Doppler Sonography in the Evaluation of Liver Diseases - SD

Introduction

My name is Antonio Marcino.

I work as a radiologist specialized in ultrasound and we're gonna talk about ultrasound, upper evaluation of liver disease do sonography in the evaluation of liver disease.

Objectives

Objectives today is describe the methodology to evaluate the liver using ultrasound upper and the main complications of liver disease.

Demonstrate different examples of this disease that can cause portal hypertension.

Identify the appropriate search for collaterals pathways and the use of doper sonography in this scenario.

And finally show the use of contrast enhanced ultrasound in Ular Inic part stem shunt evolution.

Pathophysiology and History

Vaus had already touched on the core of the pathophysiology by describing a case of v hemorrhoids and suggested that this was due to a deletion of the peripheral branches.

The suspicion that gastrointestinal hemorrhaging could be caused by the arrangement of the portal circulation was passed on two centuries later by Morgani.

He described it a patient observed by his teacher SVA, who had died from grass intestinal bleeding and was found to have polypoid compressions in the splenic vein in violation of the short gas veins.

Here we can see a Rio By Les of the Porto venous systems.

Then here we can see everything. The liver. The main portal vein is clinic vein, the spleen, the intestinal branch, and heidal plexus.

In 1650, Gleason established that portal vein was as the vessel by which blood was collected from the grass intestinal tract and returned to the systemic circulation.

In 80 75 77, Nikolai VanEck established the shunt from IVC to the portal vein.

Starting the 20 20th century Prevo collected 60 cases of liver cirrhosis where the patient died from HESIs and 80% of them had esophageal varis.

E 90 0 2 Gilbert introduced the term of portal hypertension.

Now universally accepted doppler applications, you can use doppler for the evaluation of chronic liver disease and complications, evaluation of liver transplants, evaluation of tips and focal hepatic lesions.

Exam Protocol

Exam protocol you need to study using a effective methodology based on positioning and breathing measurement of structures and vessel diameter and you can identify the PRIs direction and the lost and flow pattern of main portal vein, the branches and splenic and mesentery superior mesentery vein parameters, parameters power and priority gain, transducer frequency, baseline wall filters, velocity of the sample of spectrum PRF, persistence, focus positions, angle correction, color map size and positioning of the sample volume Is useful for this evaluation.

Here we can see an example on the left side. You can see the main portal vein without flow when you use a wall filter of a hundred hertz.

Then on the right side the whaf, the wall filter is position it and 25 hertz.

Now with this filter you can identify the main part of a flow to the liver.

Chronic Liver Disease

Chronic liver disease S is about 19%.

Boot car syndrome and cardio liver are important too.

In Brazil you have some cases, a lot of cases of STOs.

Then you can see later exam protocol.

We need to evaluate the main portal vein right and left portal branches, the EPE artery main main epithetic veins, the splenic vein, superior meer vein and look for collaterals as paraumbilical vein, esophageal vais, short gastric vein, cystic vais and shunts. Systemic shunts normal pattern of portal vein.

On the right we can see normal part of main portal vein identified and posted doppler and on the left the measurement of the main portal vein close to the hepatic ery entrance into the liver portal.

Vein change diameter 1.3 centimeter, they lost less than 12 or for some outers 15 centimeters per second.

Reverse it flow. Ugal flow can identify in some cases the direction flow to flow flow.

As you can see on this picture, the flow is to and flow The liver cover transformation and thrombosis.

Now here you can identify the ugal flow in the main portal vein and the opal flow in the HEPA artery hepatic vein doppler.

The aspect of hepatic vein is this one.

As you can see in this picture and in some situations some pathologic situations. We can identify the absence of flow In cases of boot care syndrome you can identify multiphasic flow in normal and individuals with cirrhosis.

Portalization of the hepatic vein wave form.

As you can see in the middle hepatic vein in this case the portalized apathic vein waveform.

You can identify the ization in post transplantations and restrictors partial boot carry syndrome as you can see later and some altars detected the ization of the hepatic vein waveform in cases of osis and hepatitis.

Hepatic hepatic had a flow pattern characteristic with a STO OSIS ranged from 0.7 of resistive indexes and posterity index close to 1.34.

There are many index that describe it in the literature, but in some cases there's little practical use of congestion of Porto vein, hepatic vascular indexes and arterial portal index.

The practical significance of HEPA character doppler is used for suspected of posttransplant thrombosis and low resistance flow.

When we suspect of portal vein thrombosis Definition of portal hypertension.

