用超声多普勒对门脉高压症及门奇断流术后门脉系统血液动力学的观察

本文应用超声多普勒复合装置观察了门脉高压症病人门奇断流术前后的血液动力学。结果显示,门脉高压症病人门静脉血流量明显增多,脾循环处于高动力状态,对门脉高压形成有重要作用。门脉高压症病人脾、肠血流间存在能互相代偿的关系,脾、肠血流量之和大于门静脉血流量,说明门静脉有自发性分流存在。门奇断流术后,门静脉血流量减少约25％,肠系膜上静脉流量增加约60％。断流术后门静脉压较术前无明显变化。     

Comparison between ultrasonographic signs and the degree of portal hypertension in patients with cirrhosis

The sensitivity of ultrasonography (US) for the diagnosis of portal hypertension was assessed in 48 patients with known cirrhosis. These results were compared to the hemodynamic values obtained on the same day by hepatic vein catheterization. The sensitivity of US in detecting portal hypertension was about 40% considering either a > 13 mm diameter of the portal vein, or the lack of mild caliber variation of the superior mesenteric vein. The sensitivity was more than 80% considering the presence of portosystemic venous collaterals. Presence of numerous portosystemic shunts was significantly associated with high hepatic venous pressure gradients which reflected the severity of portal hypertension.     

门静脉超声显象测量的临床意义再探讨

本文观察了176例肝硬变患者门静脉直径与门静脉压力，食管静脉曲张，消化道出血的关系，发现肝硬变患者门静脉直径显著增大，但与门静脉压力并不呈直线相关；门静脉直径与食管静脉曲张率和曲张程度呈正相关，一消化道出血率呈正相关，作者认为门静脉超声显象测量有助于诊断门静脉高压症和估计食管静脉曲张情况，并可作为预测消化道出血危险性，筛选手术患者的有用指标之一。     

Effects of a meal on normal and hypertensive portal venous system: A quantitative ultrasonographic assessment

A prospective sonographic study was undertaken in ageand sex-matched normal subjects and patients with portal hypertension to evaluate the effects of a meal on the portal venous system. Postprandial increase in portal vessel diameters was proved to be statistically significant in normal individuals, with mean variations of 27.9% (16–60%), 46.5% (25–83%), and 45.2% (20–75%), respectively, for portal, splenic, and superior mesenteric veins. In contrast, this effect was insignificant in the hypertensive portal venous system. A diminished meal-related caliber variation in portal, splenic, and mesenteric veins less than 16%, 25%, and 20%, respectively, could be diagnostic of portal hypertension.     

Ultrasonographic diagnosis of portal vein cavernous transformation in children

The aim of this work was to evaluate the efficiency, sensitivity, and specificity of ultrasonographic findings in the diagnosis of portal vein cavernous transformation and secondary splanchnic hypertension in children. Twenty patients with esophageal varices on endoscopic sclerotherapy, with ages ranging from 1 to 15 years (mean of 7.5), were compared with 20 age-matched normal asymptomatic controls. In 17 cases, diagnosis was confirmed by splenoportography. Ultrasonographic portal vein features, respiratory variations in splenic and superior mesenteric veins, lesser omentum to aorta diameter ratio and spleen size, as well as the presence of vessels in the lesser omentum and of spontaneous anastomoses, were analyzed in both groups. The efficiency of ultrasonography to establish a diagnosis of portal vein cavernous transformation reached 100%. Splenic and superior mesenteric vein respiratory variation was negligible in patients and inspiration versus expiration diameter differences ranged from 1 to 4 mm (mean of 2.4) in controls (p less than .001). Mean lesser omentum to aorta ratio was 2.07 in patients versus .9 in controls (p less than .001). Splenomegaly was found in all but two cases; lesser omentum vessels were visualized in nine cases; whereas five presented spontaneous splenorenal anastomoses and gallbladder varices were observed in five patients. Thus, ultrasonography allowed portal vein cavernous transformation to be diagnosed throughout; portal hypertension was also detected. It may be concluded that ultrasonography, either alone or associated with endoscopy, provides a reliable method for portal vein cavernous transformation diagnosis. Angiography should be reserved for preoperative or controlled hemodynamic studies.     

