Doppler ultrasound of the portal system - Normal findings

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  • IMV originates anterior to the sacrum as the superior rectal (hemorrhoidal) vein & receives branches from the sigmoid and descendingcolon as it ascends to the left of midline adjacent to the inferior mesenteric artery and left gonadal vein.In the upper abdomen, the IMV passes posterior to the distal duodenum, anterior to the left renal vein, and then anterior to the superior mesenteric artery before anastomosing with the portal venous system.In a large autopsy series, the IMV inserted into the distal splenic vein in 38.0%, the portal confluence in 32.7%, and the superiormesenteric vein in 29.3% of cases. On CT, the diameter of the normal IMV rarely exceeds 6 mm.
  • Normal size of lobuscaudatus was defined as 6.8 ± 1.3 cm for the sagittal diameter.Hogrefe B. Sonographische Morphometrie der gesunden Leber. Personal communications.In: Boozari B et al. J Hepatol 2008 ; 49 : 572 – 580.
  • Major anatomical variations of the portal vein are uncommon but include1- agenesis of the right or left portal vein2- trifurcation at the portahepatis3- right anterior portal branch arising from the left portal vein4- Right posterior portal branch arising from the main portal vein
  • PV divides into right anterior, right posterior, & left portal veins at the same level.
  • Bunny: أرنب
  • Anomalous left-sided IVC from persistence of the embryological azygos vein.
  • Ө (theta), also referred to as the Doppler angle,is the angle between the transmitted beam and the direction ofblood flow within the blood vessel (the reflector path). Converting Doppler shift frequencies to velocity measurements.
  • Ө (theta), also referred to as the Doppler angle,is the angle between the transmitted beam and the direction ofblood flow within the blood vessel (the reflector path). Converting Doppler shift frequencies to velocity measurements.
  • The larger the angle of insonation, the greater the potential source of error in velocity measurement.
  • The frame rate is the rate per second at which complete images are produced.With pulse-echo imaging alone, the frame rate can exceed 50 images per second.However, the time required to produce color flow images is much longer, which significantly lowers the frame rate. The frame rate in color imaging is dependent on several factors.For example, the size and position of the color box have a great effect on the frame rate. The width of the box is especially important: The wider the box, the more scan lines are required and the longer it will taketo acquire the data to produce the image.
  • normal-appearing wall-to-wall flow in the main portal vein.
  • Too large: signal from adjacent vessel or extraneous parenchymaToo small: false impression of reduced or even absent flow
  • Food ingestion induces hemodynamic changes.Exercise and posture changes also induce hemodynamic changes.patients in follow-up should preferably be examined by the same operator and with the same equipment whenever possible.
  • Undulating: Variation of PV diameter with inspiration:Lack of caliber variation of the splenic and mesenteric vein during respiration is another parameter that has been investigated. In 1 study, this approach had a sensitivity of 80% and specificity of 100% in diagnosing portal hypertension. However, it is a method that has not gained widespread use, likely because of difficulties in measurement accuracy and interobserver variability.PV velocity:Significantly lower mean portal venous velocity was noted in cirrhotic patients (13 ± 3.2 cm/s versus 19.6 ± 2.6 cm/s in controls) by Zironi et al & 15 cm/s was considered as best cut-off value in detection of PHT, showing sensitivity & specificity of 88% and 96%, respectively.51. Zironi G, Gaiani S, Fenyves D, et al. Value of measurement of mean portal flow velocity by Doppler flowmetry in the diagnosis of portal hypertension. J Hepatol 1992;16:298-303.
  • VPI: venous equivalent to the arterial resistive index.In most normal subjects, Vmin less than half Vmax.
  • Cross-sectional area was calculated from the formula for the cross-section of an ellipse. Congestion index is a better marker for the diagnosis of PHT as it takes into account the velocity as well as diameter of PV.
  • Triphasic waveform due to transmitted cardiac activity & Similar to waveform for the jugular vein.Two negative waves and another positive wave.
  • Measurements taken in RHV & MHVAvoid artefact from transmitted cardiac movement in LHV
  • Acceleration resulting from focal compression by regenerative nodulesValue of 0.6 of DI showed a sensitivity of 75.9% and a specificity of 81.8% for the presence of severe portal hypertension (hepatic venous pressure gradient >12mmHg) (AUC = 0.860).
