Chapter 27: The Hepatoportal System Flashcards by Billie Harney

an abnormal connection between the hepatic artery and the portal venous system

arterioportal fistula

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an abnormal connection between the hepatic artery and the hepatic vein

arteriosystemic fistula

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an abnormal accumulation of fluid within the peritoneal cavity. It is the most common complication of cirrhosis

ascites

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any nonmalignant venous thrombosis. This term is most often used in the context of malignancy, to differentiate malignant from nonmalignant thrombus

bland thrombus

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hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the IVC and the right atrium, regardless of the cause of obstruction

Budd-Chiari syndrome

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A chronic diffuse degenerative disease in which normal liver cells are damaged and replaced by fibrous connective tissue and regenerating nodules

cirrhosis

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spiraling, swirling, “helix” flow pattern demonstrating hepatopetal, hepatofugal, or simultaneous bidirectional flow; uncommon flow pattern seen in 2% of the population

Helical portal vein flow

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Compensatory mechanism to maintain perfusion to the liver by arterial vasodilation when portal vein flow is obstructed in patients with advanced cirrhosis

hepatic arterial buffer response

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a pleural effusion in patients with liver cirrhosis in the absence of cardiopulmonary disease. The pathophysiology involves the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects

hepatic hydrothorax

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Refers to retrograde flow, away from the liver (physiologically abnormal direction of flow within portal-splenic venous system)

hepatofugal

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Refers to antegrade flow; toward the liver (pathophysiologically normal direction of flow within the portal-splenic venous system)

hepatopetal

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Elevated pressure gradient between the portal vein and IVC or hepatic veins of 10 to 12 mm Hg or greater

portal hypertension

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formation of abnormal blood vessels that shunt portal blood flow bypassing the liver to the systemic circulation, decompressing increased portal venous pressure

portosystemic collaterals

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formerly known as hepatic veno-occlusive disease; is a syndrome of tender hepatomegaly, RUQ pain, jaundice, and ascites; most often occurring in patients in patients undergoing hematopoeitic cell transplantation, and less commonly following radiation therapy to the liver, liver transplantation, and ingestion of alkaloid toxins

sinusoidal obstruction syndrome (SOS)

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a percutaneously created connection within the liver between the hepatic vein and the portal vein that allows blood flow to bypass the liver as a means to reduce portal pressure in patients with complications related to portal hypertension

transjugular intrahepatic portosystemic shunt (TIPS)

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Indications for hepatoportal duplex ultrasound

liver cirrhosis
portal hypertension
thrombus
Budd-Chiari syndrome
Pre/post interventional procedures
abdominal trauma
sudden onset of ascites
patients with a history of abdominal malignancy

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most often joins the portal system at the splenoportal confluence; with portal hypertension, diameter <7mm; can demonstrate hepatofugal flow that often leads to esophageal varices

coronary vein (left gastric vein)

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origin, gastroesophageal junction, lower esophagus, and submucosal region of the gastric fundus; dilated vessels posterior to the left lobe of the liver at the GEJ

gastroesophageal veins

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fetal remnant arising from LPV, coursing along the anterior edge of the falciform ligament to the abdominal wall; connects to systemic veins around the umbilicus “caput medusa”; located in the fissure for the ligamentum teres; diameter >3mm, hepatofugal flow

recanalized paraumbilical vein/abdominal wall

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large tortuous vessels seen in the hilar region of the spleen and left kidney; shunts blood to the left renal vein, terminating in the IVC, decompressing the portal circulation

splenorenal veins

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portosystemic shunt between the cystic vein and the right branch of the portal vein, systemic veins of the anterior abdominal wall, or patent portal vein branches within the liver; dilated pericholecystic vascular channels, 3-8 mm in diameter within or outside the gallbladder wall, demonstrating low-velocity continuous flow

gallbladder varices

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most common imaging technique used to evaluate the liver and its vasculature

duplex sonography

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The hepatic artery supplies approximately ____ of blood to the liver

