This describes the ultrasound features of common conditions that lead to portal hypertension

1. Ultrasound findings in portal
hypertension
Durr-e-Sabih
MBBS. MS. FRCP. FANMB
Director MINAR- Multan
PAKISTAN
dsabih@yahoo.com

2. Portal hypertension
o Normal portal vein pressure is 5-10mm Hg
(14 cm H20)
o Wedge pressure or direct portal vein
pressure >5mm Hg than IVC
o Portal vein pressure >30cm H20

3. Portal hypertension
Presinusoidal-extrahepatic
o Portal and/or splenic vein
thrombosis
Presinusoidal-intrahepatic
o Primary biliary cirrhosis
o Schistosomiasis
o Congenital Hepatic Fibrosis
o Idiopathic noncirrhotic fibrosis
o Wilson’s disease
o Myelofibrosis
o Toxins (Polyvinyl chloride,
Methotrexate, arsenic)
Sinusoidal
o Portal cirrhosis
o Sclerosing cholangitis
o Diffuse metastatic disease
Post sinusoidal
o Budd Chiari Syndrome
o CCF
o Constrictive pericarditis

4. Portal hypertension
Presinusoidal-extrahepatic
o Portal and/or splenic vein
thrombosis
Presinusoidal-intrahepatic
o Primary biliary cirrhosis
o Schistosomiasis
o Congenital Hepatic Fibrosis
o Idiopathic noncirrhotic fibrosis
o Wilson’s disease
o Myelofibrosis
o Toxins (Polyvinyl chloride,
Methotrexate, arsenic)
Sinusoidal
o Portal cirrhosis
o Sclerosing cholangitis
o Diffuse metastatic disease
Post sinusoidal
o Budd Chiari Syndrome
o CCF
o Constrictive pericarditis

5. Portal hypertension
Presinusoidal-extrahepatic
o Portal and/or splenic vein
thrombosis
Presinusoidal-intrahepatic
o Primary biliary cirrhosis
o Schistosomiasis
o Congenital Hepatic Fibrosis
o Idiopathic noncirrhotic fibrosis
o Wilson’s disease
o Myelofibrosis
o Toxins (Polyvinyl chloride,
Methotrexate, arsenic)
Sinusoidal
o Portal cirrhosis
o Sclerosing cholangitis
o Diffuse metastatic disease
Post sinusoidal
o Budd Chiari Syndrome
o CCF
o Constrictive pericarditis

6. Where do we stand?
o Ultrasound of the liver surface is a useful diagnostic tool
in patients at risk of CLD when assessing whether they
should undergo a liver biopsy. Meta Analysis, 29
studies.1
o Ultrasound is accurate …and may identify cirrhosis
even in the absence of a typical histopathological
pattern.2
o Low frequency ultrasonography is not a sensitive test for
the diagnosis of liver cirrhosis in daily clinical practice.3
1Allan R, Thoirs K, Phillips M. Accuracy of ultrasound to identify chronic liver disease. World J Gastroenterol. 2010 Jul
28;16(28):3510-20.
2Giani S, Gramantieri L, Ventulori L. What is the criterion for differentiating chronic hepatitis from compensated cirrhosis? A
prospective study comparing ultrasonography and percutaneous liver biopsy. J Hepatol. 1997 Dec; 27(6):979-85.
3Ong TZ, Tan HJ. Ultrasonography is not reliable in diagnosing liver cirrhosis in clinical practice. Singapore Med J. 2003
Jun;44(6):293-5.

7. Where do we stand?
o Ultrasound has a sensitivity of nearly 80%
in diagnosing cirrhosis
Arguedas MR, Heudebert GR, Eloubeidi MA, Abrams GA, Fallon MB. Cost-effectiveness of screening, surveillance,
and primary prophylaxis strategies for esophageal varices. Am J Gastroenterol 2002;97:2441-2452.

8. Grey-scale ultrasound findings
o Hepatic: Irregular surface, rounded edges,
heterogeneity of texture, nodularity of
substance, shrunken size, volume
redistribution with a dominant left lobe.
o Extrahepatic: splenomegaly, dilated portal
vein, thick walled distended gallbladder,
varices in various locations and ascites.