Portal Hypertension

Portal hypertension is a hemodynamic feature when we identified hyper portal pressure more than six to 10 millimeters or a pressure gradient between portal vein and apathic veins more than five.

When you have the portal pressure more than 12, the gradient more than 12 millimeters, we identify collateral pathways, systemic collateral pathways, the portal hypertension classification, pre hepatic blood arrival absorption.

Hepatic portal hypertension. STO is an example of ZO cases of portal hypertension.

Cino DO is caused by cirrhosis and post cino is caused by ary syndrome.

The post hepatic portal hypertension is caused in cases of pericarditis and chronic heart failure Portal Hypertension diagnostic criteria, different signs of liver disease on gray scale, part of a more than 1.3 centimeter velocity, less than 12 centimeters per second, collaterals splenomegaly and splenic vein or S-M-A-S-M-D more than one centimeters STOs.

Schistosomiasis

There are some features of cystos can identify hepatomegaly in 50% of cases a relative hypertrophy of lept lobe in 81% of the cases.

In most of cases we have normal coed lobe in these patients.

Splenomegaly is found in 9200%.

Periportal and perivascular fibrile thickening are variable up to three centimeters.

There is a absence of AEs and nodules and normal liver function.

On the right side we can identify a liver with relative hypertrophy of left lobe and we can identify the thickening fibrosis, paravascular and periportal like you can see here in 73% of cases portal vein with normal speed insto miosis, the aqua hepatic veins with multiphasic pattern and 6% of portal vein thrombosis caused by low flow rate is related to the bleeding of esophageal RACIs.

Here we can identify different features of thickening, of fibrosis close to main part of vein and branches here and here on the right cirrhosis.

Cirrhosis

Cirrhosis there are many causes of liver cirrhosis and the varis cirrhosis B and C and alcohol can cause this pathology.

In these cases we can see the macro nodular cirrhosis on the right where we can identify small nodules and on the right the micro nodular cirrhosis that the appearance of B mode ultrasound in this case is close to be normal.

In liver cirrhosis we have nodules caused by regeneration and hepatic carcinoma in spleen, splenomegaly and gamma.

Again, nodules. Chel is associated in 30% of the cases.

In most of cases we have ES low flow rates in portal vein different from histo osis EPE vein, it has phasic flow complications secondary to chronic liver disease port of in thrombosis.

Portal Vein Thrombosis

You can identify acute port of thrombosis, chronic port of vein thrombosis.

It can be spontaneous post-surgical thrombosis, low flow rate thrombosis caused by esophageal vais and tumor caused by hepatocellular carcinoma.

Now you have different examples of portal vein thrombosis on the right side heel, a small branch of main portal of left branch of portal vein with a partial thrombus.

Inside here a partial thrombosis of a splenic vein and main portal vein.

In this cases we can, on the, on the left you can identify a tumor thrombosis and this finding of the tumor inside the portal vein with a flow arterial flow with low resistance Intratumoral flow.

In this case on the right a perial thrombosis a chronic perial thrombosis with some calsifications inside and in the left branch in a patient with cytosome uses evaluation of collateral vessels using doppler sonography we can identify paraumbilical vein, left gastric vein, short gastric veins, PLE shunt hemo plexus, and the system left gas vein close to the border of left lobe.

We can identify the left gas vein or the coronary vein and here is the main portal vein.

As you can see in this picture. This is the left gas vein.

Now you can see a case of Porto stenosis and left gastral vein pulse liver transplants.

On the left side we can identify a Porto vein lung at great scale and doppler and on the right side the same appearance on color Doppler collaterals from port vein at Corona vein site is are identified close to the border of the left lobe on their left and on the right.

This is a short video clip showing this collaterals from Porto vein at Corona nerve vein site.

This, this, this is the geographic appearance of this collaterals here and the stented portal vein without the the structure.

A three day post stent evaluation showing the main portal vein with the stent, a normal flow at post enter portal vein and there's no flow in the coronary vein and ined collaterals.

This is a video clip showing the normal flow at portal vein and no collaterals identified in this case.

Per umbilical vein is another collateral pathway in livers in cirrhotic livers that comes from the left lobe branch of main portal vein.

The hemo plexus and hetero perineal plexus can be identified close to this spleen and the lower pole of the left kidney.

This is the appearance of retroperitoneal collaterals and the appearance of the same case.

In this tomography here, the vessels that goes to the Al Plexus PLE shunt, you can identify the PLE shunt using doppler ultrasound close to the spleen and the left kidney.