  • Low-resistance profile: - Broad systolic peak - Gradual deceleration from systole to diastole - Well-maintained diastolic flow throughout the cardiac cycle.
  • Doppler ultrasound of the portal system - Normal findings

    1. 1. Doppler of the portal systemNormal findingsSamir Haffar M.D.Assistant professor of gastroenterology
    2. 2. Doppler of normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    3. 3. Sagittal & transverse planes of USSagittal plane Transverse planeAbraham D et al. Emergency medicine sonography: Pocket guide.Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.
    4. 4. Normal portal venous circulationMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
    5. 5. Normal hepatic circulationThe rule of three• Superior mesenteric vein 2/3 – Splenic vein 1/3• Right liver 2/3 – Left liver 1/3• Portal vein 2/3 – Hepatic artery 1/3
    6. 6. Splenic veinTransverse US viewSplenic vein behind tail, body & head of pancreasUpper limit of normal: 10 mmGastroduodenal artery & CBD & in pancreatic headMartínez-Noguera A et al. Abdom Imaging 2007 ; 32 : 136 – 149.GDACBD
    7. 7. Inferior mesenteric veinIMV inserting into portal system at confluence (33%)Plane tangential to SV directed toward left upper quadrantPlane tangential to IMV directed toward left lower quadrantWachsberg RH. Am J Roentgenol 2005 ; 184 : 481 – 486.
    8. 8. Wachsberg RH. Am J Roentgenol 2005 ; 184 : 481 – 486.Anterior to LRV & SMAPosterior to distal duodenumTangential to long axis of IMVTangential to long axis of SVAnterior to SMAInferior mesenteric veinUpper limit of normal: 7 mm
    9. 9. Jejunal veinWachsberg RH. Am J Roentgenol 2005 ; 184 : 481 – 486.DUOAnterior to duodenum & SMA before inserting into SMVShould not be identified as IMV (behind distal duodenum)Transverse sonogram
    10. 10. Respiratory variation of SV or SMV diameterForced inspiration & expirationBerzigotti A & Piscaglia F. Ultraschall Med 2011 ; 32 : 548 – 571.Splenic vein Superior mesenteric veinNormal change ≥ 40% between forced inspiration & expirationNormal SV or SMV < 10 mm
    11. 11. Left gastric vein / Coronary veinRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.Sagittal left paramedian USof upper abdomenRelationship of LGV toSV, SMV, & PVUpper limit of normal: 5 – 6 mm
    12. 12. Normal Left gastric vein anatomyCoronary veinRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.Transverse US viewLGV seen anterior to bifurcation LGV arising from SV anterior to CASagittal US view
    13. 13. Normal left gastric vein anatomySignificant minorityRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.Transverse view of upper abdomenCV located posterior to originof hepatic arterySagittal view of upper abdomenCV arising from superior aspectof SV posterior to HA
    14. 14. Changing position of transducer for PVIntercostalTransabdominal SubcostalKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.
    15. 15. Normal diameter of portal veinBerzigotti A & Piscaglia F. Ultraschall Med 2011 ; 32 : 548 – 571.Portal vein measured at crossing point with HANormal : < 13 or 16 mm
    16. 16. Normal branching pattern of portal veinAbuRahma AF & Bergan JJ. Noninvasive vascular diagnosis: Practical guide to therapy.Springer-Verlag, London , UK, 2nd edition, 2007.H shape of left portal venous bifurcationRight anterior & right posterior branches of right PV2345867
    17. 17. Branches of right & left portal veinsH shape of left PV bifurcationRight anterior & right posterior branches of right PVRumack CM, Wilson SR, & Charboneau JW. Diagnostic ultrasound.Elsevier-Mosby, St. Louis, Missouri, USA, 3rd edition, 2005.
