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Adv. Vas. Son.
Test 3 Abdominal Doppler Liver (Hepatoportal)
| Question | Answer |
|---|---|
| What is the most common imaging technique used to eval portal & hepatic venous systems? | Duplex ultrasound- used to determine presence of flow, direction, velocity, & in characterizing flow hemodynamics |
| What is Duplex useful in detecting? | Intraluminal thrombus, Hepatofugal flow, Collateral circulation, Absent flow, ↑ed or ↓ed flow in both portal hepatic venous systems |
| The liver receives ___ blood supply? | Dual |
| Hepatic Artery facts: | Supplies approximately 30% of incoming blood, Source of oxygenated blood into the liver |
| Portal Vein facts: | Supplies remaining 70% of incoming blood, Carries nutrient rich blood from gastrointestinal tract |
| Three Hepatic Veins facts: | Right, Middle, and Left, Hepatic veins drain into IVC, Primary hepatic outflow vessels |
| Main Portal Vein facts: | Begins at junction of splenic vein and SMV, Courses cephalad toward porta hepatis, Lies anterior to the IVC, Divides into left & right portal veins |
| What is the Porta Hepatis? | Largest area of the Portal Vein, On the surface of the liver where portal vein and hepatic artery enter and hepatic duct leaves |
| The Portal Vein contains no what? | No valves |
| What will Portal Veins look like? | Bright, echogenic walls due to thick collagenous tissue |
| Left Portal Vein facts: | Smaller, more anterior branch, Branches into medial and lateral divisions |
| Right Portal Vein facts: | Larger, more posterior branch, Branches into anterior and posterior branches |
| Hepatic Veins facts: | Anatomically separate from portal venous system, Thin-walled vessels, ↑ in size as they go near diaphragm, Drain into IVC near RA, Right hepatic vein usually largest, Middle & Left often join to form common trunk before entering IVC |
| Hepatic Artery facts: | Branch of celiac artery, Branches course with portal veins throughout the liver, Hepatic artery lies anteromedial to portal vein |
| How long should PT fast prior to this exam? | 8-12 hrs prior to exam , also no smoking or chewing gum |
| Indications for this exam: | Liver cirrhosis, Portal HTN, Ascities, Portal Vein Thrombosis, HX abdominal malignancy, Pre/Postintervention, Abdominal trauma, Budd-Chiari syndrome, Thrombosis of other veins |
| Why is the Right Coronal Oblique PT position useful? | Uses intercostal approach; liver as window, PT may be LPO or LLD positions, Provides excellent visualization of porta hepatis, Improves Doppler angles, ↓s anterior position distance |
| Why is the Transverse Epigastric PT position useful? | TD placed over left lobe of liver, Provide visualization of hepatic venous confluence, W/ Caudal angle, left portal vein can be seen w/ accompanying hepatic artery, Further caudal angulation will result in detection of splenic vein & portal confluence |
| When is Main Portal Vein diameter measured? | During quiet respiration as it crosses the IVC |
| Where should Spectral Doppler waveforms be obtained from? | Main, Right & Left portal Vs, Right, Middle & Left hepatic Vs, Splenic V, SMV, IVC, Hepatic A |
| TD pitfall with this exam: | TD freqs between 2-4 MHz typically used; high freqs may be used in children or thin PTs |
| Other pitfalls with this exam: | Imaging parameters such as depth, field of view, FR, & flow sensitivity are important (constant adjustment often necessary), Exam often needs experienced tech |
| Exam limitations include: | PT obesity, Diffuse liver disease, Ascities, Bowel gas, Severe abdominal pain, Breathing interference, & combative PTs |
