Ultrasound Imaging of Portal Hypertension - HD

Introduction to Portal Hypertension

I am Myron Nyk from the University of Wisconsin and Madison.

Today we're gonna talk about portal hypertension.

We'll review the basics of liver disease,

how cirrhosis affects blood flow into the liver,

and then we'll go through abdominal varis

and how they, where they are

and how they can complicate life for a surgeon.

We're going to review the normal doppler flow profiles.

We'll talk about hemodynamic changes of portal hypertension,

and then we'll go through varice.

Normal Doppler Flow Profiles

Just a brief review, hepatic artery portal vein next

to each other in the port of hepatic.

That's the flow coming into the liver.

And then the outflow is at the opposite end

of the liver via the hepatic veins.

Hepatic artery should have a nice brisk up stroke,

consistently a diastolic velocity

of about 0.2 meters per second,

and a normal, relatively low resistive index

of about 60 to 70%.

The portal vein, relatively uniform velocity,

not too much periodicity,

and a velocity of about 0.2 meters per second.

The portal flow really doesn't go

very quickly through the liver.

It just percolates through the pressure gradient

between the portal venous system,

and the right atrium is relatively small,

so the velocities are not all that great.

The liver vascular index is a comparison

of portal vein velocity and end diastolic velocity.

These two velocities should be relatively similar.

That's normal, and you can do it as a side

by side tracing like this,

or the big gulp, as I call it, where you open wide

and capture both tracings in the same image.

So the hepatic veins,

typically there are three four within a centimeter

of the right atrium.

There are a few accessories like the accessory,

right hepatic or the caudate veins.

These little guys that punch

directly into the inferior vena cava in the central part

of the liver and drain the caudate lobe.

That's why it behaves differently in cirrhosis.

That's why you get CAU eight hypertrophy.

But the periodicity,

hepatic vein waveform should have, one step

or two steps forward, one step back.

This is the normal phasic waveform,

and it is due to the atrial contraction,

causing a brief reversal of flow known as the A wave and,

and then flow surging forward into the empty right atrium.

During the s component of the flow, it's slowing,

and then the tricuspid valve opening

and then flow surging forward again into the ventricle.

That's the D wave. Basically two steps forward.

One step back, again, I like to use the term periodicity

for velocity variations.

On the hepatic venous side, when you take somebody's pulse,

you put your finger on their artery.

So I reserve pulsatility for arterial velocity variations,

periodicity for venous velocity variations,

and then ity for changes in velocity that are due

to inspiration expiration for expiratory variations.

Alright, the normal liver gets about 25% of cardiac output,

a liter and a half a flow per minute portal vein two-thirds

by volume artery only one third,

but artery provides 90% of oxygen to the liver.

Hemodynamic Changes in Liver Disease

When you have liver disease,

the artery supplies the disease process.

The, the disease process doesn't want portal venous blood.

It's got no oxygen. The nutrients are in the artery.

The portal venous blood is basically, it's coming

to the liver to be processed by the hepatocytes.

So when you get liver disease, velocity start to change,

hepatic arteries go up to supply the disease process.

Portal venous velocities go down

because the, that blood has a harder

time getting into the liver.

And then you have this disparity in the liver

vascular index typically portal the,

the end diastolic arterial flow is greater

than portal flow.

Now, this is unfortunately nonspecific.

There's a lot written about this in the Japanese literature,

and very early on, they were eager to see that it was

sensitive for the diagnosis of hepatocellular carcinoma.

Well, unfortunately, it turns out it's not very specific.

Anything can cause this, including hepatitis from any

of these, insults, tumors like lymphoma

or metastatic disease can do it.

It's really non-specific.

Now, I got one quick comment about compensatory flow.

I've seen authors, discuss this

increase in arterial flow as compensatory relative

to portal venous, velocity decrease.

And it, that's really not an accurate, concept.

The hepatic artery, it's supplying the disease process.

There's, if there's tumor, there's neovascular,

whether are arterial venous shunting.

If there's an inflammatory disease, there's hyperemia.

And so the artery, which supplies the disease process,

the flow surges forward in that artery.

The portal vein, on the other hand,

it's simply bringing blood to the liver to be processed.

If the liver becomes diseased, it's not going to be

as acceptant

of the flow coming into the liver via the portal vein.

You know, if there's tumor there, it's simply replacing

that liver and the sinusoids don't even exist

for this portal flow to come in.

