The British Journal of Radiology, 75 (2002), 919929

2002 The British Institute of Radiology

Pictorial review

Colour Doppler ultrasound ow patterns in the portal venous system

C GORG, MD, J RIERA-KNORRENSCHILD, MD and J DIETRICH, MD
Department of Internal Medicine, Philipps-University, Baldingerstrae, 35043 Marburg, Germany

Abstract. Doppler ultrasound is a well established method for assessment of the portal venous system to detect the direction of portal blood ow. It is helpful for non-invasive diagnosis of intra-abdominal portosystemic shunts, especially in patients with cirrhosis. Less attention has been paid to other inuences on portal venous ow, e.g. tricuspid regurgitation, increased hepatic out-ow resistence, respiratory cycle. The aim of this pictorial review is to describe the spectrum of physiological and pathological Doppler ultrasound ow patterns in the portal venous system.

Several physiological and pathological Doppler ultrasound ow patterns of the portal vein and/or its branches are known (Table 1). Principal determinants of portal venous pulsatility may include retrograde trans-sinusoidal transmission of atrial pulsation [1], the respiratory cycle [2] and transmission of vena caval, hepatic arterial or splanchnic arterial pulsations [2].

Pathological ow patterns
Different pathological ow patterns of portal venous blood ow exist (Table 1). A marked pulsatile hepatopetal or hepatofugal ow in the portal vein and/or its branches is seen under pathological conditions, tricuspid regurgitation, increased hepatic outow resistance, liver diseases. Pulsatile ow in the portal vein has predominantly been found in patients with severe right heart failure (Figure 4), demonstrating right atrial pressure negatively correlated with portal vein pulsatility ratio [6]. All patients with hepatofugal pulsatile ow were in the New York Heart Association (NYHA) Class III or IV [6]. A pulsatile hepatopetal ow was found more often in patients with NYHA Class I or II [6]. Pathophysiologically tricuspid regurgitation is the predominantly suggested cause for the duplex Doppler ultrasound phenomena of pulsatile portal vein ow [7].

Physiological ow pattern
In healthy adults, portal venous ow has been described as being continuous hepatopetal on Doppler ultrasound [3] (Figure 1). Minimal variations caused by respiration and cardiac cycle are evident (Figure 2). Two different scoring systems for quantication of portal venous modulation have been used. Portal vein pulsatility is characterized by the ratio between minimum and peak portal vein velocities [4]. A pulsatility ratio .0.54 was found in over 90% of normal individuals [5]. The venous pulsatility index [(maximum frequency shift2minimum frequency shift)/maximum frequency shift] was 0.480.31 (meanstandard deviation) in healthy adults [2]. Recently, even marked pulsatile hepatopetal ow of the portal vein has been described, particularly in thin subjects with a venous pulsatility index of .0.5 (Figure 3), with an inverse correlation to body mass [2]. Decreased pulsatility has been observed when the patient is sitting and during deep inspiration, and in obese subjects [1]. It has been suggested that abdominal pressure is the common factor affecting portal vein pulsatility in these subjects [2].
Received 29 November 2001 and in revised form 2 April 2002, accepted 9 May 2002. The British Journal of Radiology, November 2002

Table 1. Doppler ultrasound ow patterns in the portal venous system Physiological ow pattern Continuous hepatopetal ow Pulsatile hepatopetal ow Pathological ow pattern Pulsatile hepatopetal or hepatofugal ow in the portal vein and/or its branches Respiratory dependent hepatofugal ow in the portal vein and/or its branches Continuous hepatofugal ow in the portal vein trunk Continuous hepatofugal ow in branches of the portal vein Stagnant or venous 0 ow