Color Doppler sonographic evaluation of spontaneous portosystemic shunts and inversion of portal venous flow in patients with cirrhosis

PURPOSE: The aim of the study was to evaluate the usefulness of color Doppler sonography in the detection of spontaneous portosystemic shunts and abnormal blood flow direction in the portal vein in patients with cirrhosis. METHODS: Patients were 67 men and 42 women (mean age, 53 +/- 14 years) with cirrhosis confirmed by liver biopsy. All patients underwent abdominal gray-scale and color Doppler sonographic evaluations to detect the presence of spontaneous portosystemic shunts and to analyze portal vein blood flow direction. RESULTS: Spontaneous portosystemic shunts were found in 41 patients (38%), most often as splenorenal shunts (21%) and patent umbilical veins (14%). Less frequent were gastric collaterals, gallbladder varices, collaterals to thrombotic portal veins, mesoiliac shunts, and portorenal shunts to the right kidney. The presence of shunts was associated with that of esophageal varices (p < 0.01), ascites (p < 0.01), and inversion of portal flow (p < 0. 001) but not with splenomegaly. The direction of portal venous flow was normal (hepatopetal) in 80 patients (73%), hepatofugal in 10 (9%), and bidirectional in 7 (6%); 12 patients (11%) had partial portal vein thrombosis. CONCLUSIONS: Portosystemic shunts and the direction of portal venous flow are important features in the sonographic diagnosis of portal hypertension.     

Role of contrast-enhanced 3D magnetic resonance portography in evaluating portal venous system compared with color Doppler ultrasonography

Aim The purpose of this study was to evaluate the capability of contrast-enhanced three-dimensional (3D) MR portography in detecting abnormal findings associated with the portal venous system compared with the results of color Doppler ultrasonography (CDUS). Materials and methods MR portography findings were retrospectively compared with the results of CDUS examinations in 161 patients, who were suspected of having portal venous system abnormalities. Portal venous vessels were divided into main 5 groups including the main portal vein, its left and right intrahepatic branches, splenic vein and superior mesenteric vein. Imaging findings were classified as normal, occluded, or partially thrombosed. Results of clinical and imaging follow-up examinations including CDUS, MR portography or angiography, if available, were used as a proof of final diagnosis. The potential sites of varicose veins and collateral vessels were also examined by both imaging methods. Results Vascular abnormalities were identified in 79 of 161 patients. There was a statistically significant agreement between the results of MR portography and CDUS in evaluating portal venous system (κ = 0.871, P < 0.05). The sensitivity of MR portography was slightly superior to CDUS in detecting partially thrombosis and occlusion in the main portal venous vessels. In addition, MR portograms were superior to CDUS in the management of patients with portal hypertension by identifying portosystemic collaterals more adequately, and clearly demonstrated portal venous vessels that cannot be visualized at CDUS. Conclusion Results of present study indicates that contrast-enhanced 3D MR portography is well suited and superior to CDUS in the management of patients with portal hypertension.     

彩色多普勒超声对肝硬化门静脉高压症脾动脉栓塞术前后脾脏及脾静脉血流动力学变化的研究

目的： 观察肝硬化门静脉高压症患者行脾动脉栓塞术前后脾脏及脾静脉血流动力学变化。方法： 栓塞术前后对 １２ 例患者采用彩色多普勒超声检查进行观察。结果： 脾动脉栓塞后脾静脉、门静脉管径缩小 （Ｐ＜ ０．０１）。脾静脉、门静脉平均血流速度降低 （Ｐ＜ ０．０５）, 血流量明显减少 （Ｐ＜ ０．０１）。栓塞前后脾静脉流速与门静脉主干流速比值及脾静脉与门静脉主干流量比值比较无明显差异 （Ｐ＞ ０．０５）。从而证实在肝硬化门静脉高压形成后, 脾静脉血流量增加是门静脉高压时门静脉血流量增加的重要因素。结论：脾动脉栓塞术是缓解脾循环高动力状态间接降低部分门静脉压力的有效方法之一。远期疗效有待进一步观察。     