And so those velocities go down.

Utility of the Liver Vascular Index

Okay, so is this index useful?

Well, how often have you imaged a liver?

And you've seen this, you see this starry sky liver

where the, porta hepa, fat, the, the, the,

the little portal triads stand out brightly against

the background of a liver.

And you, you'd think this is so

because it's an emitts liver, therefore it's disease,

but you're not certain, you don't know,

maybe the liver enzymes,

you don't have those available to you.

So do you make the call or not?

Well, I would encourage you to get a doppler tracing

and then see what that liver vascular index is.

If it is altered, then make the call, you know,

say this looks like an EMS liver,

and then maybe the clinician will draw liver enzymes.

Maybe they'll consider some other, studies.

Find out why that liver looks the way it does.

Nomenclature: Hepatopetal vs. Hepatofugal

Now, I have, I have one bone to pick,

and that is on nomenclature.

The flow that is going into the liver is normally

hepato petal with a t.

It is not hepato petal, it has nothing to do with your feet.

Alright? This is a, this is, you know,

people make this mistake all the time.

The verse flow is hepato ugal,

and the analogy is centrifugal force versus

centripetal force.

Alright? That's spelled with a T.

So if you forget, maybe

that's a good way to remind yourself.

Do not call it hepato. Alright?

Portal Vein Flow Reversal and Severity of Liver Disease

The degree of,

of main portal vein flow reversal correlates

with the severity of the liver disease.

As the liver disease gets worse and worse, it shuts down

and portal velocities will decrease to zero

and then start to, increasingly reverses the disease process gets worse.

That patient who has that perfect degree of liver disease,

so that their portal flow is relatively stagnant, is easy

to make a mistake and call it thro boast.

Now, I've got a little trick for you to avoid that,

and that is to have the patient do a Valsalva maneuver.

Okay? What, what's gonna happen here?

Well, when you tell the patient to bear down

and take, take in a deep breath

and bear down, what they do is they elevate

intrathoracic pressure, okay?

That elevates the right atrial pressure that then

transmits to the inferior venous cave in the hepatic veins.

It resists hepatic venous outflow.

And that extra resistance

of outflow may take stagnant flow

and turn it into hepato ugal flow.

You then tell the patient to blow it out

and relax as we did here.

And 10 seconds later, now the flow is going into the liver,

it's surging forward.

Why? Because that intrathoracic pressure dropped briskly.

All that resistance on the hepatic venous side went away.

And all of this extra pressure that built here

is now flowing through the liver.

And so this is not,

patient whose liver disease just spontaneously worsened in,

in, in front of our eyes.

This is the result of this Valsalva maneuver,

and it helps you to avoid the pitfall

of calling something thrombo if the flow is really thready.

Abnormal Portal Vein Flow Tracings

What do you think of this portal vein flow tracing?

Okay, that's what it should be like.

It, a little bit of periodicity is okay,

but this thing is like a roller coaster.

It's really speeding up, slowing down. Why?

Well, it has to do with

capillary permeability, okay?

If you have a disease diffusely diseased liver,

then the capillary bed becomes more permeable

and that arterial systolic diastolic pressure variation can

bleed over onto the portal venous inflow side

and create this velocity variation.

Or perhaps the patient simply has a big internal arterial

venous fistula,

and so that may be causing that velocity variation.

But there's another phenomenon that can do this

to the patient, and that's the patient who has

hepa a cardiac disease.

Perhaps the patient has tricuspid regurgitation.

So remember, when the right ventricle contracts,

it contracts with a massive amount

of force compared to the atrium.

And if the tricuspid valve allows that pressure wave

to blast

through into the inferior vena caven back up the liver,

it will significantly resist that portal vein inflow

and add to that periodicity.

So here you go. This is a patient, with, a hepatitis and they have a very leaky capillary bed.

And you can see on this tracing,

which incorporates both hepatic artery in the portal vein,

that that hepatic arterial inflow, systolic blast

coincides precisely with the reversed component,

or at least the slowed component of portal vein inflow.

So the pressurizing of the liver

during hepatic arterial systole resists portal venous

inflow, okay?

It's a little trickier to do with the cardiac issues

because portal vein is on one side of the liver,

the hepatic veins are on the other side,

so you kind of have to infer that.

But, you know, if you see a patient

with an inferior vena cava that that's distended

and these big hepatic veins, I always pay attention

and get a doppler tracing

because that may be your first tip off.