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Additionally, portal veinhepatic vein stula [8] and portocaval shunts may cause pulsatile portal ow [9]. Recently it has been assumed that severe pulmonary hypertension is responsible for a second pathophysiological mechanism that may induce hepatopetal or hepatofugal pulsatile portal vein ow, irrespective of degree of tricuspid regurgitation [10, 11]. In cases with constrictive pericarditis (Figure 5) and mediastinal haematoma (Figure 6), pericardial cyst, pericardial effusion (Figure 7) or right atrial tumour (Figure 8), the high right atrial pressure is presumably responsible for a pressure-related hepatic venous out-ow block with subsequent trans-sinusoidal hepatoportal shunting, similar to the mechanical outow block that causes reversed pulsatile ow in liver cirrhosis (Figure 9) [12]. In patients with chronic hepatitis C, marked pulsatility in the portal vein has been associated with inammation but not with other parameters of the histological activity index or intrahepatic fat deposition [13]. A less well understood mechanism for reversed portal ow leads to hepatofugal ow in the portal vein and/or its branches. It is well known that the respiratory cycle modulates portal venous ow via intra-abdominal pressure (Figure 10) [1, 2]. High abdominal pressure during deep inspiration may cause reversal ow in patients with severe right heart failure or liver disease (Figure 11) and may be seen only in peripheral branches of the portal venous system (Figure 12). Under certain circumstances, even in patients with the absence of cardiac and liver disease a short time reversed portal vein ow can be seen during deep inspiration using color Doppler ultrasound (Figure 13). It is generaly accepted that colour Doppler ultrasound enables the detection of the presence and direction of blood ow in the portal venous system. Continuous hepatofugal ow in the portal vein trunk is found with an overall prevalence of 8.3% in patients with liver cirrhosis [14] (Figure 14). Prevalence did not differ in relation to the aetiology of liver cirrhosis. However, reversed ow was found more often in patients classied as Childs B and C cirrhosis than those classied as Childs A cirrhosis [14]. Reversed portal venous blood ow develops when the intrahepatic resistance is greater than the resistance of portosystemic collaterals. It is likely that the increase of intrahepatic resistance owing to structural abnormalities, i.e. hepatic vein sclerosis, Disse space collagenization and hepatocyte enlargement, plays the predominant role in the developement of reversed portal ow [15]. A possible association has been found between abnormal ow direction and the presence of oesophageal varices, ascites and spontaneous portosystemic shunts, with the strongest association
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being with shunts [16]. Analysis of the direction of ow in the portal vein is therefore strongly warranted in assessing portal hypertension. Various haemodynamic patterns with reversed ow do exist (Figures 15 and 16). The clinical signicance of this Doppler phenomenon is still unclear, but it may play a protective role against future risk of bleeding [14]. Additionally, continuous reversed portal ow has been described in iatrogenic portosystemic shunts (Figure 17), BuddChiari syndrome [17] (Figure 18), cavernous transformation of the main portal vein (Figure 19) and veno-occlusive liver disease after bone marrow transplantation [18]. Continuous hepatofugal ow in branches of the portal vein is a specic sign for portal hypertension [16]. Portosystemic collateral blood vessels develop from pre-existing small portal vessels and may lead to portosystemic shunting [14]. Depending on collateral size and amount of blood drainage from the portal venous system, hepatofugal portal venous ow may be found in the portal venous trunk, sections of the portal venous systems or only in small portal venous branches, e.g. left gastric vein (Figure 20, Figure 21) [19]. A stagnant or venous 0 ow may occur in cirrhotic patients. Very slow velocities (less than 2 cm s21) cannot be detected because the Doppler signal is lower than the threshold of the equipment receiver [6] (Figure 22). Additional respiratory modulation can be observed (Figure 23). There is some evidence that ultrasound contrast enhancement is useful for assessment of blood ow direction with regard to the discrimination on stagnant or venous 0 ow [20].

Figure 1. Doppler ultrasound of the portal vein with a continuous hepatopetal ow in a healthy adult. The British Journal of Radiology, November 2002

Pictorial review: Portal venous ow patterns

Figure 2. Doppler ultrasound of the portal vein with minimal pulsatile modulation of the portal ow in a healthy adult.

Figure 3. Doppler ultrasound of the portal vein with marked pulsatile modulation of the portal ow in a thin, healthy adult.

Figure 4. Colour Doppler ultrasound of the hepatic vein and portal vein in a patient with heart failure, New York Heart Association Calss III and tricuspid regurgitation (left), having a triphasic ow in the hepatic vein (middle) and a marked pulsatile ow of the portal vein (right).

Figure 5. Colour Doppler ultrasound in a patient with constrictive pericarditis (arrows) (left). A triphasic ow is seen in the hepatic vein (middle) and pulsatile ow in the portal vein (right). RV, right ventricle. The British Journal of Radiology, November 2002 921

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Figure 6. Colour Doppler ultrasound of the hepatic vein and portal vein in a patient with mediastinal haematoma. A triphasic ow is seen in the hepatic vein (left) and a pulsatile ow with a reversed component of the portal vein (right).

Figure 7. Colour Doppler ultrasound in a patient with pericardial effusion (left), and triphasic ow in the liver vein (middle) and pulsatile ow in the portal vein (right).

Figure 8. Colour Doppler ultrasound in a patient with primary cardial lymphoma with a tumour in the right atrium (left), triphasic ow in the hepatic vein (middle) and pulsatile ow in the portal vein (right). 922 The British Journal of Radiology, November 2002

Pictorial review: Portal venous ow patterns

Figure 9. Colour Doppler ultrasound of the hepatic vein (LV) and portal vein (VP) in a patient with liver cirrhosis having a monophasic ow in the hepatic vein (left) and a marked pulsatile ow of the portal vein (right).

