Hepato-Portal doppler ultrasound

1. DR. RAVI PATEL
RESIDENT OF RADIOLOGY
Shree Tatyasaheb Ghatghe
Cheritable trust Hospital, sangli

2. Normal Portal Venous Circulation

3. Goals of
Doppler

4. Obtain waveform at end of normal
breath-out

5. Normal Portal
Vein
Diameter: Upper limit of normal in fasting state: 13-16mm
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.

6. Variability of portal vein
velocity

8. Normal cardiac pulsatility of portal vein

9. Normalcardiac pulsatility of
portal vein

10. cardiac pulsatility of portal vein

11. Congestion index of
portal vein

12. Laminar and helical flow in
portal vein

13. Helical portal vein flow near
bifurcation

14. Helical portal vein
flow

15. Helical portal vein flow- mimic of hepatofugal flow

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

17. Normal hepatic vein waveform- 3
components

18. Normal hepatic vein waveform- 4
components

19. Normal hepatic vein waveform- 5
components

20. Classification of Doppler HV waveform
Measurement taken in RHV/MHV

21. Interpretation of hepatic
vein flow

23. Interpretation of HV spectral
waveform

24. Normal hepatic artery- Resistive Index
RI: S – ED / S Normal value = 0.5 TO 0.7

25. Normal hepatic
artery

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

27. Doppler of the portal
system Pathological
findings
Dr. Muhammad Bin
Zulfiqar
PGR-II FCPS-II SIMS/SHL

28. Doppler of the portal
system
Portal hypertension
Portal vein thrombosis

29. Causes of portal hypertension
Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3
Causes Disease
Extra-hepatic Pre hepatic
Portal vein thrombosis or compression or
stenosis
Post hepatic
Hepatic veain thrombosis or compression or
stenosis
Intra-hepatic
(M/C)
Pre-sinusoidal
Congenital hepatic fibrosis
Sarcoidosis
Schistosomiasis
Lymphoma
Post-sinusoidal –Cirrhosis most common

30. PATHO-PHYSIOLOGY OF PHT

31. Doppler US signs of PHT in
cirrhosis
• P-S
collaterals
• Portal vein
• Hepatic vein
• Hepatic
artery
Highly sensitive & specific
Dilated PV(>13mm)
Decreased mean velocity (< 15 cm/sec)
To-and-fro flow /Hepatofugal flow
(VPI) >0.48+/-0.31,A-P fistula
Compression (Pseudo-portal flow)
Enlargement & tortuosity
Increased RI(>0.7) & Velocity(>160
Cm/sec)
.

32. Porto-systemic collaterals
High sensitivity & specificity for
PHT
• Tributary
collaterals
“Drain normally into
PS”
Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3
Coronary vein (left
gastric) Short gastric
veins Branches of SMV
& IMV
• Developed
collaterals
“Developed or
recanalized”
Recanalized umbilical
vein Spleno-renal
collateral Gastro-renal
collateral
Spleno-retroperitoneal
collateral

33. Other findings of PHT
• SPLENOMEGALY
• ASCITES
• OTHER FINDINGS OF CIRRHOSIS OF LIVER

34. Common spontaneous porto-systemic
collaterals
More than 20 P-S collaterals
described
Patnquin1 H et al. Am J Roentgenol 1987 ; 149 : 71
Most common: LGV – PUV – Spleno-renal – Gastro-
renal
Coronary vein & umbilical vein are the easiest &
most productive to analyze sonographycally

35. P-S collaterals / Coronary
vein(80-90 % chances of h’ge)
Reversed flow in coronary vein is earliest sign of PHT than CV
diameter enlargement(n=5-6 mm)
Sagittal view slightly superior
Tortuosity of CV as it
extends superiorly toward
GE junction
Sagittal paramedial view
Flow in CV is away from
splenic vein

36. P-S collaterals / Gastroesophageal
collateral
Gastroesophageal collateral veins close to diaphragm
McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition,2008.
Longitudinal view of left liver lobe

37. NORMAL DIAMETER OF UV IS < 3mm WITH ABSENT FLOW
Normal umbilical vein anatomy
UV communicates with umbilical segment of LPV &
Travels down anterior abdominal wall towards umbilicus
Eventually drains into systemic system via inferior epigastric vein

