of IVC distended with echogenic thrombus
Secondary BCS due to renal cell carcinoma
Rumack CM, Wilson SR, & Charboneau JW. Diagnostic Ultrasound.
Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
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BCS / Thrombosis of PV15% of patients – Poor prognosis
Bargalló X et al. Am J Roentgenol 2006 ; 187 : W33 – W42.
Thrombosis of portal vein
Hepatofugal flow in right portal vein
Dilated hepatic artery
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BCS / Benign regenerative nodulesMultiple (> 10) – Small ( < 4 cm) – Hypervascular
Vilgrain V et al. Radiology 1999 ; 210 : 443 – 450.Bargalló X et al. Am J Roentgenol 2006 ; 187 : W33 – W42.
Two iso- & hyperechoic nodulessurrounded by thin hypoechoic halo
Low resistance arterial waveform
with high velocity
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Proposed diagnostic strategy for BCS
Valla DC. Gut 2008 ; 57 : 1469 – 1478.
DeLeve L et al. AASLD practice guidelines. Hepatology 2009 ; 49 : 1729 – 1764.
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Doppler US in SOS
Non specific
• Main PV Decreased, to-and-fro, or reversed flow
• Hepatic artery Significant elevation of RI (> 0.80)
• Hepatic veins Normal direction – Monophasic flow
• IVC Patent with flow toward heart
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
* Lassau N et al. Radiology 1997 ; 204 : 545 – 552.
• US findings Thickened GB wall – Ascites
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Sinusoidal obstruction syndrome (SOS)BMT for acute myelogenous leukemia
Desser TS et al. Am J Roentgenol 2003 ; 180 : 1583 – 1591.
Contrast-enhanced CT
Heterogeneous hepatic enhancement
Color & duplex US of HV
Monophasic flow in MHV
Imaging currently not diagnostic by itself
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