This, this patient may have some severe cardiac disease.

Look at the hepatic vein waveform. Is this normal?

Not in the least, you know, we do not have

that two steps forward.

One step back, look, instead we've got one step forward

and a big step backwards.

Okay? So maybe this person has

tricuspid regurgitation.

Whenever you see this kind of a waveform, even if you're,

you know, you're not trained in cardiac, imaging,

cardiac doppler, you can tell there's something wrong

and get this patient started on the course

of an appropriate workup for cardiac disease.

It's a useful finding.

So this is, this is the, portal vein tracing in this person.

And, and right here, these dips in portal vein velocities,

although I can't get them on the same tracing

because we're so far apart

between the pate veins and portal vein.

You can, you're rest assured that at this point

during the cardiac cycle is when this reversal

of flow occurred.

Basics of Portal Hypertension

So, normal portal pressure relatively low

with portal hypertension, it rises, it rises

because the blood has a hard time getting through the liver

and it can get up to 30 millimeter millimeters of mercury.

Normal portal gradient, less than six millimeters of mercury

above that, that defines portal hypertension.

But really it's clinically silent until it gets

above about 12 millimeters of mercury above 12.

Then we start seeing clinical evidence

of portal hypertension.

Hopefully we can catch it

before the patient develops those varis.

Portal Triad and Flow Resistance

So the portal triad is a combination of the bile duct,

the portal vein, and the hepatic artery.

And these go into the liver side by side.

Here we are deeper into the liver, this nice nutter drawing.

And you can see bile duct portal vein, hepatic artery,

and you know, these are three tubular structures.

So there's a little space between them and the mother.

Nature puts a little bit of fat there just

to fill up the space, and that's why you have that bright,

port of HEPA appearance in an emus liver.

So as these further branches

and goes into the liver, you get these very, tiny little vessels.

And these cos between the sinusoids of the liver,

the sinusoids are these little hexagonal shape, tiles.

And the blood from the portal vein will come out

and then percolate across this cellular matrix until it gets

to the central venue of the sinusoid.

And from there, this will then go on to the hepatic veins.

So this is where the business of the liver occurs, the,

this little cellular network here.

And so portal flow trickles across and goes to the vein.

Now, when you have portal hypertension, you have resistance

to this flow,

and it can be pre sinusoidal, it can occur in the branches

of the portal vein even before the blood has a chance

to get into the, cells.

It can be sinusoidal, it can be

because of disease of the cellular matrix of the liver,

or it can be post sinusoidal.

It can actually be an obstruction of the vein outflow. Okay?

Causes of Portal Hypertension

So the pre sinus soil, it's usually due

to either portal vein obstruction, maybe a clot,

maybe there's an anterior portal fistula that's

outside the liver,

or intrahepatic causes that like fibrosis,

Wilson's disease sarcoid or parasites.

This, this will actually plug up the portal veins

before the flow even has a chance to get out of the,

the portal vein sinusoidal disease.

That unfortunately is what we see the most of the Lan X.

Those are the alcoholics,

and then hepatitis from whatever reason.

And then these livers end up, looking like this.

This is the very gnarly looking cirrhotic liver.

The surface of it's called the hob nail boot liver.

Vincent Van Gogh painted that, that's, you know,

way back, that's how they used to get traction.

They used to put these little hob

nails into the sole of a shoe.

And, and that's this surface.

That's what the reminded, people of.

So then when you have hepatic venous outflow obstruction,

that's known as the Bud Keri syndrome.

And most people, when you say Bud Keri syndrome,

they immediately think of thrombosis.

Well, it's correct, but that's only part of the syndrome.

Anything that causes hepatic venous outflow obstruction

is bud Kiri syndrome.

And that can be due to cardiac disease.

I already showed you one case

with a tricuspid regurgitation.

It can even be pulmonary disease.

Anything that prevents flow from getting out

of the liver into the heart will give you blood bud kiri

physiology and will affect portal, hepatic venous outflow and

therefore create, portal hypertension.

Presentation of Hepatic Cellular Disease

So the hepatic cellular disease presentation

depends on its severity.

First thing you typically see is

mildly elevated liver enzymes.

Perhaps they get worse. And more often than not,

somebody will say, well, let's get an ultrasound.

Okay, liver enzymes are up.

Let's see, let's see if there's anything there.