38. Hepatofugal flow within UV
Longitudinal US of LLL Similar color Doppler view
Dilated umbilical vein (10 mm)
P-S collaterals / Recanalized umbilical vei
PUV observed only in hepatic or suprahepatic blockage
LLL: Left lobe of
Liver

39. Sagittal panoramic view
PUV traveling to periumbilical region where it becomes
tortuous. UV ramifies into smaller PU collaterals when it
proceeds inferiorly
Caput medusae

40. P-S collaterals / Spleno-renal
collateral
Yamada M et al. Abdom Imaging 2006 ; 31:701 – 705.
Mansour MA et al. Vascular Diagnosis. Elsevier-Saunders, Philadelphia, 1st
Transverse color Doppler
US
Splenic vein feeding large
splenorenal collaterals
Flow direction from SV to LRV
Reversed or to-and-fro flow in
SV
Schematic drawing

41. P-S collaterals / Short gastric veins
Short gastric vein as inflowing vessel to gastric varices

42. P-S collaterals / Gastro-renal
collateral
GRS-GASTRO RENAL SHUNT
4.
From cranial & dorsal side to
caudal & ventral side into
LRV
Long-axis view of GRS
GR
S
LR
V
From SV at confluence
coursing backward to join
LRV
Schematic drawing

43. P-S collaterals / Superior
mesenteric vein
Flow toward SMV in sup
branch Flow away from SMV
in inf branch
Color Doppler view
2 mesenteric branches
of superior mesenteric
vein
Semicoronal view of SMV
Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3

44. P-S collaterals / IMV & rectal venous
drainage
Wachsberg RH. Am J Roentgenol 2005 ; 184 : 481
Peri-rectal varices
Left parasagittal CDUS Transverse US posterior to bladder
Hepatofugal flow in dilated
IMV

45. P-S collaterals / Gallbladder
varices
Serpentine area in wall of GB
Cystic vein to anterior abdominal wall or patent PV branches
Most commonly observed in PV thrombosis (30%)

46. P-S collaterals / Spleno-retroperitoneal
collateral
Prominent varices surrounding posterior aspect of
spleen
Owen C et al. J Diag Med Sonography 2006 ; 22 : 317

47. Diameter of portal vein/Cirrhosis & PHT
1 Weinreb J et al. Am J Roentgenol 1982 ; 139 : 497 –
499.
2 Goyal AK et al. J Ultrasound Med 1990 ; 9 : 45 – 48.
Diameter: 16.9 mm
Sign of portal
Hypertension
Longitudinal view of
MPV
Controversy on normal PV
diameter
Up to 13 mm in one study1
Up to 16 mm in another study2
Unusual large PV: sign of PHT
Normal PV size: do not exclude
PHT

48. Cirrhosis & PHT / Portal vein velocity
Low velocity: good indicator of PHT
Normal velocity: do not exclude PHT
Controversy on normal PV
velocity
Normal mean velocity: 15 – 18
cm/sec
Shrunken liver & irregular
margin Vmax: 10 cm/s
Diagnosis of PHT
Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.
Triplex image of PV

49. Portal vein pseudoclot – Incorrect velocity
Cirrhotic patient with portal
hypertension
Slower flow in portal vein
demonstrated
Velocity scale: 7 cm/s
Rubens DJ et al. Ultrasound Clin 2006 ; 1 : 79
Velocity scale: 20 cm/s
Good flow in HA anteriorly
No flow in adjacent PV

50. Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3
Transverse CDUS of left portal vein
Hepatopetal flow Hepatofugal flow
Cirrhosis & PHT / To-and-fro flow in
PV Compression

51. Hepatopetal flow in HA
Hepatofugal flow in PV
Color Doppler of porta hepatis
Arterial flow above
baseline
Portal venous
below baseline
Duplex Doppler of same area
Flow reversal occurs primarily in peripheral portal vein branches & after reversal of flow
is seen in main portal vein in PHT.
Cirrhosis & PHT / Reversed flow in PV
branches

