Doppler of the portal system

Pathological findings

Dr. Muhammad Bin ZulfiqarPGR-II FCPS-II SIMS/SHL

Doppler of the portal system

Portal hypertension

Portal vein thrombosis

Causes of portal hypertension

Pre-sinusoidal Congenital hepatic fibrosisSarcoidosisSchistosomiasisLymphoma

Hyperdynamic Arterio-portal fistula or malformation

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Intra-hepatic

Post-sinusoidal Cirrhosis

Causes Disease

Extra-hepatic Portal vein thrombosis or compression

most common cause

Supra-hepatic Budd-Chiari syndromeRight heart insufficiency

Doppler US signs of PHT in cirrhosis

• P-S collaterals Highly sensitive & specific

• Portal vein Dilated PV

Decreased mean velocity (< 15 cm/sec)

To-and-fro flow /Hepatofugal flow

Increased pulsatility (VPI) >0.48+/-0.31

Arterio-portal fistula

• Hepatic vein Compression (Pseudo-portal flow)

• Hepatic artery Enlargement & tortuosity

Increased RI & PI

Harkanyi Z. Ultrasound Clin 2006 ; 1 : 443 – 455.

P-V: portovenous, VPI: Venous pulsatility index

Porto-systemic collaterals

High sensitivity & specificity for PHT

• Tributary collaterals

“Drain normally into PS”

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Coronary vein (left gastric)Short gastric veinsBranches of SMV & IMV

• Developed collaterals“Developed or recanalized”

Recanalized umbilical veinSpleno-renal collateralGastro-renal collateralSpleno-retroperitoneal collateral

Common spontaneous porto-systemic collaterals

More than 20 P-S collaterals described

Patnquin1 H et al. Am J Roentgenol 1987 ; 149 : 71 – 76.

Most common: LGV – PUV – Spleno-renal – Gastro-renal

P-S collaterals / Coronary vein

Most prevalent (80-90%) – Most clinically important

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Sagittal view slightly superior

Tortuosity of CV as it extendssuperiorly toward GE junction

Sagittal paramedial view

Flow in CV directed superiorly& away from splenic vein

P-S collaterals / Gastroesophageal collateral

Gastroesophageal collateral veins close to diaphragm

McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.

Longitudinal view of left liver lobe

Normal umbilical vein anatomy

UV communicates with umbilical segment of LPV

Travels down anterior abdominal wall toward umbilicus

Eventually drains into systemic system via inferior epigastric vein

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Hepatofugal flow within UV

Similar color Doppler view Longitudinal US of LLL

Dilated umbilical vein (10 mm)

P-S collaterals / Recanalized umbilical vein

PUV observed only in hepatic or suprahepatic blockage

LLL: Left lobe of Liver

Sagittal panoramic view

PUV traveling to periumbilical region where it becomes tortuous.UV ramifies into smaller PU collaterals when it proceeds inferiorly

P-S collaterals / Recanalized umbilical veinCaput medusae

Porto-systemic collaterals

• Coronary vein & umbilical vein are the easiest

& most productive to analyze

• Other collaterals detected sonographically

albeit with more difficulty in some cases

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

P-S collaterals / Spleno-renal collateral

Yamada M et al. Abdom Imaging 2006 ; 31:701 – 705.Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005.

Transverse color Doppler US

Splenic vein feeding large

splenorenal collaterals

Flow direction from SV to LRV

Reversed or to-and-fro flow in SV

Schematic drawing

P-S collaterals / Spleno-renal collateral

Flow inversion in splenic vein

Flow inversion in SV increases dg of spleno-renal shunt

Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005

P-S collaterals / Short gastric veins

Sato T et al. J Gastroenterol 2002 ; 37 : 604 – 610.

Short gastric vein as inflowing vessel to gastric varices

P-S collaterals / Gastro-renal collateral

Yamada M et al. Abdom Imaging 2006 ; 31 : 701 – 705.Maruyama H et al. Acad Radiol 2008 ; 15 : 1148 – 1154.

From cranial & dorsal side to

caudal & ventral side into LRV

Long-axis view of GRS

GRS LRV

From SV at confluencecoursing backward to join LRV

Schematic drawing

P-S collaterals / Superior mesenteric vein

Flow toward SMV in sup branchFlow away from SMV in inf branch

Color Doppler view

2 mesenteric branchesof superior mesenteric vein

Semicoronal view of SMV

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

P-S collaterals / Inferior mesenteric vein

Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005.