胰源性区域性门静脉高压的MRI表现

目的：探讨胰源性区域性门静脉高压（PSPH）的MR特点及临床意义。方法收集2005年5月～2012年12月73例PSPH患者的MRI图像,包括T1 WI双回波序列,轴位T2 WI压脂序列及轴位和冠状位多期动态增强扫描序列（LAVA）,分析原发病灶、脾静脉及侧支循环的MR表现。结果73例PSPH均表现为脾静脉狭窄、闭塞、中断。（1）胃冠状静脉（GCV）入口未受累的52例中,胃冠状静脉迂曲扩张43例、胃短静脉（GSV）扩张52例、胃网膜静脉（GEV）扩张52例、胃结肠干（GCT）迂曲扩张30例,食管静（esophageal vein,EV）迂曲扩张2例,脾静脉-（左）肾静脉交通支3例;（2）胃冠状静脉入口受累的21例病例中,胃冠状静脉、胃短静脉、胃网膜静脉及胃结肠干均迂曲扩张,食管静脉迂曲扩张16例,脾静脉-（左）肾静脉交通支19例。结论 MR可显示胰腺原发病灶及其相关的胰源性门静脉高压的侧支循环特点。     

门静脉高压症介入治疗前后血流动力学变化分析

目的探讨肝炎后门静脉高压症的多重介入治疗方法的可行性.方法分析22例部分脾动脉栓塞术和12例行经颈内静脉肝内门体分流术并胃冠状静脉栓塞术患者的彩色多普勒检查资料.结果经颈内静脉肝内门体分流术并胃冠状静脉栓塞术后脾静脉、门静脉管径缩小(P<0.05),门静脉、脾静脉流速流量明显增加,呈高动力状态.部分脾动脉栓塞术后脾静脉、门静脉平均血流速度降低(P<0.05),血流量明显减少(P<0.01).结论经颈内静脉肝内门体分流术并胃冠状静脉栓塞术若与部分脾动脉栓塞术联合运用可缓解门脉系循环高动力状态、降低门静脉压力.     

Doppler sonographic findings in children with idiopathic portal vein cavernous deformity and variceal hemorrhage.

OBJECTIVE: To describe the flow patterns in the portal vascular territory in children with portal vein cavernous deformity. METHODS: The study included 12 children (age 4-10 years) with hematemesis, melena, or both in whom B-mode gray scale sonography revealed small anechoic spaces replacing the site of the portal vein. The portal vein cavernous deformity was present either alone (in 8 patients) or with congenital hepatic fibrosis (in 4). Doppler sonography (color and spectral) was performed to assess the flow in the portal vascular territory, splenic vein, intrasplenic veins, and abdominal collaterals. RESULTS: Doppler sonography confirmed the venous flow waveform in the cavernous portal vein in all children with normal flow direction in the few intrahepatic portal vein branches and also in the intrahepatic veins. Splenomegaly was present in all. The intrasplenic veins were dilated in all but had normal flow direction except in 2 with spontaneous trans-splenic shunts. Gallbladder varices were shown in 4 patients, and perisplenic collaterals were shown in 3. CONCLUSIONS: Doppler sonography is a valuable noninvasive imaging technique for assessment of the portal hemodynamic profile in patients with portal vein cavernous deformity, which can affect subsequent treatment decision making. Trans-splenic shunts are uncommon, but this Doppler sonographic report documents such shunts in children with portal hypertension.     

二维彩色多普勒超声观测肝硬化门脉高压症脾肺固定合并门奇断流术前后门脉系统血流动力学改变

本文应用二维彩色多普勒超声对8例肝硬化门脉高压症的门脉系统血流动力学在脾肺固定合并门奇断流术前后分别进行定量研究和对比分析。结果表明术后门静脉及睥静脉的内径、平均流速和血流量比术前明显缩小和降低(P<0.001～0.05),门、睥静脉的血流量减少,两者呈正向相关关系(r=0.93,p<0.001)。结果认为该手术能使门静脉系统发生断流、分流和减流.使门静脉系统血流量减少,门脉高压及脾胃区高压缓解。双功能超声对门脉高压症手术方法的选择及效果的评价是一种有临床应用价值的无创性检查方法。     

双功多普勒检测门脉血流动力学的临床应用

应用双功多普勒检测了３２例正常对照者，３８例慢性肝炎，１７例肝硬化和３２例原发性肝癌患者的门脉血流动力学，发现肝硬化，原发性肝癌组门静脉内径显著大于正常对照组和慢性肝炎组；门脉血流速度则三组患者均显著低于对照组；门脉血流量仅慢性肝炎组显著低于对照组；三组患者的门脉充血指数均显著大于对照组。本文初步探讨了门脉血流动力学检测的临床意义及各种生理因素对门脉血流的影响。     