As you can see in this picture or using the same approach of tomography and MRI in this case we have the MRI appearance here and the appearance of PLE notion and B mode, gray scale ultrasound and on doppler.

As phasial vais we can identify in some case as phasial vais close to the border, the inferior board of left lobe And close the esophageal.

Here we can identify the varis close to our order and inferior cystic varis.

This is another pathway of collaterals in this patient with STOs we can identify on color doppler this small branches of blood vessels and the comparison with computed tomography.

Here is another case of cystic reis In a patient with liver cirrhosis on gray scale ultrasound and color dolin boot car syndrome.

Budd-Chiari Syndrome

Boot car syndrome involves the PET Q vein or IVC thrombosis.

There are many causes of bary syndrome and melo proliferative disorders are more common in involvement of one.

Many PET Q vein may be as symptomatic.

In some cases the forms luminant, acute seia acute or chronic forms of boot care syndrome thrombosis and fibrosis of the hepatic veins can be partial or complete in one or in all the main hepatic veins.

The velocity and intensity of thrombosis BS define in some cases the severity of symptoms and portal hypertension in these cases is identified by refractory ASEs, hepatic failure and phasial varis acute form of ary syndrome is the highest form on grade scale ultrasound.

We can identify the increase of the coated lobe asci, heterogeneous hepatomegaly and renal failure on color doppler, absence of lobe in the pet veins and IVC In some cases, portal vein thrombosis is a bad prognosis for these patients.

Here is a case of acute good care syndrome in a patient with thrombosis of the right main hepatic vein.

Chronic form is the most frequent presentation.

Complications of portal hypertension determine the prognosis death in 50% of cases in two years.

It's verbal clinical presentation according to the number of vein involved and the development of collateral vessels.

In some cases chronic forms is difficult. The differential diagnosis of cirrhosis, chronic form sonographic findings, Cade lab hypertrophy is identified in 50% of cases and it's also present in patients with cirrhosis.

Increase encoded low vein diameter if greater than three millimeters. It's a sign of boot care syndrome, chronic form of boot care syndrome with sensitivity of 50% and a specificity of 94% reverse flow in the main portal vein and branch due to the obstruction of a pad vein.

The drainage pathway is the main portal vein in this case.

We can identify the reverse flow in the left branch of the main portal vein as you can see on colored doppler and and post doppler in the lower left side.

Here the pet character is heed and The left branch of main portal vein, you can identify the reverse flow.

The iner collaterals is the most sensitive diagnostic sign. It's present in more than 80% of cases.

Doppler and B mode Ultrasound is the first line to diagnosis as osteopathic collaterals are identified by computed tomography and MRI collateral vessels.

Intra collateral vessels are identified in these cases.

As you can see on the right these, the comma collaterals, the hockey stick collaterals and these spiders here in short video clip you can identify some haw stick and comma collateral pathways, some subcapsular collateral pathways close to the border of the living M collateral vessels close to IVC.

In this case, we can identify these vessels close to their their normal hepatic vein and here the collaterals close to the IVC wave, portalize it pattern of blood flow.

In this case we can identify the hypertrophy of coda lobe, different collaterals in the left lobe and this collaterals in the right lobe with color draining to the IVC.

In this case we have the boot car syndrome of the right hepatic vein and the collateral coming from the right lobe to the left lobe.

Here is an example of post-transplant Stenosis of hepatic vein with short inpe shunts from the middle to the left hepatic branch.

As you can identify and color doppler and in the angiography study a short inter protections front middle to the left hepatic branch and here the normal findings of left hetic vein.

Cardiac Liver

Cardiac liver is caused by Pacific congestion of the liver.

We can find homogeneous hepatomegaly dilation of IVC and HEPA veins, ASEs and some in some cases a heterogeneous texture and cirrhosis.

Monophasic flow or monophasic flow can be identified.

This is a case of cardiac liver where we can identify the IVC, the reverse it flow in the main port of vein.

The main pet veins is inpe arterial shunts.

Spontaneous shunt can be identified by B mode ultrasound or doppler color.

In this case we can identify two motions in the left lobe of the liver, this shunt and another one with color double.

Here is another case of an of portal V and its branch identified in B mode ultrasound and color dolin transjugular iner port system shunt evaluation with DO sonography tips is an interventional procedure using a self expanding metallic stent set through transjugular accesss it reduce pressure in the system, decrease complications secondary to hypertension due to the ineffectiveness of other forms of treatment indications.

