This document discusses the Doppler ultrasound assessment of the portal venous system. It begins with an overview of the sonographic and Doppler evaluation of the portal system's anatomy and normal circulation. It then covers the assessment of specific vessels like the portal vein, hepatic veins, and hepatic artery through grayscale ultrasound and Doppler evaluation. Key aspects like normal vessel diameters, waveforms, and flow direction are defined. The document concludes by outlining the important Doppler assessment techniques and parameters used to evaluate the portal system.

1. Doppler of the portal System
Dr. Muhammad Bin Zulfiqar
PGR FCPSII SIMS/SHL

2. • Sonographic Anatomy of Portal System
• Gray scale Sonography of Portal System
• Doppler Sonography of Portal System

3. Normal Portal Venous Circulation

4. Normal hepatic circulation

5. Splenic Vein

6. Inferior Mesenteric Vein
• Anterior to left renal vein and SMA and posterior to
duodenum.
• Upper limit of normal is 7 mm.
• IMV inserting into portal confluence 33%.

7. Jejunal Vein

8. Respiratory variation of SV or SMV diameter

9. Normal left gastric (coronary) vein
• Coronary vein seen anterior to bifurcation of celiac artery.
• Coronary vein draining into splenic vein.
• Upper normal limit is 5-6 mm.

10. Portal Vein
• On fasting state upper normal limit of portal vein is 13-14 mm.

11. Branches of right and left portal vein

12. Umblical vein remnant
Normal < 3mm
Ligamentum Teres hypoechoic remnant of UV.
Communicates with LPV
Transverse view of LT Longitudinal view of LT Color Doppler view
No detectable flow
within UV remnant

13. Major anatomical variant of portal system

14. Agenesis of left portal vein

15. Anatomic variants of portal vein

16. Normal hepatic veins
• Three hepatic veins enter IVC 2 cm caudad to right atrium.
• Middle and left hepatic veins form common trunk (60 %).
• Right, middle and left HV seen as bunny on points to IVC.
• Hepatic veins divide liver into couinaud system segments.

17. Hepatic vein variant

18. Normal Hepatic Artery

19. Normal Hepatic Artery
CT : Celiac trunk

20. Hepatic Artery

21. Anatomical variations of hepatic artery

22. Goals of Doppler

24. Sites of duplex insonation of portal system

25. Prerequisite for doppler USG
• Color box/ Overlay
• Adjusting color velocity scale
• Adjusting color gain
• Changing color baseline to avoid aliasing
• Inversion of color flow
• Changing color doppler wall filter
• Angle of Insonation

26. Color box/ Overlay

27. Adjusting color velocity scale

28. Adjusting color gain

29. Changing color baseline to avoid aliasing

30. Inversion of color flow

31. Changing color doppler wall filter

32. Angle of Insonation

33. Obtain waveform at end of normal breath-out

34. Normal pulsed doppler of portal vein
• Sample gate placed in middle of portal vein.
• Width of sample gate approximately half the lumen.
• Pulsed Doppler obtained at end of normal breath out.

35. Measurement of portal vein velocity

36. Variability of portal vein velocity

37. Normal Portal Vein
Diameter: Upper limit of normal in fasting state: 13-14mm
Age related variation add 1 for every 10 years after 60years.
> 20-30% increase with food and inspiration.
Flow Direction: Towards liver (hepatopetal)
Through entire cardiac cycle.
Velocity: Varies greatly
Mean Velocity : 15-18 cm/sec
Varies with cardiac and respiration activity undulating
appearance of waveform

39. Normal cardiac pulsatility of portal vein

40. Normal cardiac pulsatility of portal vein

41. Normal cardiac pulsatility of portal vein

42. Congestion index of portal vein

43. Portal vein flow volume

44. Laminar and helical flow in portal vein

45. Helical portal vein flow

46. Helical portal vein flow near bifurcation

47. Helical portal vein flow- mimic of hepatofugal flow

48. Color Doppler of normal hepatic vein
• Normal diameter < 10mm 2 cm before
entrance into IVC.

49. Normal hepatic vein waveform- 3 components

50. Normal hepatic vein waveform- 4 components

51. Normal hepatic vein waveform- 5 components

52. Classification of Doppler HV waveform
Measurement taken in RHV/MHV
RHV: Right hepatic vein
LHV: Left hepatic vein

53. Interpretation of hepatic vein flow

55. Interpretation of HV spectral waveform

56. Normal hepatic artery- Impedance indices
Resistive Index and Pulsatility Index
RI: S – ED / S Normal value = 0.65 +/- 0.1
PI: S – ED / M Normal Value = 0.92 +/- 0.1

57. Normal hepatic artery

58. Interpretation of hepatic artery flow
Low resistance flow – Normal
Decreased diastolic flow – ESLD
Reversed diastolic flow – ESLD
ESLD: End stage liver disease

59. THANK YOU