25%

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carries oxygenated blood through branches in portal triad and enters sinusoids to reach central veins within liver

hepatic artery

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The portal vein supplies approximately ____ of blood to the liver

75%

carries nutrient rich blood from the gastrointestinal tract to the portal triad and enters sinusoids to reach central veins

portal vein

Dual blood supply liver

hepatic artery portal vein

actual beginnings of hepatic venous systems; enter sublobular veins, which unite and converge to form 3 hepatic veins that drain into IVC

central veins

The ______ comprise primary hepatic outflow vessels.

hepatic veins

The portal triad consists of:

branch of hepatic artery branch of portal vein bile duct

begins at junction of splenic vein and superior mesenteric vein

main portal vein

runs along lesser curvature of stomach; drains into portal system near portal splenic confluence

main portal vein

The main portal vein lies ____ to the IVC>

transverse fissure on visceral surface of liver between caudate and quadrate lobes

porta hepatis

At the porta hepatis, the _____ and _____ enter the liver and the _____ leaves the liver.

portal vein hepatic artery hepatic duct

The main portal vein divides into a smaller, more anterior and cranial _____ portal vein and a larger, more posterior and caudal ____ portal vein.

left right

The portal veins branch into ____ and ____ divisions on the left.

medial lateral

The portal veins branch into ____ and _____ divisions on the right.

anterior posterior

The _____ have no valves.

portal veins

composed mostly of loosely arrayed, non parallel connective tissue fibers and minor amount of collagen

main portal vein

composed mostly of tightly packed collagen fibers

hepatic veins

The hepatic veins are ______.

intersegmental

Patient preparation

fast overnight

The _____ branches off the celiac trunk to the right.

hepatic artery

excellent visualization of porta hepatis

right coronal oblique

provides optimal visualization of splenic vein and splenic artery

left coronal oblique

The liver is evaluated for ____, ___, and ____.

size texture surface contour

The normal portal vein diameter during quiet respiration is ___ mm or less.

The portal vein may increase up to __ mm with deep inspiration

Normal portal venous outfloq

hepatopetal; laminar, low-velocity flow with mild respiratory and moderate pulsatile variations

abnormalities associated with helical flow

portosystemic collaterals

Portal vein velocity ____ during inspiration and _____ during expiration

decreases increases

Postprandially, portal vein flow velocity increases __-___%

50-100

Resting PSV in portal vein

16 cm/s

mean flow velocity portal vein

19.6 + 2.6 cm/s

Diameter of the splenic vein measures up to __ mm.

Normal splenic vein flow and direction

antegrade

Splenic vein velocity _____ during inspiration and _____ during expiration

decreases increases

Normal PSV of splenic vein

9-30 cm/s

Normal mean velocity of splenic vein

5 to 12 cm/s

Normal spectral Doppler waveform of splenic vein

respirophasic with slight pulsatility

drains into portal system near portal splenic confluence

left gastric or coronary vein

The left gastric vein measures up to __ mm in diameter

The superior mesenteric vein can measure up to __ mm at the trunk.

Normal flow of SMV

antegrade

Normal PSV of SMV

8 and 40 cm/s

Normal mean velocity of SMV

9 to 18 cm/s

Normal spectral Doppler waveform of SMV

respirophasic with slight pulsatility

SMV velocity ____ during inspiration and ____ during expiration

decreases increases

Postprandial velocity SMV increases __ - ___ %

50-100

Normal diameter of right hepatic vein

less than 6 mm

The hepatic veins normally exhibit pulsatile waveforms with two ____ waves and two ____ waves.

antegrade retrograde

Ventricular systole demonstrates the __-wave

Ventricular diastole demonstrates the __-wave

reflects overfilling of right atrium at end of ventricular systole, resulting in retrograde wave

V-wave

Atrial contraction demonstrates the __-wave

The PSV of the hepatic veins ranges between __ and __ cm/s

22 39

The hepatic artery demonstrates ____ flow.