    18. 18. Umbilical vein remnantNormal ≤ 3 mmRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.Transverse view of LLLigamentum teresHypoechoic remnant of UVCommunicates with LPVLongitudinal view of LLNo detectable flowwithin UV remnantColor Doppler viewLigamentum teresHypoechoic remnant of UV
    19. 19. Normal caudate lobeStudy of 66 healthy subjectsBargalló X et al. Am J Roentgenol 2003 ; 181 : 1641 – 1645.Sagittal epigastric lineSagittal diameter: 45 ± 9 mmAntero-posterior diameter: 24 ± 6 cmCaudate lobe size Caudate lobe veinThin caudate vein≤ 2 mm in all healthy subjects
    20. 20. Major anatomical variations of portal systemGallego C et al. RadioGraphics 2002 ; 22 : 141–159. Agenesis of right or left portal vein Trifurcation at porta hepatis Right anterior portal branch arising from left PV Right posterior portal branch arising from main PVMost frequent
    21. 21. Agenesis of left portal veinSato M et al. Eur Radiol 2000 ; 10 : 362 – 364.Absence of horizontal portion of LPVAberrant vessel from anterior RPV to vertical portion of LPV
    22. 22. Anatomical variants of portal veinTrifurcation of PVRight anterior brancharising from left PVRight posterior brancharising from main PVBattaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.
    23. 23. Normal hepatic veinsThree hepatic veins enter IVC 2 cm caudad to right atriumMiddle & left hepatic veins form common trunk (60%)Battaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.
    24. 24. Normal hepatic veinsBest seen on subcostal oblique viewMansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st edition, 2005Right, middle, & left HV seen as “bunny” on points to IVC6/75/842Hepatic veins divide liver into Couinaud system segments
    25. 25. Hepatic vein variantsBattaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.2 left hepatic veins2 right hepatic veins 2 middle hepatic veins2 right & 2 left hepatic veins Left accessory hepatic vein
    26. 26. Hepatic vein variantsBattaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.Left accessory HV2 left hepatic veins2 middle hepatic veins
    27. 27. Short hepatic vein orificesDesser TS et al. Am J Roentgenol 2003 ; 180 : 1583 – 1591.Short hepatic veins from pericaval liver segmentsDrain directly into IVC caudad to its junction with HV
    28. 28. Left-sided IVCMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Normal anatomy of IVC Anomalous left-sided IVCPersistence of embryological AV
    29. 29. Normal hepatic arteryT-shaped bifurcation of celiac trunkCharacteristic landmarkRevzin MV & Pellerito JS. Ultrasound Clin 2007 ; 2 : 477– 492.
    30. 30. Normal hepatic arteryMeasurement of HA at two cm distal to its origin from CTNormal diameter: 5 ± 1 mmBuscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55.
    31. 31. Hepatic arteryAbraham D et al. Emergency medicine sonography: Pocket guide.Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.Hepatic artery between main portal vein & CBDLongitudinal oblique view of porta hepatis
    32. 32. Anatomical variations of hepatic artery* Michels NA. Am J Surg 1966 ; 112 : 337 – 47.Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.10 anatomic variants of HA (dissection of 200 cadavers)*• Right hepatic artery from SMA• Common hepatic artery from SMA• Common trunk for celiac axis & SMA• Celiac trunk absent & its branches arise from aorta
    33. 33. Right hepatic artery from SMABattaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.Common hepatic artery gives rise to GDA & LHARight hepatic artery replaced by branch of SMASMABranch of SMACHASMALHARHAGDA
    34. 34. Common hepatic artery from SMABattaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.Entire hepatic artery replaced by SMASMACHALHARHASMACHA
    35. 35. Left hepatic artery from left gastric arteryBattaglia S et al. J Ultrasound 2010 ; 13 : 49 – 56.LHA originates from LGARuns alongside venous ligamentLGALHACHARHA LHALGA
    36. 36. Doppler of normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    37. 37. Goals of Doppler• Detection flow in a vessel• Detection direction of flow• Detection type of flow: Arterial or venousNormal or abnormal• Measurement of flow velocity
    38. 38. What is the Doppler phenomenon?Doppler shift frequency (fd): ft – frThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.ftfr
    39. 39. Doppler equation∆ F Doppler shift frequency (kHz)F0 Ultrasound transmission frequency (MHz)V Blood cell velocity (cm/sec)Cos Ө Cos of angle between US & flow directionC Speed of sound in soft tissue (1 540 m/sec)∆ F = 2 F0 V Cos Ө / C
    40. 40. ∆ FF0VCos ӨC∆ F = 2 F0 V Cos Ө / C1.6 kHz5 MHz60°1 540 m/secThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.Doppler equationConverting Doppler shift frequency to velocity?50 cm/s
    41. 41. Angle of insonation & Doppler effectKim MJ et al. Curr Probl Diagn Radiol 2009 ; 38 : 53 – 60.Ө angle between transmitted beam & target vesselAngles between 30° & 60° usually used for flow velocityAngles exceeding 60° inadequate for flow velocity
    42. 42. Percentage error in velocity measurements& angle of insonationIn order to minimize this errorAngles of insonation > 60° should not be used
    43. 43. Each examination should be performed withTahmasebpour HR et al. RadioGraphics 2005 ; 25 : 1561 – 1575.• Gray-scale US• Color Doppler• Power Doppler• Spectral Doppler
    44. 44. Sites of duplex insonation of portal systemPatnquin1 H et al. Am J Roentgenol 1987 ; 149 : 71 – 76.
