Ultrasound in portal hypertension

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 [email protected]

2. Portal hypertension Normal portal vein pressure is 5-10mm Hg (14 cm H 2 0) Wedge pressure or direct portal vein pressure >5mm Hg than IVC Portal vein pressure >30cm H 2

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

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

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

6. Where do we stand? 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 Ultrasound is accurate …and may identify cirrhosis even in the absence of a typical histopathological pattern. 2 Low frequency ultrasonography is not a sensitive test for the diagnosis of liver cirrhosis in daily clinical practice. 3 1 Allan R, Thoirs K, Phillips M. Accuracy of ultrasound to identify chronic liver disease. World J Gastroenterol. 2010 Jul 28;16(28):3510-20. 2 Giani 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. 3 Ong 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? 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 Hepatic: Irregular surface, rounded edges, heterogeneity of texture, nodularity of substance, shrunken size, volume redistribution with a dominant left lobe. 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 If anterior surface is difficult to analyse , look at the deep liver surface. 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 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

13. Other features Dilated portal vein Splenomegaly Thick walled gb varices Volume redistribution Gallbladder wall varices Coronary vein

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

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

16. Dilatation of the portal vein in portal hypertension 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 . 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

17. Portal vein in portal hypertension

18. Portal vein in portal hypertension

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

20. © Shlomo Gobi, Jerusalem PV flow

21. Other vessels (inconsistent findings) Congestion index ( pv area/ pv veloctiy ; normal ~0.07, cirrhosis when > 0.1) Hepatic artery RI can increase with cirrhosis 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 Splanchnic veins can dilate

22. Hepatic vein Doppler spectra

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

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

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

26. Portal vein thrombosis

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

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

29. Cavernous transformation

30. Budd Chiari Syndrome Occlusion of hepatic veins with or without ivc occlusion 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

31. Hepatic vein thrombosis

32. Caudate lobe enlargement and emissary veins

33. Thank you