And so we will image the liver, we will look

to see if there's anything structurally abnormal,

but I'll tell you, you don't often see much.

You can have hepatocellular dysfunction,

have a perfectly normal looking liver by, by ultrasound.

But I would encourage you in that situation to look

with doppler because doppler

and those changes in portal vein inflow velocity

and the increasing hepatic arterial flow, it'll happen way

before you're going to see any true imaging appearance.

So if you have liver disease, that hepatic artery revs up,

those velocities are gonna start going up as that

supplies the liver disease.

And then if it gets bad enough,

you're gonna start seeing a slowing of portal venous flow

or maybe even reversal imaging

alone isn't gonna tell you that.

Source of Reversed Portal Blood

Now, here's a question for you. Reverse portal blood.

Where's it coming from? What is giving us that?

I mean, this blood has to come from somewhere, alright?

It's coming from the hepatic artery

because as the liver disease gets so worse, the,

even the hepatic artery has a hard time getting its flow to

that central vein.

And what's the path of least resistance?

Well, it's that portal vein that's sitting right next to it

and the flow shunts right across into that portal vein.

And the result is hepato ugal flow.

Imaging Portal Hypertension

So interventionalists,

were imaging portal hypertension a long time.

Here go, here's an SMA arteriogram portal venous phase,

and you can see big engorged portal vein attenuated

intrahepatic branches,

and then all of these guys, what is all of this?

These are varice, this is the stomach,

the spleen's already been removed from this patient.

And these are varice in the stomach wall.

And notice how right here,

there's a real big cluster of them.

This is where they become the esophageal varice.

This is where the blood flow,

which is likely reversed in this portal vein will come into

this area, into these vessels,

then up the esophagus into the aus vein to the return

of the systemic circulation.

Portal Systemic Shunts

Now, there are multiple portal systemic pathways.

Netter very nicely drew the portal circulatory system.

Right here are the short gastric veins.

They are between the upper portion of the spleen

and the greater curvature of the stomach.

On this side of the stomach, we have the left gastric

or the coronary vein.

This drains the lesser curvature.

This drains the greater curvature.

But when you have portal hypertension,

these veins reverse flow

and end up going up these little guys that are in the wall

of the esophagus

and up to the asus vein to the systemic circulation.

So this is a portal systemic shunt.

All of us in utero had an umbilical vein after we're born.

It withered away. Never put the umbilicus over here

just for convenience.

But, the, um, withered umbilical vein.

Nevertheless, a little remnants still remains.

And in about 20% of patients

who develop portal hypertension,

they'll actually recanalize it

or develop a little para umbilical vein.

And so that flow from the portal venous system continues up

in the portal vein of the liver.

But it all goes into the left portal vein

and down this shunt to the belly button.

And from there, back to the systemic circulation, pleo,

renal varis are in the left flank.

And these are typically communications between the blood

and the splenic vein and the renal vein.

And I will tell you, these are never direct communications

unless a surgeon created it.

Most often, they're very convoluted

and they'll take up a component of mesenteric vasculature,

maybe the retroperitoneal vasculature.

Oftentimes they will find the left gonadal vein.

In the research we've done, it's amazing how often

sp renal varis will find the left gonadal vein.

And then there are hemorrhoidal varis there down here, next to the rectum because you know, you gotta, it's

systemic circulation just outside

and then portal circulation here.

But that's a pretty rare, portal hypertension varix.

Importance of Identifying Varices for Surgery

So why should we bother looking at these things?

Well, several reasons.

Number one, if a surgeon's gonna operate this patient,

it really is beneficial for them to know

where these varis are.

Varis are very thin walled vessels.

They are veins, so they're thin walled to start with.

And then they are over distended.

So they're thinned out even more.

So if you're a surgeon and you are operating

and you stumble one in one of these things, they're hard

to get control of.

'cause as you start to tie 'em off or, or compress them or

or clamp them, they tear, they're,

they're just horrible at tearing.

And so surgeons will do anything they can

to avoid stumbling into a varie bed.

It helps a lot in planting transplant surgery.

They need to stay away from these guys.

And then it also helps in, taking care

of the portal pressures

before the patient actually goes to surgery.

Now, most

of these liver transplant candidates, they'll have a tips.

They'll have a shunt placed

to decompress the portal venous system to have these

varis shrivel up.

And in addition, these varis will be coiled.

So for the next part of this talk,

we'll we'll bring in a little bit of CT

and maybe a little Mr.