52. Cirrhosis & PHT / Reversed flow in PV
branches
Right anterior PV branch
Hepatofugal flow
Right posterior PV branch
Hepatopetal flow

53. Hepatofugal flow in portal vein
Portal vein flow away from liver
• Cirrhosis
• Budd-Chiari syndrome &
SOS(sinosoidal
obstruction syndrome)
• TIPS
• Arterio-portal fistula
Tumor: HCC –
Hemangioma
Percutaneous liver biopsy
Percutaneous biliary
drainage
Rupture vein aneurysm
Rendu-Osler-Weber
disease

54. Hepatofugal portal /
TIPS
Right portal vein to right hepatic
vein
Reversion of hepatofugal
flow Stent devoid of color
signals Malfunction of
TIPS
1 week after TIPS
Hepatofugal flow in RPV
Vigorous color flow in
stent
Immediately after TIPS

55. Arterio-portal fistula / High-flow
hemangioma
Hwang HJ et al. J Clin Ultrasound 2009 ; 37 : 511
65-year-old man with high-flow hemangioma
in LLL
Hypoechoic nodule with intratumoral flow
Peritumoral hepatofugal flow in segmental
PV Hepatopetal flow in proximal PV

56. Arterio-portal fistula / Post-liver
biopsy
Bertolotto M et al. J Clin Ultrasound 2008 ; 36 : 527 –
Vascular lesion
between HA & PV
branches Inverted
flow in PV
Oblique gray-scale USOblique CDUS
Focal echogenic
area
in region of biopsy
Spectral Doppler
US
High-velocity flow
Low-resistance
flow Turbulent
flow

57. Arterio-portal fistula / Rendu-
Osler-Weber
Bertolotto M et al. J Clin Ultrasound 2008 ; 36 : 527 –
Low-resistance arterial
flow
Arterialized & inverted PV
flow
Dilated tortuous structures Dilated vascular structures with
aliasing

58. Cirrhosis & PHT / Prominent hepatic arte
Enlarged HA with tortuous or ‘‘corkscrew’’
appearance
Increased flow in HA to compensate decreased flow
in PV
Swart J et al. Ultrasound Clin 2007 ; 2 : 355 –

59. Causes of enlargement of
hepatic artery
• Cirrhosis
• Hepatic diseases associated with alcoholism
• Congenital hepatic fibrosis
• Vascular tumors
• Hereditary hemorrhagic telangiectasia
Buscarini E et al. Ultraschall Med 2004 ; 25 : 348

60. Parallel channel sign
Gray-scale US
IH parallel channel sign
Suspicious of dilated
IHBD
Color & pulsed Doppler US
Flow in both intra-hepatic luminal
Portal vein & hepatic artery
Absence of dilated intra-hepatic bile duct

61. Parallel channel sign
von Herbay A et al. J Clin Ultrasound 1999 ; 27 : 426
Gray-scale US
IH parallel channel sign
Suspicious of dilated IHBD
Color & pulsed Doppler US
Blood flow in anterior structure
No flow in posterior structure
Confirmation of dilated intra-hepatic bile duct

62. Doppler in cirrhosis
/ PHT
Prognostic implications
• Collaterals
• Portal
vein
PUV
Reversed
LGV S-R
shunt
Low flow/
Inversed
flow
High bleeding risk in
surgery
High bleeding risk of
EV
increased hepatic
congetion index &CI for
TIPS & porto-caval
shunts
• Hepatic artery
• Hepatic vein
Increased PI
Monophasic
ESLD
ESLD
Increased DI Severe PHT (> 12 mmHg)

63. Portal Vein Thrombosis

64. Classification of portal vein
thrombosis
• Duration Acute
Chronic
• Severity Complete
Partial
• Causes Malignant
Non-malignant

65. Portal vein
thrombosis
• Etiology Extra-hepatic: multiple causes
Cirrhosis ± HCC: complete –
partial
Very low portal
flow
Gray scale better than color Doppler
• Sensitivity
• False
positive
• Partial
• Indications Before hepatic surgery
Before porto-caval
shunt
Before hepatic
Equal to CT – Power Doppler increase Sen

66. Splenic vein thrombosis in Gastric
carcinoma

67. Superior mesenteric vein
thrombosis
Pancreatic
cancer
Sagittal view of pancreas & SMV
Thrombosed
SMV
Mass in
Pancreatic neck
Shunt between SMV
& systemic venous return

68. Superior mesenteric vein
thrombosis
Transverse image of SMA & SMV
SMA
SMV

69. Acute thrombosis of portal vein
Complete
thrombosis
http
Echogenic material visualized within portal
vein. Increased diameter of portal vein.