9. Liver surface
The diagnosis of cirrhosis by high resolution ultrasound of the liver surface. V Simonovsky.
BJR, 72(199), 29-34

10. Visceral surface
irregularity
o If anterior surface is difficult to
analyse, look at the deep liver
surface.
o Liver interface at the
gallbladder fossa is easily
accessible for
irregularity. This might
even be more sensitive
Filly RA, Reddy SG, Nalbandian AB, Lu Y. Callen PW. Sonographic evaluation of liver nodularity: Inspection of
deep versus superficial surfaces of the liver. Journal of Clinical Ultrasound Volume 30, Issue 7, pages 399–407,
September 2002

11. Hepatic vein wall contour
o Hepatic vein contour might
be seen even before any
other feature of cirrhosis
becomes evident
Vessal S, Naidoo S, Hodson J, Stella DL, Gibson RN (2009). Hepatic vein morphology: a new sonographic
diagnostic parameter in the investigation of cirrhosis? J Ultrasound Med 28(9): 1219–1227
Smooth normal
Mildly irregular
Markedly irregular

12. Texture
Normal
Fatty
Heterogeneous

14. Other features
Dilated portal vein
Splenomegaly
Thick walled gb
varicesVolume redistribution
Gallbladder wall varices
Coronary vein

15. Vascular findings
o Dilatation of the portal vein
o Flow disturbances
o Congestion index
o Hepatic artery findings
o Hepatic vein findings
o Splanchnic veins and arteries
o Portosystemic collaterals
The Role of Ultrasonography in Portal Hypertension. Nakshbandi NAA. Saudi Jr.
Gastero.enterol. 2006 12(3):111-117

16. Vascular findings
o Dilatation of the portal vein
o Flow disturbances
o Congestion index
o Hepatic artery findings
o Hepatic vein findings
o Splanchnic veins and arteries
o Portosystemic collaterals
The Role of Ultrasonography in Portal Hypertension. Nakshbandi NAA. Saudi Jr. Gastero.enterol. 2006
12(3):111-117

17. Dilatation of the portal vein in
portal hypertension
o Absolute portal vein calibre has been considered a sign of
portal venous hypertension 1 with cutoff values of 13–15
mm. Very poor sensitivity (0.13–0.4). The lack of
sensitivity is likely due to the presence of collateral
pathways that decompress the system and inward stenting
by the fibrous sheath of portal vein 2.
o A small percent of normals have portal vein diameters >13
mm.
1 Weinreb J, Kumari S, Phillips G, Pochaczevsky R (1982) Portal vein measurements
by real-time sonography. AJR Am J Roentgenol. 139(3):497–499
2 Lafortune M, Marleau D, Breton G, Viallet A, Lavoie P, Huet PM (1984) Portal venous
system measurements in portal hypertension. Radiology 151(1):27–30

18. Portal vein in portal hypertension

19. Portal vein in portal hypertension

20. Flow patterns
o Normal portal vein flow
• Continuous, hepatopetal, minimal variation by
cardiac cycle and respiration (pulsatility ratio
<0.54; Pulsatility Index (PI) 0.48+0.31)
o Abnormal portal vein flow
• Continuous but with Increased Pulsatilility
• Respiratory dependent hepatofugal
• Continuous hepatofugal
• Stagnant of no-flow

21. © Shlomo Gobi, Jerusalem
PV flow

22. Other vessels (inconsistent
findings)
o Congestion index (pv area/ pv veloctiy; normal
~0.07, cirrhosis when > 0.1)
o Hepatic artery RI can increase with cirrhosis
o Hepatic venous flow velocity can increase due
to compression by nodules and decrease due
increased liver stiffness. Liver stiffness also
alters spectrum and triphasic becomes
monophasic
o Splanchnic veins can dilate

23. Hepatic vein
Doppler spectra

24. Portovenous collaterals
o Recanalized paraumbilical veins
o Varices in gallbladder walls
o Coronary:gastro-oesophageal
collaterals behind the left lobe of
the liver
o Collaterals at the splenic hilum;
these can extend above or
below the spleen
o In the pelvic midline or laterally

25. Varices
Paraumbilical
Splenic hilum
Gallbladder wall varices
Gastro-oesophagial
Anterior abdominal wall
Pelvic

26. Portal vein thrombosis
o Malignant
• HCC
• Metastatic disease
• Pancreatic carcinoma
• Primary
Leiomyosarcoma of
the portal vein
o Tumour Thrombus
o Benign
• Chronic Pancreatitis
• Appndicitis
• Varicial Injections
• Septicemia
• Trauma
• Splenectomy
• Portacaval shunts
• Pregnancy and other
hypercoagulable states
• Dehydration
• Umbilical vein catheterization

27. Portal vein thrombosis

28. Bland thrombi can
resolve/recanalize
Patient had occluding right portal vein thrombus 6 months back

29. Tumour thrombus
Continuity with mass
Vascularity
PET will discriminate best

30. Cavernous transformation

31. Budd Chiari Syndrome
o Occlusion of hepatic veins with or without
ivc occlusion
o Ultrasound features include:
• Ascites, enlarged bulbous liver (acute) with
heterogeneity due to areas of haemorrhagic
infarction
• Caudate lobe enlargement with emissary veins,
occluded hepatic veins and abnormal venous
collaterals

32. Hepatic vein
thrombosis

33. Caudate lobe enlargement
and emissary veins

34. Thank you