hepatopetal; monophasic, low-resistance waveform with continuous antegrade flow throughout cardiac cycle

When portal venous perfusion decreases, hepatic arterial flow _____

increases

With food ingestion the portal vein velocity _____

increases

The normal PSV of hepatic artery

70-120 cm/s

The mean velocities of the hepatic artery

20-40 cm/s

The normal resistance index of the hepatic artery

0.55 and 0.7

The IVC demonstrates normal ____ flow

antegrade

proximal Doppler IVC

pulsatile due to effects of right atrial pressure

distal Doppler IVC

respirophasic

Normal PSV IVC

44-118 cm/s

IVC size ranges from __ - ____ mm in diameter

1.5-2.5

The IVC is normally dilated ____ level of obstruction

below

hepatopetal flow rerouted away from the liver through collateral channels to low-pressure systemic vessels

portal hypertension

Normal pressure of IVC and hepatic veins

5 and 10 mm Hg

Portal hypertension should be suspected if the pressure gradient exceeds:

10-12 mm Hg

Most common etiology of portal hypertension

sinusoidal obstruction due to cirrhosis

Most common cause of cirrhosis is

hepatitis C

2nd most common cause of cirrhosis is

alcohol abuse

Primary complication of portal hypertension

gastrointestinal bleeding from ruptured esophageal and gastric varices

3 levels of portal hypertension

prehepatic intrahepatic posthepatic

An enlarged MPV diameter is an indicator of _____

increased portal venous pressure

Most specific finding of portal hypertension

portosystemic collateral

_____ varices are found in 14-60% of patients

splenorenal

_____ and _____ varices are found in 30-35% of patients.

paraumbilical abdominal wall

_____ varices are found in 50% of patients.

gastroesophageal

Most prevalent collateral pathway found in 80-90% of patient.

coronary vein or left gastric vein

hepatic arterial flow increases as a homeostatic mechanism to maintain hepatic perfusion

arterialization (increased hepatic artery flow)

hepatic artery enlargement, increased flow, tortuous "corkscrew" appearance, high-velocity flow

arterialization

abnormal communications between the artery and the vein in which blood flows directly from an artery into a vein bypassing some capillaries

arteriovenous fistulae

Three types of intrahepatic fistulas

portosystemic venous arterioportal arteriosystemic

Portosystemic venous fistula

portal vein to hepatic vein or IVC

arterioportal fistula

hepatic artery to portal vein

arteriosystemic fistula

hepatic artery to hepatic vein

nonsurgical procedure performed to decompress portal venous system for management of uncontrollable variceal bleedingand refractory ascites

TIPS

curvilinear echogenic structure with corrugated borders that course through hepatic parenchyma and extends squarely into both in flowing portal vein and outflowing right hepatic vein

TIPS stent

Normal velocities in TIPS stent

90 - 190 cm/s

Velocites tend to ____ from portal end to hepatic end of stent

incrase

Mean velocity is ___ cm/s at portal venous end of TIPS stent

Mean velocity is ___ cm/s at midportion of TIPS stent

120

Normal spectral waveform in TIPS stent

high velocity turbulent flow and pulsatility; respirophasic

The portal vein velocity may increase ___ to ___ cm/s greater than pre-TIPS velocities

37-47

The hepatic artery may exceed ___ cm/s post TIPS

130

results from flow stasis secondary to cirrhosis and portal hypertension

portal venous thrombosis

sudden onset of ascites, acute abdominal pain, elevated D-dimer

portal venous thrombosis

PVT persists of to 12 months; multiple serpignous vessels can appear within 6 to 20 days after acute occlusion to reestablish portal flow

cavernous transformation

spectrum of hepatic disorders that occur in setting of right-sided heart failure

congestive hepatopathy

increased right atrial pressure creating both antegrade and retrograde componenets