Hepatofugal flow in IMV originating from PV confluence

P-S collaterals / IMV & rectal venous drainage

Wachsberg RH. Am J Roentgenol 2005 ; 184 : 481 – 486.

Peri-rectal varices

Transverse US posterior to bladder Left parasagittal CDUS

Hepatofugal flow in dilated IMV

P-S collaterals / Gallbladder varices

Harkanyi Z. Ultrasound Clin 2006 ; 1 : 443 – 455.

Serpentine area in wall of GB

Cystic vein to anterior abdominal wall or patent PV branches

Most commonly observed in PV thrombosis (30%) 80% association (Dahnert)

P-S collaterals / Spleno-retroperitoneal collateral

Prominent varices surrounding posterior aspect of spleen

Owen C et al. J Diag Med Sonography 2006 ; 22 : 317 – 328.

Cirrhosis & PHT / Diameter of portal vein

1 Weinreb J et al. Am J Roentgenol 1982 ; 139 : 497 – 499.2 Goyal AK et al. J Ultrasound Med 1990 ; 9 : 45 – 48.Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Diameter: 16.9 mmSign of portal hypertension

Longitudinal view of MPV

Contoversy on normal PV diameter

Up to 13 mm in one study1

Up to 16 mm in another study2

Unusual large PV: sign of PHT

Normal PV size: do not exclude PHT

Cirrhosis & PHT / Portal vein velocity

Low velocity: good indicator of PHT

Normal velocity: do not exclude PHT

Controversy on normal PV velocity

Difficult to rely on velocity for dg

Normal mean velocity: 15 – 18 cm/sec

Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.

Shrunken liver & irregular marginVmax: 10 cm/sDiagnosis of PHT

Triplex image of PV

Portal vein pseudoclot – Incorrect velocity

Cirrhotic patient with portal hypertension

Slower flow in portal vein

demonstrated

Velocity scale: 7 cm/s

Rubens DJ et al. Ultrasound Clin 2006 ; 1 : 79 – 109.

Velocity scale: 20 cm/s

Good flow in HA anteriorly

No flow in adjacent PV

Cirrhosis & PHT / Portal vein flow

Normal flow

Kok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.

Reversed flow

Advanced PHT

SOS

Porto-systemic shunt

To and fro flow

Advanced PHT

Heart failure

Arterio-portal fistula

SOS: Sinusoidal obstruction syndrome

Cirrhosis & PHT / To-and-fro flow in PV

Cardiac cycle

Hepatopetal & hepatofugal with each heart beat

Seen before frank hepatofugal flow

Wachsberg RH et al. RadioGraphics 2002 ; 22 : 123 – 140.

Duplex US of LPV during suspended respiration

Cirrhosis & PHT / To-and-fro flow in PV

Respiratory cycle

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

On real-time US, these alterations corresponded to respiratory cycle

Transverse color Doppler US of left portal vein

Hepatopetal flow Hepatofugal flow

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Transverse CDUS of left portal vein

Hepatopetal flow Hepatofugal flow

Cirrhosis & PHT / To-and-fro flow in PV Compression

Causes of to-and-fro flow

Exaggerated pulsatility

Minimum velocity below baseline

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

- Portal hypertension

- Tricuspid regurgitation

- Right heart failure

- Aerterio-portal vein fistula

Cirrhosis & PHT / Reversed flow of PV

Hepatopetal flow in HA & hepatofugal flow in PV

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Not pathognomonic feature of cirrhosis

Severe PHT – Rare

Hepatopetal flow in HA

Hepatofugal flow in PV

Color Doppler of peripheral liver

Arterial flow above baseline

Portal venous below baseline

Duplex Doppler of same area

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Cirrhosis & PHT / Reversed flow in PV branches

Cirrhosis & PHT / Reversed flow in PV branches

Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005.

Right anterior PV branch

Hepatofugal flow

Right posterior PV branch

Hepatopetal flow

Hepatofugal flow in portal vein

Portal vein flow away from liver

• Cirrhosis

• Budd-Chiari syndrome & SOS

• TIPS

• Arterio-portal fistula Tumor: HCC – Hemangioma

Percutaneous liver biopsy

Percutaneous biliary drainage

Rupture vein aneurysm

Rendu-Osler-Weber disease

Hwang HJ et al. J Clin Ultrasound 2009 ; 37 : 511 – 524.

Hepatofugal portal / TIPS

Right portal vein to right hepatic vein

Hwang HJ et al. J Clin Ultrasound 2009 ; 37 : 511 – 524.

