Ultrasound findings in portal hypertension

Durr-e-SabihMBBS. MS. FRCP. FANMB

Director MINAR- MultanPAKISTAN

dsabih@yahoo.com

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

Portal hypertensionPresinusoidal-extrahepatic o Portal and/or splenic vein

thrombosis

Presinusoidal-intrahepatico Primary biliary cirrhosiso Schistosomiasiso Congenital Hepatic Fibrosiso Idiopathic noncirrhotic

fibrosiso Wilson’s diseaseo Myelofibrosiso Toxins (Polyvinyl chloride,

Methotrexate, arsenic)

Sinusoidalo Portal cirrhosiso Sclerosing cholangitiso Diffuse metastatic disease

Post sinusoidalo Budd Chiari Syndromeo CCFo Constrictive pericarditis

Portal hypertensionPresinusoidal-extrahepatic o Portal and/or splenic vein

thrombosis

Presinusoidal-intrahepatico Primary biliary cirrhosiso Schistosomiasiso Congenital Hepatic Fibrosiso Idiopathic noncirrhotic

fibrosiso Wilson’s diseaseo Myelofibrosiso Toxins (Polyvinyl chloride,

Methotrexate, arsenic)

Sinusoidalo Portal cirrhosiso Sclerosing cholangitiso Diffuse metastatic disease

Post sinusoidalo Budd Chiari Syndromeo CCFo Constrictive pericarditis

Portal hypertensionPresinusoidal-extrahepatic o Portal and/or splenic vein

thrombosis

Presinusoidal-intrahepatico Primary biliary cirrhosiso Schistosomiasiso Congenital Hepatic Fibrosiso Idiopathic noncirrhotic

fibrosiso Wilson’s diseaseo Myelofibrosiso Toxins (Polyvinyl chloride,

Methotrexate, arsenic)

Sinusoidalo Portal cirrhosiso Sclerosing cholangitiso Diffuse metastatic disease

Post sinusoidalo Budd Chiari Syndromeo CCFo Constrictive pericarditis

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.

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.

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.

Liver surface

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

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

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

TextureNormal

FattyHeterogeneous

Other featuresDilated portal vein

Splenomegaly

Thick walled gb

varicesVolume redistribution

Gallbladder wall varicesCoronary vein

Vascular findingso Dilatation of the portal veino Flow disturbanceso Congestion indexo Hepatic artery findingso Hepatic vein findingso Splanchnic veins and arterieso Portosystemic collaterals

The Role of Ultrasonography in Portal Hypertension. Nakshbandi NAA. Saudi Jr. Gastero.enterol. 2006 12(3):111-117

Vascular findingso Dilatation of the portal veino Flow disturbanceso Congestion indexo Hepatic artery findingso Hepatic vein findingso Splanchnic veins and arterieso Portosystemic collaterals

The Role of Ultrasonography in Portal Hypertension. Nakshbandi NAA. Saudi Jr. Gastero.enterol. 2006 12(3):111-117

Dilatation of the portal vein in portal hypertensiono 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

Portal vein in portal hypertension

Portal vein in portal hypertension

Flow patternso 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

© Shlomo Gobi, Jerusalem

PV flow

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 cirrhosiso 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

Hepatic veinDoppler spectra

Portovenous collaterals

o Recanalized paraumbilical veinso Varices in gallbladder wallso 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

Varices Paraumbilical

Splenic hilum

Gallbladder wall varices

Gastro-oesophagial Anterior abdominal wall

Pelvic

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

Portal vein thrombosis

Bland thrombi can resolve/recanalize

Patient had occluding right portal vein thrombus 6 months back

Tumour thrombus

Continuity with massVascularityPET will discriminate best

Cavernous transformation

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

Hepatic veinthrombosis

Caudate lobe enlargementand emissary veins

Thank you