Figure 10. Colour Doppler ultrasound of the portal vein (left and middle) in a patient with heart failure, New York Heart Association Calss III, having a marked pulsatile ow with reversed ow during deep inspiration (arrows) (right).

Figure 11. Doppler ultrasound in a patient with a pericardial effusion (PE) (left) and a pulsatile ow in the portal vein with a short reversed ow during deep inspiration (arrow) (right). RV, right ventricle; LV, left ventricle. The British Journal of Radiology, November 2002 923

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Figure 12. Colour Doppler ultrasound of the splenic vein (left and middle) in a patient with liver cirrhosis, oesophageal varices and ascites. Arrows indicate ow direction. A marked pulsatile ow was seen in the portal venous system with reversed ow in the hilar splenic vein during deep inspiration (arrow, right).

Figure 13. Colour Doppler ultrasound of the portal vein (left and middle) in a patient 1 week post-gastrectomy. Arrows indicate ow direction. During normal inspiration (arrow A) a breath dependent reversed ow was seen (right).

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Pictorial review: Portal venous ow patterns

(a)

(b)
Figure 14. (a) Colour Doppler ultrasound of the portal venous system in a patient with alcoholic fatty liver cirrhosis and continuous hepatofugal ow in the portal vein (the arrows indicate ow direction). (b) The same patient had hepatofugal ow in the mesenteric vein (left) and regular hepatopetal ow in the splenic vein (right). Arrows indicate ow direction.

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Figure 15. Four different haemodynamic ow patterns of continuous ow in the portal vein, the splenic vein and the mesenteric vein (Gaiani S, et al. 1991 [14]). (a) Isolated reversed ow in the mesenteric vein. (b) Isolated reversed ow in the splenic vein. (c) Reversed ow in the portal vein and the splenic vein. (d) Reversed ow in the portal vein and the mesenteric vein.

(a)

(b)
Figure 16. (a) Colour Doppler ultrasound of the portal venous system in a patient with liver cirrhosis and continuous hepatofugal ow in the portal vein (left) and hepatopetal ow in the mesenteric vein (VMS) (right). Arrows indicate ow direction. (b) The same patient had reversed ow in the splenic vein (left). The splenic vein (VL) drained into a large perirenal collateral. Arrows indicate ow direction. 926 The British Journal of Radiology, November 2002

Pictorial review: Portal venous ow patterns

Figure 17. Colour Doppler ultrasound of the portal vein in a patient with liver cirrhosis and a transjugular intrahepatic portosystemic shunt (TIPS) (left). In the umbilical segment of the portal vein a reversed ow was seen (right). Arrows indicate ow direction.

Figure 18. Colour Doppler ultrasound of the portal vein in a patient with breast cancer, diffuse metastative disease of the liver and occlusion of the hepa-tic veins (Budd-Chiari syndrome) (arrows left). In the portal vein a reversed ow was seen (middle, right). Arrows indicate ow direction. VC, vena cava.

Figure 19. Colour Doppler ultrasound in a patient with cavernous transformation of the portal vein (left) having reversed ow in the splenic vein (middle) and a large perisplenic collateral (right). Arrows indicate ow direction. P, pancreas; Co, conuens. The British Journal of Radiology, November 2002 927

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Figure 20. Colour Doppler ultrasound in a patient with liver cirrhosis and portal hypertension and reversed ow in the left gastric vein (VCV). VP, portal vein.

Figure 21. Colour Doppler ultrasound of the spleen in a patient with liver cirrhosis. Trans-splenic vessels were seen (middle) with a hepatofugal venous ow (right). Arrows indicate ow direction.

Figure 22. Colour Doppler ultrasound of the portal vein in a patient with fatty liver cirrhosis and a 0 ow in the portal vein (VP).

Figure 23. Colour Doppler ultrasound in a patient with alcoholic fatty liver cirrhosis with a hepatopetal ow during expiration (left) an a venous 0 ow in the portal vein during inspiration (right). 928 The British Journal of Radiology, November 2002

Pictorial review: Portal venous ow patterns

Conclusion
Color Doppler ultrasound of the portal vein and its branches shows a wide spectrum of different ow patterns. In patients with liver cirrhosis, assessment of the direction of portal ow is helpful for diagnosis of portal hypertension. Various other conditions, such as cardial and respiratory cycles, may inuence portal venous ow.

References
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