Ultrasound examination of the liver: Normal vascular anatomy

Various treatments for liver diseases, including liver transplant (particularly partial liver resection from a living donor), treatment of liver tumors, and TIPS, require detailed knowledge of the complex vascular anatomy of the liver. The hepatic artery and portal vein provide the organ with a double blood supply whereas venous drainage is furnished by the hepatic veins.Multislice computed tomography and magnetic resonance imaging provide undeniably excellent information on these structures. On ultrasound, the inferior vena cava, the openings of the hepatic veins, and the main branch of the portal vein can always be visualized, but intrasegmental vessels (portal, arterial, accessory hepatic venous branches) can be only partially depicted and in some cases not at all.In spite of its difficulty and limitations, hepatic sonography is frequently unavoidable, particularly in critically ill patients, and the results are essential for defining diagnostic and therapeutic strategies. For this reason, a thorough knowledge of the sonographic features of hepatic vascular anatomy is indispensable.     

介入断流术治疗肝硬化门脉高压合并上消化道出血的疗效分析(附11例报告)

目的通过对肝硬化门静脉高压并发上消化道大出血的患者采用经皮肝穿刺食管胃底静脉栓塞术联合部分脾栓塞治疗,评价其对肝硬化门静脉高压并发上消化道大出血的疗效。方法回顾性分析11例肝硬化门静脉高压并发上消化道大出血采用介入断流术治疗的病例资料,测定治疗前后门静脉的压力、门静脉的内径及血小板的变化情况,并进行随访观察以判定疗效。结果本组患者介入操作成功率和即时止血率均为100%;胃冠状静脉栓塞前、胃冠状静脉栓塞后和脾动脉栓塞后的门静脉压力分别为:(37.24±4.02)、(40.38±4.15)和(26.33±4.14)cmH_2O,胃冠状静脉栓塞前后门静脉压力比较,(P=0.088);脾动脉栓塞后与胃冠状静脉栓塞前门静脉压力比较,(P0.001);介入断流术治疗前和治疗后两周B超测量的门静脉内径为:(1.39±0.16)cm、(1.39±0.15)cm,治疗前后门静脉内径比较,(P=0.97);介入断流术治疗前和治疗后两周的血小板数为:(59.36±16.91)×10~9/L、(173.64±55.47)×10~9/L,治疗前后血小板数比较,(P0.001)。结论介入断流术止血效果迅速可靠,即时降低了门静脉压力,并逐步改善外周血情况,是治疗肝硬化门静脉高压合并上消化道出血的一种安全有效手段。     

内镜套扎联合部分脾栓塞术治疗门脉高压症及其对血流动力学的影响

目的 :探讨一种新的治疗门脉高压症的手术方法。方法 :对 41例合并食管静脉曲张和脾功能亢进的门脉高压症患者实施内镜套扎 -部分脾栓塞联合治疗 ,手术前后采用彩色多普勒超声检查门奇静脉侧支循环情况 ,与对照组进行对比研究。结果 :除 1例患者出现异位栓塞死亡 ,1例出现脾脓肿经开腹手术治疗得到治愈外 ,未发生其他严重并发症。联合术后患者食管曲张静脉得到根治 ,脾功能亢进缓解。手术后患者门静脉血流速度减慢 ,血流量减少 (P <0 .0 5) ,奇静脉血流量降低 (P <0 .0 1 ) ,胃左静脉血流速度减慢 (P <0 .0 5)。术后随访 2～ 2 4个月 ,未出现复发性出血。结论 :联合术能有效地治疗门脉高压症食管静脉曲张出血和脾功能亢进 ,减少了闭塞曲张静脉所需重复套扎次数及近期再出血 ,同时术后减少了门静脉血流速度 ,血流量 ,降低了套扎术后复发出血的风险 ,该方法操作简单 ,侵袭性小 ,尤其适应于肝功能较差 ,难以耐受分流及断流手术的门脉高压症患者。     