regurgitant portal vein flow

highly pulsatile inverted "W" type pattern; prominent V-wave; diminished S-wave

hepatic vein waveform congestive hepatopathy

results from chronically increased pressure and sinusoidal stasis; causes an accumulation of deoxygenated blood, parenchymal atrophy, necrosis, collagen deposition, fibrosis

congestive hepatopathy

Budd-Chiari syndrome is classified according to:

etiology site of obstruction

results from endoluminal thrombus or webs

primary hepatic vein obstruction

occurs outside of venous system, maliginant tumor infiltration, parasitic mass, extrinsic compression by neighboring mass

secondary hepatic venous flow obstruction

Collaterals that are most frequently seen that drain into unobstructed hepatic veins

accessory hepatic veins caudate lobe veins subcapsular veins portal veins

condition resulting from toxic injury to hepatic sinusoidal endothelial cells, which then undergo necrosis and sloughing, occluding hepatic sinusoids, and terminal hepatic venules

sinusoidal obstruction syndrome

_______ most commonly occurs after hematopoeitic stem cell transplantation

sinusoidal obstruction syndrome

What percentage of blood is supplied to the liver through the portal vein?

75%

What is the transverse fissure on the visceral surface of the liver between the caudate and quadrate lobes?

porta hepatitis

Which of the following describes the portal veins within the liver? a. thin, invisible walls; course between the liver segments b. thin, invisible walls; course within the liver segments c. thick, bright walls; course between the liver segments d. thick, bright walls; course within the liver segments

Which landmark identifies the start of the proper hepatic artery from the common hepatic artery?

gastroduodenal artery

What is the relationship between the main portal vein and the inferior vena cava?

MPV is anterior to the IVC

Which of the following patient positions offers excellent visualization of the porta hepatis? a. transverse epigastric b. transverse right costal c. right coronal oblique d. left coronal oblique

At which location should the portal vein diameter be measured?

where it crosses the inferior vena cava

Which transducer can be useful for assessing the liver surface for nodularity?

7 to 9 MHz linear

What is normal portal vein diameter with quiet respiration?

13 mm or less

Severe liver disease, presence of portosystemic collaterals, and size mismatch between a donor portal vein and native portal vein can all cause what type of flow in the portal vein?

helical

What does an increase in caliber of less than 20% in the splenic vein during deep inspiration indicate?

portal hypertension

Which of the following increases blood flow within the portal, splenic, and superior mesenteric veins? a. inspiration and ingestion of food b. inspiration and exercise c. expiration and exercise d. expiration and ingestion of food

When assessing hepatic vein flow, the S and D waves should show blood flow toward which organ?

heart

What is a normal resistive index in the hepatic artery?

0.5 to 0.7

What is the most common etiology for portal hypertension in North America?

cirrhosis

What is the primary complication of portal hypertension?

gastrointestinal bleeding

Which of the following is NOT a duplex sonographic finding associated with portal hypertension? a. increased portal vein diameter b. decreased or absent respiratory variation in the portal and splenic veins c. hepatopetal flow in the portal and splenic veins d. portosystemic collaterals (varices)

What is the most common portosystemic collateral shunt in the presence of portal hypertension?

splenorenal varices

What type of flow may be seen in the portal vein when an arterioportal fistula is present?

pulsatile hepatofugal flow

Which of the following is a treatment of portal hypertension that involves jugular vein cannulation with stent placement in the liver? a. mesocaval shunt b. splenorenal shunt c. TIPS d. PVTS

Which of the following is NOT a normal finding in a transjugular portosystemic shunt? a. hepatofugal flow in the main portal vein b. velocities within the stent in the range of 90 to 190 cm/s c. hepatofugal flow in intrahepatic portal veins beyond the site of stent connection d. increased flow velocities in the splenic vein

Upon duplex evaluation of the portal system, the vascular technologist visualizes increased portal vein caliber with no detectable flow by color, power, and spectral Doppler. Increased hepatic arterial flow is also documented. What do these findings suggest?

