Doppler of the portal system

Pathological findings

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

Portal Vein Thrombosis

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

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

Classification of portal vein thrombosis

• Duration Acute

Chronic

• Severity Complete

Partial

• Causes Malignant

Non-malignant

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

Splenic vein thrombosisGastric cancer

Malignant thrombus tends to distend vein+ exhibitpulsatile flow, a bland thrombus does not!

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

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

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

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

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.

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

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

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

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)

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.

Budd Chiari syndrome

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

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.

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

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

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

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

Budd-Chiari syndrome

Hepatic veins transformed to fibrotic cords

“Hepatic vein star”

Boozari B et al. J Hepatol 2008 ; 49 : 572 – 580.

Hyperechoic cord

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.

BCS / Reversed flow in HV upstream to obstacle

Solid endo-luminal material in distal part of MHV

Reverse flow in proximal part of MHV

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

BCS / Large subcapsular vein

Large tortuous subcapsular vein draining into IVC

Bargalló X et al. Am J Roentgenol 2006 ; 187 : W33 – W42.

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.

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

BCS / Suggestive intra-hepatic collateral

Erden A. Eur J Radiol 2007 ; 61 : 44 – 56.

Undulated course “h-shaped”

Hockey-stick Curvilinear Curved

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

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

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

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

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.

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

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

Proposed diagnostic strategy for BCS

Valla DC. Gut 2008 ; 57 : 1469 – 1478.

DeLeve L et al. AASLD practice guidelines. Hepatology 2009 ; 49 : 1729 – 1764.

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

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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