I'm gonna show you, the course of these varis

because it's important for us to understand them.

The unfortunate thing with ultrasound is, we're kind

of looking through a little keyhole.

You can only see a little bit of the anatomy at the time.

And these varis, they go from diaphragm to pelvis,

from the left side of the body

to the right, they're all over the place.

So let me just kind of show you where they run.

So you, you know where to look for them.

Visualizing Varices with CT 3D Angiograms

So we're gonna be doing, some CT 3D angiograms here,

and I'm gonna do it the old way with shaded surface display.

So after a ct, we get the whole torso data set.

We use some electronic scalpel, electronic thresholding

to get rid of the real, light stuff.

Then we create a bone, model.

We subtract that away,

then we use a little more electronic scalloping to get rid

of a few other structures,

and we're left with the venous system.

We can then split that up, color it, different colors

for the various components,

and then put that back together again.

I threw the spleen back in here.

We'll throw it back into the body.

So, so what do we got here?

We have the portal vein right here is the SMV,

this is the splenic vein.

This is the inferior vena cava.

And then here, this guy,

this is a big inferior mesenteric vein,

varix going down towards the pelvis.

And then see that yellow thing

that is the left gonadal vein coming up into the renal vein

into the IVC.

So this is a portal systemic shunt.

Very nice for the surgeons to know where they are.

We can throw a little bone in there

so you get the big picture because they want

to avoid these things.

Short Gastric Varices

Okay, left flank longitudinal diaphragms here.

That's the spleen. Here's the stomach

with a little fluid in there.

What are these things? Turn a little color on.

These are blood vessels, right?

These are short gastric varis.

They're typically north of the splenic vascular pedicle

because they are going up towards the GE junction.

And then from there up the esophagus.

So on a 3D model, here they are, there are typically a bunch

of little small vessels.

The stomach is living in here.

There's the spleen splenic vein here.

They are north of the splenic vein.

And I'm, I've always seen them in conjunction

with the left gastric vein.

It's very rare for them to be isolated.

Here's another patient. Same thing. There's the spleen.

These vessel, splenic, vascular pedicle is right here.

These things are heading north

and combined with the left gastric flow, going up

to the GE junction, there's the diaphragm.

You can see the varice right here.

They're very tortuous and convoluted.

That's the pedicle, that's the splenic vascular pedicle.

All of these things are heading north towards the asus vein.

Left Gastric Varix

The left gastric varix, it typically, it's one large vein,

it'll eventually start to branch out.

It heads off from here

or the coronary vein, it heads north towards the same area

and it shunts blood away from the portal system.

This is what it looks like on ultrasound

behind the left lobe of the liver.

Now this is a problem

because this is already a liver transplant recipient.

This was like the fourth

or fifth one we ever did at the University of Wisconsin.

It was a long time ago, but this liver was not doing well.

And the surgeon sent the patients to us

to rule out hepatic artery thrombosis.

That's what they always tell us, right?

Well, hepatic artery was fine,

but what we found

to everybody's surprise was this big left gastric varix

with a lot of blood flow in 'em.

Here's the angiogram that that followed.

SMA arteriogram portal venous phase.

So there is blood flow in this portal vein,

but not very much.

Look at the concentration

of contrast here in this varix versus this liver.

So this massive varix was not

ligated at the time of surgery.

And all the portal venous flow, instead of going

through the liver is short circuiting.

It is bypassing the liver

and heading right to the systemic circulation.

I mean, blood is stupid.

It's just gonna go against the path of least resistance.

Why should it percolate

through the liver when it can just easily flow right

through this varix?

So this is an unfortunate case.

You know, we identified the syndrome because of that.

And now these varis are ligated

or embolized prior to the patient going on

for their transplant surgery on a three t

reconstruction.

This is what they look like.

Superior mesenteric vein, splenic vein,

portal vein, nothing.

There's no branches of the portal vein in the liver

because all the flow is just shunting up this

massive varix man.

You can see eventually these things bifurcate up

and they're going right along the esophagus

and in the esophageal wall there,

see there's gas in the lumen of the esophagus right there.

And then a big variceal plexus.

Here's another patient, same thing.

Very impressive collateral plexus endoscopists can see them.

This is the esophagus, that's the probe.

And all these little, red circles right under them,

those are the varis within the esophageal wall.

Now, if you have one of these, this is bad.

These are the varis that bleed.