70. Partial thrombosis of
portal vein
Echogenic material occluding lumen of PV by ≈ 50%
Sacerdoti D et al. J Ultrasound 2007 ; 10 : 12

71. Partial thrombosis of
portal vein
Swart J et al. Ultrasound Clin 2007 ; 2 : 355 –
Gray scale ultrasound
Partial echogenic thrombus
Color & pulsed Doppler
Complete filling of main PV
obscuring the clot

72. Non-malignant PV thrombosis in cirrhosis
Systematic review – Many unresolved issue
• Incidence 10 – 25%
• Pathophysiology Cirrhosis no longer hypocoagulable state
• Clinical findingsAsymptomatic disease
Life-threatening condition
• Manageme
nt
1st line treatment: warfarin or LMWH
2nd line treatment: thrombectomy,TIPS
Tsochatzis EA et al. Aliment Pharmacol Ther 2010; 31 : 366 –

73. Diagnosis of malignant PV
thrombosis
• Color Doppler
US
PV > 23 mm in diameter
Arterial-like flow on Doppler
Increased serum α-FP
CT- or US-guided
• FNAC(
22-25 g
needle)
• CEUS Contrast-Enhanced
Ultrasound

74. Portal vein thrombus in HCC
Swart J et al. Ultrasound Clin 2007 ; 2 : 355 –
FNAC 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

75. Malignant PV thrombosis /
CEUS
Dănilă M et al. Medical Ultrasonography 2011 ; 13 : 102 – 107.
Gray-scale US
Malignant PVT
Enhancement
Wash-
out
Late phase
Wash-
out
Contrast-Enhanced US
Arterial phase Portal phase

76. Portal vein pseudoclot –
Augmentation
Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3
Color Doppler US of main portal vein
At rest
No detectable flow
Compression of lower
abdomen Augmented portal
venous flow

77. Chronic portal vein
thrombosis
Portal
cavernoma
Parikh et al. Am J Med 2010 ; 123 : 111 –
Hepatopetal collaterals around thrombosed portal
vein

78. Portal cavernoma
(porto-systemic and portoportal collatera
Gray-scale ultrasound Color & pulsed Doppler

79. PORTAL VEIN STENOSIS
GRAY SCALE- STENOTIC PORTION MAY NOT BE VISUALIZED.
CD- ACCELERATED FLOW IN NARROWED SEGMENT WILL PRODUCED ALIASING EFFECT
PD-HIGHER VELOCITY

80. Budd–Chiari syndrome is a condition caused
by occlusion of the hepatic veins that drains the liver.
BUDD-CHIARI SYNDROME

81. epidemology
m:f 1:2
3rd and 4th decade
Median age – 35
Location
 Hepatic vein 62%
 IVC 7%
 Both IVC & hepatic veins 31%
 Associated portal vein thrombus 14%

82. Etiology:
majority of patients have an underlying hematologic
abnormality.
Tumor
Hepatocellularcarcinoma
Carcinoma ofpancreas
Carcinoma ofkidneys
Metastaticdisease
Normal biopsy findings do not exclude this entity
Other causes
-hepatic vein thrombosis
-hepatic vein comression
-hepatic vein stenosis

83. CLINICAL PROFILE
• CLASSICAL TRIAD-
1-ABDOMINAL PAIN
2-ASCITES
3-HEPATOMEGALY (HYPERTROPHY OF CAUDATE
LOBE > 3mm)

84. Role of imaging:
• Evaluation of occlusion of the hepatic veins
and inferior vena cava
• Caudate lobe enlargement(>3mm)
• Inhomogeneous liver enhancement
• Intrahepatic collateral vessels and
hypervascular nodules.