    45. 45. Doppler of normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    46. 46. Doppler panel on console of US imagersKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Each parameter can be adjusted to optimize coloror spectral Doppler components of examination
    47. 47. Color box size / OverlayKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Oversized color box↑ frame rate & ↓ resolutionReduced color box size↓ frame rate & ↑ resolutionColor box should be as small & superficial as possible
    48. 48. Adjusting color velocity scaleKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Color velocity scale 2 cm/secColor aliasing in PV & its branchesHigh color velocity scale 69 cm/secApparent absence of flow in PVColor velocity scale 30 cm/secNormal flow in a patent PV
    49. 49. Adjusting color gainKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Gain setting: 44%Gain setting: 100%Gain setting: 65%
    50. 50. Changing color baseline to avoid aliasingKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Color baseline too highFlow within PV appears redAccurate directional flow dataColor baseline loweredFlow within PV appears greenColor equivalent of aliasing
    51. 51. Inversion of color flowKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Reversal of this inversionAppropriate directional flow notedPortal venous flow appears blueFalsely suggests flow reversal
    52. 52. Changing color Doppler wall filterKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Highest wall filter settingColor signal from low velocityflow filtered outFilling in of flow in hepatic veinsLow filter setting
    53. 53. Angle of insonationKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Transducer positioned perpendicular to flowNo color assigned, yielding false finding of absent flow
    54. 54. Doppler of normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    55. 55. Obtain waveform at end of normal breath-out• Take normal breath• Take normal breath-out• Stop breathing• Then obtain a waveformDeep inspiration should be avoided when possibleRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
    56. 56. Anatomy of spectral DopplerAngle correctionCursorBeam pathSample volumeBaselineEDVThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.PSVShade of gray related to strength of signalreceived at that frequencyTime (s)
    57. 57. Optimizing gate size & positionKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Sampling of flow in both portal vein & hepatic veinsGate size too large
    58. 58. Adjusting spectral velocity scaleSpectral scale: 200 cm/sec Spectral scale: 50 cm/secKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Color Doppler image, color bar, & color scale unchangedSpectral component is active
    59. 59. Adjusting spectral Doppler gainGain setting 0% Gain setting 38%Gain setting 77% Gain setting 100%Kruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.
    60. 60. Changing spectral baseline to avoid aliasingKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Aliasing of spectral waveformInaccurate waveform dataSpectral baseline loweredAccurate quantitative data obtainedHigh spectral baseline
    61. 61. Changing wall filterKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.High wall filter settingLoss of low-velocity-flow ofwaveform above baselineSpectral waveform fills in towardbaseline as wall filter reducedSequential reduced wall filter
    62. 62. Inversion of spectral flowKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Appropriate color flowSpectral waveform below baselineInversion of spectral waveformSpectral waveform above baseline
    63. 63. Adjusting Doppler angle thetaAngle 0° – Vmax 18 cm/secAngle 52° – Vmax 29 cm/secAngle 30° – Vmav 21 cm/secAngle 70° – Vmax 52 cm/secKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.
    64. 64. Doppler of the normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    65. 65. Normal pulsed Doppler of portal veinKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.Sample gate placed in middle of main portal veinWidth of sample gate approximately half the lumenPulsed Doppler obtained at end of normal breath out
    66. 66. Measurement of portal vein velocityVmaxVminVmeanTAMV** TAMV: Time Average Mean Velocity
    67. 67. Variability of portal vein velocity• Inter-observer variability• Inter-machine variability (same equipment)• Different states of fasting (at least 6 hours fasting)• Differences in positioning (supine)• Different exercise status (at least 10 min)• Different phases of respiration (end of breath-out)• Presence of collateral (especially re-canalized UV)• Different cardiac outputRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.Berzigotti A & Piscaglia F. Ultraschall in Med 2011 ; 32 : 548 – 571.