These patients bleed to death.

They're, it's, it's, it's very messy.

I remember I was once in the intensive care unit when a

patient came in with esophageal variceal bleed.

There was blood everywhere. It was really a mess.

And, and the patient didn't make it, unfortunately.

So the left gastric varix behind the left lobe of the liver,

typically in a longitudinal orientation, you know,

here's the cava, there's the left gastric varix.

So if you wanna find the left gastric varix, you go

through the left lobe of the liver.

If you find the short gastric varis, you go

through the spleen or where the spleen used to be.

Midline longitudinal image,

tubular structure heading outta the liver,

going south with flow in it.

There's another patient, same thing.

Recanalized Umbilical or Paraumbilical Vein

This is the rec canalized umbilical vein

or the para umbilical vein.

Okay? So spl spi, mesenteric splenic portal vein,

right branch left flows gumming down.

So the blood flow, it wants to go up these veins, it wants

to get into the liver, but it can't look at that liver.

It's just cirrhotic. And so the flow goes left

and then right down the umbilical vein down towards the

um, umbilicus.

Now it stays deep to the rectus sheath, right?

That's where the umbilical vein ran.

So it's behind that muscle sheath.

From there, it can go in one

of several different directions.

We're not back to the systemic circulation yet.

So in, the classical teaching is

that these patients will develop a capi Medusa.

This is a, a statue I found on a trip in Rome.

This was I think in the Vatican.

And it's the Medusa, it's the Greek goddess.

And she had snakes in her hair. All right?

So this is the most classic cap at Medusa I've ever

seen in a patient.

These blood vessels have blood in them that a couple

of minutes ago was flowing through the gut,

went up the portal vein, tried to get in the liver,

it couldn't, it came down to the umbilicus

and then it flows via these branches in the body wall.

And then from here, see right there, it disappears.

It's punching through the body wall, going

to find the external iliac vein

and from there back to the systemic circulation.

But to be honest with these are pretty rare.

You don't see cap medusa that often.

You know, here's another one.

Here's the CT angio to go with it.

And here's the clinical image of, you can see these worms

just deep under the skin in the body.

While that's that paraumbilical vein, it got to the porta,

to the, um, umbilicus in there.

You can see these, okay?

But those are rare in most patients.

That umbilical vein will continue on

via an inferior epigastric vein.

And from there down to the external iliac vein,

and that way back to the systemic circulation, probably 80%

of patients with a para umbilical will have this.

A lot of these people will also have flow

that tries to go north.

It goes up into the substernal region.

These are small components,

but nevertheless, they can exist.

Look at this one. So this one chose the right

inferior epigastric vein.

It's impressive left portal vein right there out

of the liver, down the body wall, all the way to the ex.

Extra, down the external I into the external

iliac vein right there.

Here's the, inferior epigastric on the other side.

That's what the normal size of it should look like.

And even in this patient too,

notice there's a little substernal branch heading north

towards the, just finding another pathway back

to the systemic circulation.

Now, unusual things can happen at the umbilicus.

Remember this, this vessel cod out

of the body wall normally.

So for it to find the inferior epigastric,

usually there's a little twist or two.

Sometimes it's deep and sometimes it could be superficial.

This was a prisoner. He had umbilical hernia.

And so they got the CT scan

to analyze the hernia prior to taking it to surgery.

What's this? That's the falsa format.

It looks a little prominent, right?

Here's this thing going down.

Well, there's his hernia

and there was some pacified bowel in that neighborhood.

So we got asked to look at this with ultrasound.

So here's his portal vein,

left branch going right into this umbilical vein portal,

venous flow profile right down the anterior abdominal

wall to the umbilicus.

And from there it went out under the skin. What happened?

Well, is this a surprise to anybody?

No, because that's the way the umbilicus went, right?

It went out to the placenta.

So it left the body at that point.

And in a fair percentage of these patients,

they will have a little knuckle of, of the varix

that projects outside of the rectus sheath

and a little bit of a cap at Medusa trying to form here.

In this person I got called

to the intensive care unit in this portal, hypertensive.

They were trying to figure out what this was,

and they were asking me if I would biopsy this.

Let me give you a little advice. Do not biopsy this.

This is, this is the ultimate Audi, right?

This is a patient who has portal hypertension.

Here's this 3D CT with this little variceal knuckle

that is external to the skin.

So this person, you know, he's in risk

of exsanguination, don't deal with it.