TIPS Evaluation

Refractory esophageal persis in 10% of cases Refractory ES boot care syndrome and the bridge as a bridge to transplants do sonography is useful for tips before tips to see the patents of portal vein and membrane branches, the EPE veins and IVC, the flow direction of this branch.

Collateral vessels can be identified, use para umbilical vein and left gastric vein asci a PET and anatomical variations.

This is meant the methodology of tips.

Here you can identify the right hepatic vein and here the stent close to the portal vein and the right hepatic vein complications.

The main complications of tips is stenosis, normal parameters postly flow, turbulent flow in the stent.

In some studies increased velocity in the tips from 90 to 190 centimeters per second.

Velocity is similar inside the stent.

An increased velocity in the portal vein in most cases, portal vein branches drain into the stent.

We can identify the stenosis in the promo third in the middle third and the distal third of the stent or the stenosis can be a diffuse.

The importance of deep stenosis is because 30 to 40% of patients are asymptomatic.

DOR is a noninvasive method, can identify the anatomical over variations and can guide the procedure.

There are many parameters of stenosis in the literature.

An increased velocity at the site of the stenosis and increased velocity in OSI velocity.

Continuous flow in the stent.

The velocity in may portal vein less than 30 to 40 centimeters per second.

A decrease of velocity in may port vein and the last gradient inside the stent stenosis at distal third omo hyperplasia turbulent flow at the junction between the stent and ape vein In 70% of cases.

This is an exam, the first exam where we can identify a velocity of main port vein close to 50 centimeters per second, a normal velocity in the promo. Third of tips in the middle third and the distal third of tips in the follow up eight months later and the patients as in symptomatic patients.

We can identify the reduced velocity in the main portal vein and an increase of velocity in distal third of the tips close to 230 centimeters per second.

In the geographic study, we identified stenosis in the distal third of the stent treated by using another stent inside and the first exam after angioplasty, the flow come back to the normal parameter parameters.

The port of vein velocity is close to 40 centimeters per second and similar velocities in the promo median and distal third of the stent close to 200 centimeters per second stenosis of the promo and middle third can cause it by intimal hyperplasia.

Biliary fistulas secondary to state placement and in 24% of cases occurs in the middle. Third few cases in portal extremity, more symptomatic greater instance of bleeding.

This is an example of stenosis of the middle third where we can identify on color doppler and the post doppler. This the place of the stenosis.

Here is the angiographic confirmation of this stenosis treated using angioplasty and another stent inside the tips.

The doppler control after angioplasty identify the ity flow in the middle third promo third and distal third of the tips.

This is a case of stenosis at the portal extremity where I can identify a high velocity in the portal extremity close to 300 centimeters per second.

In our experience, we use as a velocity we inside the tips for stenosis at 230 centimeters per second.

The velocity in portal vein in the main portal vein is normal around 51 centimeters per second and less than 26 centimeters per second is the sign of stenosis.

The gradient, the gradient between two points in base exams vary from 0.5 centimeters per second to 88 centimeters per second and in cases of osis varied from 110 centimeters per second up to 400 centimeters per second.

Contrasted hazard ultrasound in tips here we can identify the appearance of dips in these cases with a normal contrasting enhance ultrasound in normal dips and in cases of we find the stenosis.

This is one case of stenosis in tips.

Low velocity in main portal vein.

The peral flow in the left branch of main portal vein a low velocity at promo third of the tips close to 26 centimeters per second and in the middle third we identified a velocity of 478 centimeters per second on doppler ultrasound in this case using contrasted enhance ultrasound, we identified the tips here and two points of stenosis in the middle and in the distal third of the stent.

As you can see here, and in some cases tips and contrasted headset ultrasound is useful to evaluate the junction between the right main parted vein and the IVC close to the right side of the herd.

In this case, we identified fight a high velocity in the middle third of the tips and the normal appearance using contrast enhanced ultrasound.

In this case we identified using contrast enhanced ultrasound, the IVC tips and the right atic vein.

Conclusion

In conclusion, it's important the knowledge of the hemodynamic aspect and variations based on basic tests and follow up tests using multiple parameters for tips. Evaluation and attention to the absolute values of velocity and geography is reserved for treatment and microbial contrast.

Agents improve sensitivity and specificity.

In some cases the summary suspicion of the pathology, the type of the study to be performed.

We can identify the B mode signs, a careful doer evaluation with special attention to the vascular territory of the interest guide.

Further investigations with MRI, CT or medical decisions.

Okay.