    68. 68. Normal portal vein• Diameter Upper limits of normal: 13 – 16 mm> 20 – 30% increase with food & inspiration• Flow direction Towards liver (hepatopetal)Throughout entire cardiac cycle• Velocity Varies greatly (Max – Mean – Min – TAMV)Mean velocity: 15 – 18 cm/sVaries with cardiac & respiration activityUndulating appearance of waveformGoyal N et al. Clin Radiology 2009 ; 64 : 1056 – 1066.
    69. 69. Mean portal vein velocity in cirrhosisMean portal vein velocity (cm/sec)Controls CirrhosisGaiaini et al1 19 2.1 11.4 3.7Moriyasu et al2 15.3 4 9.7 2.6Zoli et al3 16 0.5 10.5 0.6Ohnishi et al4 17 3.9 12 31 Gaiaini et al. Hepatology 1989 ; 9 : 815 – 819.2 Moriyasu et al. Am J Roentgenol 1986 ; 146 : 735 – 739.3 Zoli et al. J Ultrasoud Med 1985 ; 4 : 641 – 646.4 Ohnishi et al. Gastroenterology 1985 ; 89 : 180 – 185.15 cm/sec best cut-off value of mean PV velocity
    70. 70. Interpretation of portal vein flowNormal flowKok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.Reversed flowAdvanced PHTSOSPorto-systemic shuntTIPSTo and fro flowAdvanced PHTHeart failureArterio-portal fistula
    71. 71. Normal cardiac pulsatility of portal vein1 Gallix BP et al. Am J Roentgenol 1997 ; 169 : 141 – 144.2 Wachsberg RH et al. J Clin Ultrasound 1995 ; 23 : 3 – 15.VPI (Venous Pulsatility Index) =Vmax – VminVmaxNl: 0.48 ± 0.311PVP (Portal Vein Pulsatility) = Vmin / Vmax Nl: 0.39 ± 0.102VmaxVmin
    72. 72. Normal cardiac pulsatility of portal veinNo pulsatilityVPI: 0PVP: 1Moderate pulsatilityVPI: 0.4PVP: 0.6Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
    73. 73. Increased pulsatility of portal veinExaggerated pulsatilityMinimum velocity below baselineRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.- Portal hypertension- Tricuspid regurgitation- Right heart failure- Arterio-portal vein fistula
    74. 74. Cross sectional area (cm²)Mean flow velocity (cm/sec)Congestion index of portal veinMoriyasu F et al. Am J Roentgenol 1986 ; 146 : 735 – 739.CI ≥ 0.08 Portal hypertensionSensibility: 65-95% – Specificity: 100%Normal Value 0.07 ± 0.03 cm.secInter-observer variability in area measurementsInter-observer variability in velocity measurementsVariability compounded when parameters combined in ratio
    75. 75. Portal vein flow volumeQ = Flow volume (ml/min)Vm = Mean velocity of PV (cm/sec)A = Area of portal vein (cm²)Q = Vm x A x 60Normal values: 825 ± 200 ml / min15 ml / min / kg
    76. 76. Spleno-Portal Index (SPI)Liu CH et al. Radiology 2008 ; 248 : 132 – 139.Maximal images of spleenSplenic indexTransverse d (cm) . Vertical d (cm)Spleno-portal index: splenic index / mean PV velocityDuplex US of portal veinMean PV velocity
    77. 77. ROC of spleno-portal index (SPI)143 compensated cirrhosis (Child-Pugh: A)Liu CH et al. Radiology 2008 ; 248 : 132 – 139.SPI threshold of 3.0Sen 92%, Sp 93%, PPV 91% & NPV 94% for esophageal varicesAUROC: 0.933.0
    78. 78. Laminar & helical flow in portal veinRosenthal SJ et al. RadioGraphics 1995 ; 15 : 1103 – 1111.Laminar flow Helical flowHepatopetal & hepatofugal flow“bidirectional flow”Hepatopetal flow
    79. 79. Helical portal vein flowIf not properly recognizedIt can produce mistaken impression of PV flow reversalRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.Color Doppler US of PV Pulsed Doppler US of PV
    80. 80. Helical portal vein flowNear the bifurcation• Normal subjects 2%• Severe chronic liver disease 20%• Post-liver transplantation Donor PV > recipient PV• Portal vein stenosis• TIPSRobinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
    81. 81. Helical portal vein flowMimic of hepatofugal flowWachsberg RH et al. RadioGraphics 2002 ; 22 : 123 – 140.Hepatopetal flow within liver confirms that net flow is hepatopetal
    82. 82. Doppler of the normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    83. 83. Color Doppler of normal hepatic veinsNormal diameter: < 10 mm2 cm before entrance into IVCAtrial systole Ventricular systoleBuscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55.