These things can be quite big and quite prominent.

And, we had this patient,

we were gonna do a paracentesis and I couldn't help myself.

So remember what I told you about a Valsalva maneuver

and increasing the pressure in the portal venous system.

That's what happened when I told him to bear down.

He's resisting venous return.

And so the whole portal venous system just engorged up

that quickly and this thing became more prominent.

Varices Complicating Surgical Approaches

Varices can complicate the surgical approach

to underlying pathology.

Alright, I'm in a liver transplant program.

I see a lot of these patients

and you may say to yourself, this isn't important to me.

I'm not gonna be seeing these people.

Well, you know, guess what?

You will, because they're out there.

They may not be sick enough

to be in a liver transplant center,

but there's no reason that, you know, just patient

with mild liver disease may not have varice.

Here's the perfect case.

So a 52-year-old female presented to her hospital

with left lower quadrant pain.

She happened to be a doctor's wife.

She had fever, elevated white count.

And the clinician acutely said,

diagnosed diverticulitis.

Okay? So he said to her, we need to do a, a,

maybe a CT scan or a barman.

She says, no, no, no, I

don't want to go through all of that.

So he called me up

and he said, would you mind looking with ultrasound?

Just tell me if she's got a big

diverticular mass down there.

What he failed to tell me, she also had liver disease.

She was a two martini lunch kind of a gal.

And she liked her wine with dinner.

There was a past history of portal hypertension,

but she, she, she apparently was behaving herself.

Alright, so here's this ultrasound

of the left lower quadrant.

And here within the circle you can clearly see this

big ugly mess.

There's some air bubbles in it.

This is a big diverticular process.

Part of it's probably an abscess. You know, it wasn't easy.

It, it wasn't a hard diagnosis at all.

But what's this, what is this structure

that's got all this color in it right over the top

of this diverticular mess?

Well, I showed you this patient earlier.

This is this woman that had the large rec canalized

umbilical vein going down to the inferior epigastric.

This is where her abscesses, guess

where the surgeon would have had to cut if they were going

to be approaching this diverticular abscess

right through that varix.

So when we, when we found this, when we told them,

the surgeons were extremely grateful to us,

this patient went on to get antibiotics to cool off

for diverticulitis.

She got a tips, this got embolized,

and then a month later she had her surgery to rid her of

that diverticular mess.

If we had not identified this

and pointed this out, surgery would've been a lot bloodier.

So we made a big impact.

Gallbladder Varices

Varices can sometimes go through the gallbladder wall

and everyone that I've seen in my career has always been

associated with portal vein thrombosis.

So here's this person. He had this,

he had hepatocellular carcinoma

and it was growing into his portal vein.

He had his recre canalized umbilical vein down here,

epigastric right to the external iliac.

But what's more important is

what was going on in his gallbladder wall.

You see these little whiskers over here.

When we looked at it with ultrasound,

you found these tubular structures in the gallbladder wall.

When we turned on our color, there was flow in them.

This was not cystic artery.

This is part of the portal venous system.

It was venous flow profile. Here's a latex cast.

These are varice in the gallbladder wall.

Here's another example, okay?

And there's the, here's a good CT to go with it.

If you look at this, there's a cavernoma here.

This portal vein was thrombose.

And here in the gallbladder wall you can see this

large varix.

So a nice example of a gallbladder varix with an associated

sequela of thrombosis.

Splenorenal Collaterals

Splinter renal collaterals can be enormous.

They're out there in the left side of the body

between the spleen and the kidney.

And they go all over the place.

They're huge tubular structures.

There's the kidney, there's the spleen,

there's the left renal vein right there

with just a huge amount of flow going back

to the systemic circulation.

And these varis are huge. They're all over the place.

Typically they're heading down into the mesentery

and they very often involve that gonadal vein.

So here's the 3D rendering flow coming down into the pelvis,

finding the left gonadal vein,

left renal vein up the inferior vena cava.

Another one big complex mass of vessels coming down,

finding the gonadal vein up.

Left renal vein back to the systemic circulation.

This is the most direct one I've seen

between renal vein and splenic vein.

And it too very convoluted course.

So if you're going to be looking with doppler

and you're gonna be looking for varice

'cause you got reverse flow in the portal vein, look out

around the spleen, look out around the left kidney.

You'll be amazed what you find.

Remember this one I showed you earlier? Same thing.