| Portal Vein NORMAL findings: | Bright, echogenic walls, Diameter w/ quiet respiration normally ≤ 13mm, Flow normally directed toward liver, Slight variation in flow vel due to ♥ activity & respiration; mostly continuous, low vel flow, Mean Flow Vel ~15-18 cm/s (peak from 10-30 cm/s) |
| What does Hepatopetal mean? | Toward liver |
| Portal Vein NORMAL CHANGES include: | ↑ in diameter w/ deep inspiration, Flow & velocity ↑ w/ expiration & ingestion of food (post-prandially flow velocity ↑s) |
| Hepatic Veins facts: | Thin walls, less reflective than portal Vs, Smaller vein diameters, Normal flow is Triphasic w/ both antegrade &retrograde components (corresponds to pressure changes in ♥), Color will be red & blue due to pulsatility, Peak vels range from 22-39 cm/s |
| With Hepatic veins Normal respiratory variations can augment __________? | Waveforms with inspiration |
| The Valsalva Maneuver can diminish what? | Waveform pulsatility |
| Left and Middle hepatic veins join before the IVC in what % of individuals? | 96% |
| Hepatic Veins enlarge as they ________ ___ __________? | Approach the diaphragm |
| Where are these vessels best imaged? | In TRV plane subcostally |
| What does hepatofugal mean? | Away from liver |
| What is NORMAL hepatic vein flow? | Hepatofugal, Pulsatile, due to RA pressure changes, Respiratory variation |
| Hepatic Artery facts: | Smaller diameter than portal vein, Flow is hepatopetal, Spectral Doppler waveforms demonstrate low-res flow w/ antegrade flow throughout entire ♥ cycle, Hepatic A flow ↓s when portal flow ↑s (&vice versa), PSV in hepatic A from 70-120 cm/s, RI btw 0.5&0.7 |
| What is termed Hepatic Buffer response? | Hepatic Artery flow decreases when portal dlow increases ( and vice versa) |
| Portal HTN the most common cause in North America is due to what? | Obstruction due to cirrhosis |
| Cirrhosis causes distortion of normal liver architecture does what? | Distorts vascular channels which increases resistance to portal venous flow |
| What are the primary causes of cirrhosis? | Hepatitis C, and Alcohol abuse |
| Portal HTN etiology Pre-hepatic: | Thrombosis of portal vein or splenic vein, Extrinsic compression of portal vein |
| Portal HTN etiology Intra-hepatic: | Cirrhosis, hepatic fibrosis, lymphoma |
| Portal HTN etiology Post-hepatic: | IVC obstruction, hepatic vein obstruction, hepatic artery stenosis, CHF |
| Portal HTN technique: | Measure Portal V. diameter (>13mm=BAD), For ALL Doppler use low PRF & wall filter, Assess Portal V vel & direction, Eval Portal V & branches for thrombus, Measure the spleen: enlarged? (>13 cm=BAD) |
| Portal HTN can lead to: | Ascites, Splenomegaly, GI- esophageal varices & bleeding (primary complication), Jaundice, Signs of hepatic failure |
| Portosystemic Collateral anatomy: | Detection of varices is the most specific finding of portal HTN |
| What are the commonly seen collaterals with portal HTN? | Paraumbilical vein (recanalized w/ hepatofugal flow), Coronary vein (Lt gastric vein), Gastroesophageal veins, Splenorenal vein |
| What is a Portosystemic shunt? | Collateral pathways when flow cannot pass through and out of the liver |
| Lt gastric vein AKA coronary vein facts: | Retrograde flow occurs in this vessel in 80-90% of PH, ↑ed pressure in this vein may cause esophageal varices |
| Where do gastric varices occur? | Near the stomach (epigastrum), Under the left lobe of the liver, and near the spleen |
| Recannalized paraumbilical vein facts: | Heptofugal flow (away) |
| What do hepatopetal & hepatofugal describe? | Flow direction the portal veins and tributaries. "Petal" is TOWARDS as one would "pedal" a bike forward; "Fugal" is AWAY as a "fugitive" runs away |
| Splenorenal shunt facts: | Splenic vein to left renal vein |