    84. 84. Normal hepatic vein waveform – 3 componentsKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.A Atrial systoleS Ventricular systoleD Atrial diastoleAS DS wave > D waveCommonly described as triphasic
    85. 85. Normal hepatic vein waveform – 4 componentsA Atrial systoleS Ventricular systoleV Atrial overfilling transitional waveBelow, at, or above baselineD Atrial diastoleKruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675.
    86. 86. Normal hepatic vein waveform – 5 componentsA Atrial systoleC Small spike following A waveS Ventricular systoleV Atrial overfilling transitional waveD Atrial diastoleScheinfeld MH et al. RadioGraphics 2009 ; 29 : 2081 – 2098.
    87. 87. Relationship of EKC, CVP & HV waveformDesser TS et al. Am J Roentgenol 2003 ; 180 : 1583 – 1591.
    88. 88. Classification of Doppler HV waveformMeasurement taken in RHV or MHVZhang L et al. BMC Gastroenterology 2011 ; 11: 84 – 90.Triphasic waveformBiphasic waveformMonophasic waveform
    89. 89. Interpretation of hepatic vein flowKok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.Triphasic BiphasicCirrhosisBudd-Chiari syndromeMetastasesAscitesHealthy subjectsMonophasicCirrhosisBudd-Chiari syndromeMetastasesAscitesHealthy subjectsNormal
    90. 90. Damping index of HV waveformSevere portal hypertension : HVPG > 12 mmHgKim MY et al. Liver International 2007 ; 27 : 1103 – 1110.Minimum velocity of downward HVMaximum velocity of downward HVDamping index =Normal value: < 0.6Severe portal hypertension: ≥ 0.6
    91. 91. Damping index of HV waveform in cirrhosisDI: 0.26HVPG: 7 mmHgDI: 0.72HVPG: 15 mmHgKim MY et al. Liver International 2007 ; 27 : 1103 – 1110.
    92. 92. ROC of damping index in hepatic veinDamping index ≥ 0.6  severe PHTSensitivity 76% – Specificity 82 % – AUC 0.86Severe portal hypertension : HVPG > 12 mmHgKim MY et al. Liver International 2007 ; 27 : 1103 – 1110.DI:0.6
    93. 93. Evaluation of HV spectral waveforms Direction of flow BCSNo flowReversed flowArrhythmiaPatient or technical factorsIrregularFatty infiltrationCirrhosisMetastatic infiltrationBCS or SOS↑ abd pressure (Valsalva)MonophasicRight heart failureTricuspid regurgitationYes Regularity of flowAntegrade Mono- bi- or triphasicRegular D wave > S waveBi- or triphasicNormalNoScheinfeld MH et al. RadioGraphics 2009 ; 29 : 2081 – 2098.
    94. 94. Doppler of normal portal system• Normal US of portal system• Normal Doppler US of portal systemPrinciples of Doppler USAdjusting color Doppler USAdjusting spectral Doppler USNormal portal veinNormal hepatic veinsNormal hepatic artery (impedance indices)
    95. 95. Impedance indicesResistance index (RI) or Pourcelot’s indexRI: S – ED / SNormal: 0.65 ± 10Buscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55.
    96. 96. Impedance indicesPulasatility index (PI)RI: S – ED / MNormal: 0.92 ± 0.1Schneider AW et al. J Hepatol 1999 ; 30 : 876 – 881.
    97. 97. Normal hepatic arteryLow resistance flowDiameter* 5 ± 1 mmPSV 70 ± 10 cm/secRI 0.65 ± 10PI 0.92 ± 0.1* Buscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55.Measurement of HA at 2 cm distal to its origin from CT
    98. 98. Interpretation of hepatic artery flowESLD: End Stage Liver DiseaseKok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.Decreased diastolic flowESLDReversed diastolic flowESLDLow resistance flowNormal
    99. 99. Thank You

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