超声检查附脐静脉开放腹壁静脉曲张在门静脉高压临床分型的意义

目的应用彩色多普勒超声对门静脉高压附脐静脉开放和腹壁静脉曲张门腔之间侧支循环进行研究,确定门脉高压分型。方法超声检查86例肝硬化门静脉高压、13例布加综合征及6例门静脉主干、脾静脉血栓3组门静脉高压患者的腹壁静脉曲张门腔之间侧支循环吻合情况及血流方向。结果肝硬化门静脉高压组腹壁静脉曲张在脐以上血流流向头端,而脐以下血流流向腹端。布加综合征合并下腔静脉阻塞组,血流均流向上胸端。门静脉主干、脾静脉血栓未见脐静脉开放及腹壁静脉曲张。结论应用彩色多普勒超声判断附脐静脉开放和腹壁静脉曲张门腔之间侧支循环的情况,可明确血管阻塞部位、程度、范围,为肝前、肝内及肝后门静脉高压分型的诊断提供有效依据,对临床制定合理治疗方案具有指导意义。     

Réunion annuelle du Club francophone d’échoendoscopie (CFE), 22 janvier 2010 (sous l’égide de la SFED): nouveautés en échoendoscopie

Linear endoscopic ultrasonography (EUS), using the duplex Doppler or the color Doppler, is a promising technology, and many studies have described the specific features of EUS in portal hypertension. EUS is a reliable way for the diagnosis of portal vein thrombosis, which has the advantage of avoiding the use of contrast agents in cirrhotic patients. EUS gives a direct vision of vessels, permitting a detailed analysis (thickness of walls of the vessels, partial or total thrombosis, flow inside the main portal vein, and perigastric collaterals). Azygos venous blood flow, as an index of blood flow through the gastroesophageal collaterals and varices, can be studied by EUS. Many interventional techniques can be developed with EUS (to obliterate gastric varices and to diagnose hepatocellular carcinoma). This tool must probably be used in daily practice.     

Effect of respiration,exercise, and food intake on hepatic vein circulation.

Since the effects of respiration, nutrition, and exercise on blood flow in the hepatic vein are not well understood, the objective of this study was to determine the hemodynamic influence of these factors on hepatic venous circulation using Doppler ultrasonographic tracings. The venous blood flow of the middle hepatic vein was determined during arrested full inspiration, midinspiration, and expiration in 25 healthy subjects. The maximum velocity and the systolic-to-diastolic ratio of the blood flow were measured. The portal vein blood flow velocity was measured in 20 volunteers before and after food intake. The portal vein blood flow and the hepatic vein flow velocity were examined in eight volunteers after exercise. During inspiration, maximum blood flow velocity of the hepatic veins decreased compared to midinspiration (P < 0.001). With expiration the maximum velocity increased (P < 0.001). After food consumption, there was no change in the velocity of the hepatic veins, but the portal vein blood flow increased (P = 0.041). After physical exercises, the maximum velocity of the hepatic venous flow increased, on average, about 148% (P = 0.01), and the portal vein blood flow decreased about 44% (P = 0.027). To achieve standard measurements of hepatic venous blood flow, the state of respiration and physical exertion should be established. The nutritional status had only a minor influence on hepatic vein measurements.     

超声检测门脉高压患者肝脾动脉阻抗指数与门脉压力相关性研究

目的探讨肝动脉、脾动脉阻力指数（HARI、SpARI）及门脉高压指数（PHI）在评价门脉高压中的应用价值。方法57例临床确诊门脉高压并行门奇断流或脾肾分流术的患者被纳为门脉高压组,对照组为25例健康志愿者。门脉高压组均在术前1d行超声检查,对照组在空腹8h以上行超声检查。采用频谱多普勒检测门静脉平均血流速度（PVVel）、HARI、SpARI及肝脾动脉搏动指数（HAPI、SpARI）,并计算门脉高压指数（PHI）。门脉高压组门脉压力以术中胃网膜右静脉直接测压为准。结果对门脉高压组采用直接压力测定法测得门脉压力为（30.090±4.151）mmHg。门脉高压组HAPI、SpAPI及PHI高于正常对照组（P=0.012,P=0.034,P=0.026）,而PVVel、HARI及SpARI在两组之间差异无统计学意义。以HAPI=1.34诊断门脉高压的敏感性为73%、特异性80%、准确性74%。HARI、HAPI与门脉压力呈显著正相关（r=0.699,r=0.582,P均〈0.001）。门脉压力与肝功能Child-Pugh分级呈显著正相关（r=0.589,P=0.044）。结论HAPI在门脉高压组显著高于正常对照组,且与门脉压力呈显著正相关,因此HAPI可作为评价门脉高压的有效指标。