Reversion of hepatofugal flowStent devoid of color signalsMalfunction of TIPS

1 week after TIPS

Hepatofugal flow in RPVVigorous color flow in stent

Immediately after TIPS

Arterio-portal fistula / High-flow hemangioma

Hwang HJ et al. J Clin Ultrasound 2009 ; 37 : 511 – 524.

65-year-old man with high-flow hemangioma in LLL

Hypoechoic nodule with intratumoral flowPeritumoral hepatofugal flow in segmental PVHepatopetal flow in proximal PV

Arterio-portal fistula / Post-liver biopsy

Bertolotto M et al. J Clin Ultrasound 2008 ; 36 : 527 – 538.

Vascular lesion betweenHA & PV branchesInverted flow in PV

Oblique CDUS Oblique gray-scale US

Focal echogenic areain region of biopsy

Spectral Doppler US

High-velocity flow Low-resistance flowTurbulent flow

Arterio-portal fistula / Rendu-Osler-Weber

Bertolotto M et al. J Clin Ultrasound 2008 ; 36 : 527 – 538.

Low-resistance arterial flow Arterialized & inverted PV flow

Dilated tortuous structures Dilated vascular structures with aliasing

Helical portal vein flow

Near bifurcation

• Normal subjects 2%

• Severe liver disease 20%

• TIPS

• Post-liver transplantation Donor PV > recipient PV

• Portal vein stenosis

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Helical portal vein flow

If not properly recognized, it can produce

the mistaken impression of PV flow reversal

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Helical portal vein flow

Mimic of hepatofugal flow

Wachsberg RH et al. RadioGraphics 2002 ; 22 : 123 – 140.

Hepatopetal flow within liver confirms that net flow is hepatopetal

Cirrhosis & PHT / Prominent hepatic artery

Enlarged HA with tortuous or ‘‘corkscrew’’ appearance

Increased flow in HA to compensate decreased flow in PV

Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.

Causes of enlargement of hepatic artery

• Cirrhosis

• Hepatic diseases associated with alcoholism

• Congenital hepatic fibrosis

• Vascular tumors

• Hereditary hemorrhagic telangiectasia

Buscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55.

Parallel channel sign

von Herbay A et al. J Clin Ultrasound 1999 ; 27 : 426 – 432.

Gray-scale US

IH parallel channel sign

Suspicious of dilated IHBD

Color & pulsed Doppler US

Flow in both intra-hepatic lumina

Portal vein & hepatic artery

Absence of dilated intra-hepatic bile duct

Parallel channel sign

von Herbay A et al. J Clin Ultrasound 1999 ; 27 : 426 – 432.

Gray-scale US

IH parallel channel sign

Suspicious of dilated IHBD

Color & pulsed Doppler US

Blood flow in anterior structure

No flow in posterior structure

Confirmation of dilated intra-hepatic bile duct

Cirrhosis & PHT / Changes of hepatic artery flow

Kok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.

Decreased diastolic flow

ESLD

Reversed diastolic flow

ESLD

Normal flow

Normal in mostpatients

Cirrhosis & PHT / Pulsatility index of HACirrhotic patients vs controls – Correlation with HVPG

Schneider AW et al. J Hepatol 1999 ; 30 : 876 – 881.

PI: 0.85

20 controls0.92 ± 0.1

PI: 1.22

50 cirrhotic patients1.14 ± 0.18

Directly correlated with HVPG (Hepatic venous pressure gradient)

Cirrhosis & PHT / Changes of hepatic vein flow

Kok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.

Triphasic Biphasic

CirrhosisBudd-Chiari syndromeMetastasesAscitesHealthy subjects

Monophasic

CirrhosisBudd-Chiari syndromeMetastasesAscitesHealthy subjects

Damping index of HV waveform

Severe portal hypertension : HVPG > 12 mmHgKim MY et al. Liver International 2007 ; 27 : 1103 – 1110.

Minimum velocity of downward HV

Maximum velocity of downward HVDamping index =

Normal value: < 0.6

Severe portal hypertension: ≥ 0.6

Damping index of HV waveform in cirrhosis

DI: 0.26 HVPG: 7 mmHg

DI: 0.72HVPG: 15 mmHg

Kim MY et al. Liver International 2007 ; 27 : 1103 – 1110.

