Doppler ultrasound of portal vein thrombosis

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  • Important unanswered questions in cirrhotic portal vein thrombosis:Does occurrence of PVT alter the natural history of cirrhosis and therefore should asymptomatic patients be treated withthe goal of recanalization or prevention of further thrombus extension?Should all patients with cirrhosis and PVT be aggressively anticoagulated?Should this apply only to patients on transplantation waiting list?If recanalization does not occur should patients be offered second-line treatment with transjugularintrahepaticportosystemic shunts?How long should the interval be whilst being anticoagulated before considering therapy to have failed?How should patients be monitored?Is oral warfarin better than low-molecular weight heparin?
  • Doppler ultrasound of portal vein thrombosis

    1. 1. Doppler ultrasound of portal vein thrombosis Samir Haffar M.D. Assistant Professor of Gastroenterology
    2. 2. Portal vein thrombosis • Etiology Extra-hepatic: multiple causes Cirrhosis ± HCC: complete – partial Budd-Chiary syndrome: 15% – poor prognosis • Sensibility 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
    3. 3. Acute portal vein thrombosis
    4. 4. Splenic vein thrombosis Gastric cancer
    5. 5. 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
    6. 6. Superior mesenteric vein thrombosis Transverse image of SMA & SMV http://www.ultrasoundcases.info SMA SMV
    7. 7. Intestinal infarction Considered 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
    8. 8. 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
    9. 9. 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 bidirectional spikes on PV waveform Duplex of MPV
    10. 10. Acute thrombosis of portal vein Complete thrombosis http://www.sites.tufts.edu Echogenic material visualized within portal vein Increased diameter of portal vein
    11. 11. Partial thrombosis of portal vein Echogenic material occluding lumen of PV by ≈ 50% Sacerdoti D et al. J Ultrasound 2007 ; 10 : 12 – 21.
    12. 12. Partial thrombosis of portal vein Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375. Black & white ultrasound Partial echogenic thrombus Color & pulsed Doppler Complete filling of main PV obscuring the clot
    13. 13. 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.
    14. 14. 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.
    15. 15. 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 thrombus Low-resistance arterial waveform
    16. 16. Malignant PV thrombosis / CEUS 38 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
    17. 17. 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 abdomen Augmented portal venous flow
    18. 18. Portal vein pseudoclot – Incorrect angle Velocity: 24 cm/sec Wall filter: medium Angle 90° Velocity: 7 cm/sec Wall filter: medium Angle < 90° Radiol Clin N Am 2006 ; 44 : 805 – 835.
    19. 19. Chronic portal vein thrombosis
    20. 20. Chronic portal vein thrombosis Portal cavernoma Parikh et al. Am J Med 2010 ; 123 : 111 – 119. Hepatopetal collaterals around thrombosed portal vein
    21. 21. Portal cavernoma Gray-scale ultrasound Color & pulsed Doppler
    22. 22. P-S collaterals / Gallbladder varices Harkanyi Z. Ultrasound Clin 2006 ; 1 : 443 – 455. Sepentine area in wall of GB Cystic vein to anterior abdominal wall or patent PV branches Most commonly observed in PV thrombosis (30%)
    23. 23. 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 veins Isolated gastric varices Hepatopetal flow in LGV Splenic vein thrombosis
    24. 24. P-S collaterals / Transcapsular collaterals Chronic PVT due to necrotizing pancreatitis or surgery Seeger M et al. Radiology 2010 ; 257 : 568 – 578. Transcapuslar collateral from SB varices to PVs Color Doppler image Submucosal varices in small-bowel loop US image Ectopic intestinal varices & transcapsular collaterals Schematic diagram
    25. 25. 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 (in press).
    26. 26. Portal cholangiopathy Biliary & 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 (in press). Cholangiographic images essential to confirm diagnosis
    27. 27. MRC in portal cholangiopathy Besa C et al. Abdom Imaging 2011 (in press). Multiple smooth strictures due to extrinsic compression Stenosis with marked dilatation of proximal biliary tree Differentiate from bile duct cancerDifferentiate from PSC
    28. 28. Thank You

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