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. Superior mesenteric vein thrombosis
Transverse image of SMA & SMV
http://www.ultrasoundcases.info
SMA
SMV
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. 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. 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. Acute thrombosis of portal vein
Complete thrombosis
http://www.sites.tufts.edu
Echogenic material visualized within portal vein
Increased diameter of portal vein
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. 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. 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. 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. 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. 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. 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. 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.
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. 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. 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. 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. 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. 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
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?