DI of 0.6: Sen 76%, Sp 82, & AUC 0.86 for severe PHT

HVPG :Hepatic venous pressure gradient

Doppler in cirrhosis / PHTPrognostic implications

• Collaterals PUV High bleeding risk in surgery

Reversed LGV High bleeding risk of EV

S-R shunt Low bleeding risk of EV

• Portal vein Low flow High risk of HE

Inversed flow CI for TIPS & porto-caval shunt

Congestion index High bleeding risk of EV

• Hepatic artery Increased PI ESLD

• Hepatic vein Monophasic ESLD

Increased DI Severe PHT (> 12 mmHg)

Portal Vein Thrombosis

Classification of portal vein thrombosis

• Duration Acute

Chronic

• Severity Complete

Partial

• Causes Malignant

Non-malignant

Portal vein thrombosis

• Etiology Extra-hepatic: multiple causes

Cirrhosis ± HCC: complete – partial

Budd-Chiary syndrome: 15% – poor prognosis

• 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

Splenic vein thrombosis

Gastric cancer

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

Superior mesenteric vein thrombosis

Transverse image of SMA & SMV

http://www.ultrasoundcases.info

SMA

SMV

Acute thrombosis of portal vein

Complete thrombosis

http://www.sites.tufts.edu

Echogenic material visualized within portal vein.Increased diameter of portal vein.

Partial thrombosis of portal vein

Echogenic material occluding lumen of PV by ≈ 50%

Sacerdoti D et al. J Ultrasound 2007 ; 10 : 12 – 21.

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

Non-malignant PV thrombosis in cirrhosis

Systematic review – Many unresolved issue

• 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.

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.

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

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

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

Chronic portal vein thrombosisPortal cavernoma

Parikh et al. Am J Med 2010 ; 123 : 111 – 119.

Hepatopetal collaterals around thrombosed portal vein

Portal cavernoma

Gray-scale ultrasound Color & pulsed Doppler

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

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

THANK YOU

Transjugular Intrahepatic Portosystemic Shunt

TIPS

Highly effective for

– Reducing ascites

– Recurrent variceal hemorrhage

– Improving quality of life

High rate of stenosis or thrombosis

High rate of hepatic encephalopathy

Normal Doppler parameters for TIPS

• Portal vein Hepatopedal flow – Velocity > 30 cm/sec

• IHPV Hepatofugal flow

• Hepatic artery Increased PSV

• Stent Flow completely filling the stent

Monophasic pulsatile flow

Vmin: 90 cm/sec – Vmax: 190 cm/sec

Vmax – Vmin: 50 – 100 cm/sec

Temporal changes: ↑ or ↓ less 50 cm/sec

Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 – 70.

Follow-up of TIPS by Doppler US

• 24 to 48 hours (baseline)

• 3 months

• 6 months

• 12 months

• Annually thereafter

Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 – 70.

Real goal of surveillance

Detect stenosis before complete thrombosis

TIPS / Normal

Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 – 70.

Stent within liver parenchymaHepatopetal flow in MPVHepatofugal flow in RPV

Color Doppler of TIPS Color & pulsed Doppler of TIPS

Monophasic pulsatile flow

Velocity: 106 cm/sec

TIPS / Mirror image artifact

If not recognized: migration into heart (emergency intervention) If uncertainty persists: chest radiograph

Wachsberg RH. Ultrasound Quarterly 2003 ; 19 : 139 – 148.

Stent on either side of diaphragm

Mirror image artifact Variant of mirror image artifact

Stent above diaphragmTrue TIPS visible by rotating probe

TIPS / migration

Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 – 70.

Proximal portion migrated out of PV into parenchymal tract

This resulted in complete thrombosis of stent

Longitudinal view of TIPS

TIPS – Stenosis

Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 – 70.

Mid TIPS

Mean portal vein Right portal vein

Mid TIPS Distal TIPS

Vel 26 cm/sec

Aliasing 371 cm/sec 98 cm/sec

Hepatopetal flow

TIPS / occlusion

Ricci P et al. J Ultrasound 2007 ; 10 : 22 – 27.

Homogeneous hyperechoic intraluminal material

without any color flow within TIPS

Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.

Detectable flow within UVFlow directed away from LPV Indicating recanalization & PHT

Similar color Doppler viewLongitudinal US of LLL

UV extending from LPVDiameter: 1.8 mm

P-S collaterals / Recanalized umbilical vein

Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005

P-S collaterals / Omental varices

Transverse view with linear transducer (7-MHz)

Omental varices just beneath abdominal wall

P-S collaterals / Lumbar & epigastric collaterals

Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005

Large collateral vein between LK & lower pole of spleen

shunting blood from splenic hilum to lumbar & epigastric veins

Intestinal infarctionConsidered from presentation until resolution of pain

• 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

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

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