It's instead of SMV, it's finding the IMV down

to the plexus down to the pelvis.

How about this one? This one took the SMV down

to the right lower quadrant

and it too found a gonadal vein back

to the inferior vena cava.

This was a wild one.

This is a, a, a left gastric varix

that never really made it to the esophagus.

It took a turn

and came down the left adrenal vein to the left renal vein

and back to the systemic circulation.

Varis can be really wild.

Here's one that's taken this, it's probably the IMV

and it's going down to the

paraumbilical region.

And from there, back to the systemic circulation,

here's A IVC direct

or a uh, SMV shunt that goes directly

to the inferior vena cava.

It found a lumbar vein. Get the picture.

These things can be anywhere.

Varices in Pelvic Ultrasound

Alright, so you're doing a pelvic ultrasound

'cause a woman has a palpable mass in the adnexa

and they think it could be ovarian cancer.

Big ugly mass multicystic ovarian cancer, not

after you turn on the color.

This is another one of these large

variceal plexus all the way down into the pelvis.

And finally, here's two nice CTA examples of

a hemorrhoidal variceal plexus.

You can see that it comes down, from the IMV

and into this large plexus behind the bladder.

I'm not going to do transrectal ultrasound

to find these things, but just be aware they do exist.

New Tools for Identifying Portal Flow

There's some other new tools to help us identify portal flow

and portal circulation.

This is a tool called PC Viper.

It's an MR based tool that's developed at the,

university of Wisconsin.

It can very nicely show, portal flow

and identify, portal varice in the big picture.

And the nice thing is it doesn't, require radiation.

Here you can see,

this patient had portal vein thrombosis.

There's no flow in that segment.

Flow from the spleen is leaving spleen,

but it's going south in the superior mesenteric vein.

I don't know where it's gonna find some

collateral communication.

And interestingly,

the left portal vein flow is hepato ugal, right?

Portal vein flow is hepato peel.

Cavernous Transformation of the Portal Vein

Alright, just a few other custodial items.

This is the region of the, portal vein.

What do you think of this, appearance?

This is a cavernoma, it's cavernous transformation

of the portal vein after thrombosis in,

in these patients, they re collateralize flow,

but it's never one robust vessel.

It's typically a lot of little small ones.

And you see all these little, serpiginous structures.

Here's another example of one.

And, typically they will have just multiple,

multiple little vessels cosing through this region.

And, they can penetrate a,

a fair distance into the liver.

Notice this left, branch really extends, out there

that that cavernoma extends well

into the left lobe of the liver.

Helical Flow in the Portal Vein

So just don't be surprised when you're looking

with your doppler, flow in the,

portal vein can sometimes be seen to be helical.

And this Mr very nicely shows us why it is not a

manifestation of any kind of pathology.

It's simply how the fluid stream from the SMV

and the splenic vein converge within the portal vein.

Instead of fusing in parallel, they,

they spin around each other.

Tumor Thrombus in the Portal Vein

All right, what do you think of this portal vein?

Here it is, it's, kind of a two,

but it's very echogenic, right?

And so there's thrombus within this,

but what kind of thrombus?

It could be bland thrombus, right?

Well, we threw a little color on there

and all of a sudden we're seeing color within it.

So what do we have to consider?

We have to consider tumor thrombus.

And when you look, this is blue.

So the direction of flow is actually away from

the transducer.

And that makes sense

because the tumor originates in the liver.

And as it grows out, it's going to bring the neovascular

with it in a downward direction.

And then what'll finally clinch it,

if you get a spectral tracing

and you find an arterial waveform in the portal vein,

that's tumor thrombus being supplied by the hepatic artery.

Conclusion

So in conclusion,

varial pathway pathways can be just about anywhere.

If you see reversed flow in the portal vein,

take a little effort

and search around the body to try and find these things.

They are critical in the pre-transplant patient.

It's important to identify them so

that they can be thrombo.

It'll increase the likelihood of success

of the liver transplant.

And even if you're not in a transplant program,

you could really make, a surgeon happy

by identifying these

because an unsuspected varix can just ruin

a good surgeon's day.

The capi Medusa, it's a rare finding.

It's only present in a small percentage of patients

with the rec canalized paraumbilical vein.

When you have a cystic mass in the pelvis, don't forget

to turn on a Doppler.

It's a useful tool. It it, it's a piece of the puzzle.

It helps us make diagnoses, but you have to use it.

Thank you.