| What does arterialization do? | ↑s in portal venous pressure cause a ↓ in portal vein flow, ↓ed portal vein flow results in ↑ed hepatic artery flow, Hepatic artery becomes enlarged, shows ↑ed flow, & becomes tortuous (corkscrew appearance)-color shows turbulent flow |
| What is the treatment of Portal HTN? | Techniques to decompress the portal venous system |
| What is TIPS? | A stent connecting the portal vein to the hepatic vein, Typically right portal vein connected to the right hepatic vein, Placed via jugular vein into liver |
| How does TIPS work? | Blood is rerouted away from the liver out through the stent into the hepatic vein and back to the heart (does not connect the cause of portal HTN) |
| What does TIPS stand for? | Transjugular Intrahepatic Portosystemic Shunt |
| Where should velocities be recorded for TIPS? | Main Portal Vein, Portal Vein end of shunt, Mid shunt, Hepatic vein end of shunt, IVC or outflow vein |
| TIPS direction of flow should what? | Be noted w/in shunt & adjacent portal veins, splenic vein, & SMV (Flow should be toward shunt) |
| Should color fill the shunt? | Yes |
| What is the normal stent velocities range? | 90-190 cm/s |
| Main portal vein and hepatic artery velocities increase with what? | The presence of the shunt |
| TIPS occlusion should be suggested when? | In echogenic material visualized within stent (no flow detected with spectral and color doppler) |
| When doing a TIPS exam all system settings should be optimized to detect what? | LOW flow states |
| TIPS ABNORMAL findings include: | Change in direction of flow w/in portal veins, Retro flow w/in the outflow hepatic vein, Vel <50 cm/s w/in stent, Vel <30 cms in main portal vein, Focal ↑ in stent vel >200cm/s, ↑or↓ in vel of >50cm/s w/in same portion of stent as compared to prior exam |
| Other TIPS ABNORMAL findings: | Vel gradient >50cm/s from one portion of the stent to another, Recurrent ascites, varices or splenomegaly |
| Portal vein Thrombosis can be caused by: | Stasis secondary to cirrhosis & portal HTN, Inflammatory process, Hypercoagulable states, Surgical intervention, Abdominal malignancy, Sepsis, Trauma |
| Portal Vein Thrombosis clinical findings include: | Acure abdominal pain, sudden onset of ascites, Elevated D-dimer |
| Obstruction can be caused by: | True thrombus or by intravasular tumor |
| What is the intravascular tumor associated with? | Hepatocelluar carcinoma or pancreatic carcinoma |
| CHF causes? | Edema of the liver secondary to vascular congestion, ↑ed right ♥ pressures will impact portal and heptic waveforms (Portal vein flow becomes markedly pulsatile, Hepatic vein waveforms demonstrated highly pulsatile "W"-type pattern), IVC also dilated |
| What is Budd-Chiari Syndrome? | Obstruction of hepatic venous outflow due to thrombus or tumor invasion |
| Clincal features of Budd-Chiari Syndrome? | Right upper quadrant pain, Jaundice, Ascites, Hepatomegaly, Splenomegaly, Liver funtion abnormalities |
| Budd-Chiari Syndrome causes include: | Cirrhosis, Hypercoagulable disorders, Use of Birth control pills, Abdominal trauma, Tumor invasion (extrinsic compression), Hepatomegaly or Splenomegaly, IVC or Hepatic vein occlusion or stenosis (thrombus) |
| Sonographic findings of Budd-Chiari Syndrome: | Dilation of IVC w/ intraluminal echoes, Dil. of hepatic veins w/intraluminal echoes, Stenosis of occlusion of the hepatic veins & IVC, Absence of hepatic vein & IVC flow, Ascites/Hepatomegaly, Splenomegaly, Portosystemic collaterals |
| Another sonographic finding with Budd-Chiari Syndrome is? | Continuous, turbulent and reversed flow in the non-occluded portions of hepatic veins and IVC |
Created by:
EmilyGriffin
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