85. Budd-Chiari syndrome Presents with - acute or
chronic form.
acute - results from an acute thrombosis of the
hepatic veins or the IVC
Chronic form is related to fibrosis of the
intrahepatic veins.

86. Ultrasound findings
• Enlargement of the caudate lobe.
• Ascitis
• Partial or complete inability to see the hepatic veins ;
stenosis with proximal dilatation, and thrombosis
• Narrowing of IVC due to compression by the enlarged
caudate lobe.
• Color Doppler studies shows absent or flat or reversed
flow in the hepatic veins,IVC, or both
• increased resistive index within the hepatic artery - >0.75
is seen

91. Classification of BCS According
to the Level of Obstruction
Type I Obstruction of IVC with or without
secondary hepatic vein occlusion
Type II Obstruction of major hepatic veins
Type III Obstruction of the small centrilobular
venules.

92. Sinusoidal obstruction syndrome (SOS), formerly known as Hepatic Veno-
occlusive disease (HVOD), is a congestive hepatopathy with an acute severe
form and a more chronic milder form that may manifest as disproportionate
thrombocytopenia

93. Sinusoidal obstruction syndrome (SOS),formerly known as Hepatic Veno-occlusive disease (HVOD),
is a congestive hepatopathy with an acute severe form and a more chronic milder form
that may manifest as disproportionate thrombocytopenia

94. Transjugular Intrahepatic Portosystemic
Shunt TIPS
Highly effective for
– Reducing ascites
– Recurrent variceal
hemorrhage
– Improving quality of life
High rate of stenosis or
thrombosis High rate of
hepatic encephalopathy

95. Normal Doppler parameters for
TIPS
• Portal vein
• IHPV
• Hepatic
artery
• Stent
Hepatopetal flow – Velocity > 30 cm/sec
Hepatofugal flow
Increased PSV
Flow completely filling the stent
Monophasic pulsatile flow
Vmin: 90 cm/sec – Vmax: 190 cm/sec
Vmax – Vmin: 50 – 100 cm/sec
Temporal changes: ↑ or ↓ less 50 cm/sec
Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 –

96. Follow-up of TIPS by
Doppler US
Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 –
• 24 to 48 hours (baseline)
• 3 months
• 6 months
• 12 months
• Annually thereafter
Real goal of surveillance
Detect stenosis before complete
thrombosis

97. TIPS / Normal
Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 –
Stent within liver
parenchyma Hepatopetal
flow in MPV Hepatofugal
flow in RPV
Color Doppler of TIPS Color & pulsed Doppler of TIPS
Monophasic pulsatile flow
Velocity: 106 cm/sec

98. TIPS / Mirror image artifact
If not recognized: migration into heart (emergency
intervention)
If uncertainty persists: chest radiograph
Stent on either side of
diaphragm
Mirror image artifact Variant of mirror image artifact
Stent above diaphragm
True TIPS visible by rotating probe

99. TIPS /
migration
Proximal portion migrated out of PV into parenchymal
tract This resulted in complete thrombosis of stent
Longitudinal view of
TIPS

100. TIPS – Stenosis
Middleton WD et al. Ultrasound Quarterly 2003 ; 19 : 56 –
Main portal vein Right portal vein
Mid TIPS Mid TIPS Distal TIPS
Vel 26 cm/sec
Aliasing 371 cm/sec 98 cm/sec
Hepatopetal flow

101. TIPS / occlusion
Ricci P et al. J Ultrasound 2007 ; 10 : 22 –
Homogeneous hyperechoic intraluminal
material without any color flow within TIPS

102. PORTAL VEIN GAS
• M/C CAUSE-BOWEL ISHEMIA
• ON GRAY SCALE-small mobile bright reflector
in the lumen of the portal vein and its
branches.
• ON PD- Rain bow color map(multiple bright
white signals imbedded with in the portal vein
signals)

103. PORTAL VEIN GAS
small mobile bright reflector in the lumen
of the portal vein
Rain bow color map

104. 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 –
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
Acute transmural mesenteric infarction

105. 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
Thickening of small bowel
wall Bright flecks within the
wall