portal vein thrombosis

Besides IVC dilatation, what distinct finding helps differentiate between congestive heart failure and portal hypertension?

increased pulsatility in the hepatic veins only

Which of the following is NOT a sonographic finding in Budd-Chiari syndrome? a. dilatation of the IVC with intraluminal echoes b. pulsatile, phasic flow in nonoccluded portions of the hepatic veins c. enlarged caudate lobe d. ascites and hepatomegaly

Clinical features of sinusoidal obstruction syndrome include all of the following EXCEPT: a. sudden onset of hepatomegaly b. abdominal pain c. weight loss d. fluid retention and ascites

The junction of the splenic and superior mesenteric veins forms the _____

main portal vein

The ____ portal vein branches into anterior and posterior segments, and the _____ portal vein branches into medial and lateral segments.

right left

Hepatic veins _____ in size as the approach the diaphragm.

increase

The patient and transducer position that provides optimal visualization of the splenic vein and artery is the ______/

left coronal oblique

Using a lower frequency transducer with a smaller footprint is more effective in obtaining acoustic windows using the ____ approach.

intercostal

In patients with portal hypertension, congestive heart failure, constrictive pericarditis, and portal vein thrombosis, portal vein diameters can be expected to ______

increase

Portal vein flow is normally _____ in direction with constant antegrade flow throughout the cardiac cycle.

hepatopetal

Patients with tricuspid regurgitation, right-sided congestive heart failure, or arteriovenous fistulas may present with ____ flow in the portal vein.

helical

Both the ____ and _____ veins demonstrate monophasic flow with slight pulsatility that is directed toward the liver.

splenic superior mesenteric

Hepatic veins exhibit ____ waveforms that correspond to cyclic pressure changes within the heart.

pulsatile

With ingestion of food, portal vein flow velocities _____, whereas hepatic artery velocities _____.

increase diminish

Patient size, right atrial pressure, and fluid overload or heart failure affect IVC _____.

diameter

Portal hypertension becomes significant when the pressure gradient between the portal vein and IVC exceeds _____

10-12 mm Hg

Until recently, the most common cause of cirrhosis was alcohol abuse, however, _____ infection now accounts for a larger percentage of cases.

hepatitis c

Cirrhosis would be considered a(n) ____ cause of portal hypertension.

common

Sonographic findings of portal hypertension can include portal vein diameter greater than __ mm and ______ flow in the portal vein.

16 hepatofugal

The most specific finding of portal hypertension is the detection of ______

portosystemic collateral veins

Color duplex imaging findings of an enlarged hepatic artery with high-velocity, turbulent flow, and a tortuous "corkscrew" appearance is referred to as ______

arterialization

Penetrating trauma, iatrogenic trauma due to liver biopsy, transhepatic cholangiography, and transhepatic catheterization of the bile ducts or portal veins may create a(n) _______ which may cause life-threatening portal hypertension

arterioportal fistulaAn

An abnormal connections between the portal vein and the hepatic vein is termed as _______, which can lead to an increased pulsatility in the portal vein waveform

portosystemic venous fistula

A TIPS is typically placed to the management of uncontrollable _____ and refractory ascites.

variceal

If portal vein thrombosis persists without lysis, development of periportal collateral veins increases and is known as ______

cavernous transformation

A spectrum of hepatic disorders that occurs in the setting of right-sided heart failure and causes an accumulation of deoxygenated blood, parenchymal atrophy, necrosis, collagen deposition, and ultimately fibrosis is termed ______

congestive hepatopathy

Malignant tumor infiltration, parasitic mass, or extrinsic compression from a neighboring mass can result in _____ hepatic venous outflow obstruction./

secondary

A patient with fatigue, abdominal swelling, and signs and symptoms of portal hypertension but with patency of the large hepatic and portal veins would likely be diagnosed with ______

sinusoidal obstruction syndrome

Chapter 27: The Hepatoportal System Flashcards

(183 cards)