Hepatosplenic schistosomiasis portal hypertension: effect of esophagogastric devascularization with splenectomy on the diameter and mean flow velocity in the portal system (ultra-sonographic Doppler

BACKGROUND: Esophagogastric devascularization with splenectomy has been used for the treatment of upper digestive bleeding due to esophagic varices in hepatoportal mansoni's schistosomic portal hypertension. Nevertheless, early portal thrombosis has hampered this surgical technique (13.3% and 53.2%), compromising the good results on the hemorrhagic side. Supposing that portal circulatory changes, due to the surgical treatment, may play an important role in this kind of complication, our objective was to identify the hemodynamic facilitating factors. Portal hemodynamic aspects, identified by ultra-sonographic Doppler study, from two groups of patients: non-operated upon and splenectomized with esophagogastric devascularization in late post-operatory phase (in excess of 6 moths), with portal hypertension due to mansoni hepatoesplenic portal hypertension and in similar clinical conditions, were compared. METHOD: Fifty eight ambulatorial patients were studied, all had portal hypertension caused by mansoni's hepatosplenic schistosomiasis and previous bouts of digestive bleeding. They were divided in two groups: A--29 followed clinically/endoscopically, and group B--29 previously submitted to esophagogastric devascularization with splenectomy. In all was measured the diameter and mean flow velocity in the portal vein and its right and left branches by ultra-sonographic Doppler study. The results were submitted to statistical analysis for inter- and intra-group comparison. RESULTS: Group A (non-operated): the portal vein diameter was greater than the right and left branches (10.6 +/- 2.9, 8.0 +/- 1.8, 9.1 +/- 2.6 cm), the mean flow velocities in the portal vein and its branches were similar (15.62 +/- 6.17, 14.92 +/- 5.33, 16.12 +/- 4.18 cm/seg). Group B (operated): the diameter and mean flow velocity in all vessels were reduced (8.8 +/- 1.7, 5.2 +/- 1.2, 7.5 +/- 2.2 cm/12.53 +/- 2.60, 8.86 +/- 1.75, 9.69 +/- 3.75 cm/seg). CONCLUSIONS: After esophagogastric devascularization with splenectomy, there was a reduction of the diameter and mean flow velocity in the portal vein, its right and left branches.     

Late morphologic and hemodynamic changes in the splenic territory of patients with mansoni's hepatosplenic schistosomiasis after distal splenorenal shunt. (Ultrasonography-Doppler study)

BACKGROUND: The distal splenorenal anastomosis (Warren's operation) has been indicated for the treatment of high digestive bleeding caused by esophagic varices because it would ideally reduce the venous pressure in the cardiotuberositary territory without changing the mesenteric-portal venous flow. However, the changes it produce in the splenic territory have not been fully understood. AIM: To appraise the late morphologic and hemodynamic changes in the splenic territory produced by the distal splenorenal anastomosis in patients with portal hypertension due to mansoni's hepatosplenic schistosomiasis complicated by esophagic bleeding. METHOD: Ultrasonography-Doppler study of the splenic region of 52 patients with portal hypertension due to mansoni's schistosomiasis and previous bleeding by esophagic varices. They were divided in two groups: 40 non operated upon and 12 with a distal splenorerenal anastomosis. The following parameters and indices were compared between the two groups: a) morphometric parameters (splenic artery and vein's diameter, splenic diameters (longitudinal, transversal and antero-posterior); b) velocimetric parameters of the splenic vessels (systolic peak velocity in the splenic artery, mean flow velocity in the splenic vein; c) biometric index of the spleen (longitudinal x transversal); volumetric index of the spleen (longitudinal x transversal x antero-posterior x 0,523); hemodynamic indices of the splenic artery's impedance: pulsatility and resistivity. RESULTS: The patients with distal splenorenal anastomosis showed: a) reduction in splenic indices: volumetric (non operated 903,83 +/- 452, 77 cm / distal splenorenal anastomosis 482,32 +/- 208,02 cm (46,64%)) and biometric (non operated 138,14 +/- 51,89 cm /distal splenorenal anastomosis 94,83 +/- 39,83 cm (33,35%)); b) no change: splenic artery's diameter (non operated 0,57 +/- 0,16 cm/distal splenorenal anastomosis 0,57 +/- 0,23 cm); velocity in the splenic artery non operated 107 +/- 42,02 cm/seg/distal splenorenal anastomosis 89,81 +/- 41,20 cm/seg), resistivity (non operated 0,58 +/- 0,008/distal splenorenal anastomosis 0,56 +/- 0,06) and pulsatility (non operated 0,91 +/- 0,19/distal splenorenal anastomosis 0,86 +/- 0,15, splenic vein (non operated 1,10 +/- 0,30 cm/distal splenorenal anastomosis 1,19 +/- 0,29 cm); c) increase: mean flow velocity in the splenic vein (non operated 20,54 +/- 8,45 cm/seg/distal splenorenal anastomosis 27,83 +/- 9,29 cm/seg). CONCLUSIONS: The comparison of the ultrasonography Doppler results of the two groups of patient (non operated and distal splenorenal anastomosis) showed that in patients with distal splenorenal anastomosis there was a decrease of the volume of spleen; increase in the mean flow velocity in the splenic vein; no changes in the morphologic and hemodinamyc parameters of the splenic artery neither in its velocimetric indices.     

Transjugular preoperative portal embolization (TJPE) a pilot study

BACKGROUND/AIMS: Because of our previous experience with transjugular intrahepatic portosystemic shunt, we decided to apply the transjugular approach to preoperative portal embolization. The aim of this pilot study was to determine the feasibility and the potential advantages and disadvantages of this new method. METHODOLOGY: Under ultrasound guidance the right or left portal branch was punctured from the right, median or left hepatic vein. Then, a catheter was placed near the portal bifurcation and used to perform right portal branch embolization with a mixture of Histoacryl and Lipiodol. Pre- and post-transjugular preoperative portal embolization duplex ultrasound and CT scan were performed to assess portal flow and liver tissue growth. Hospital stay, pain and hepatic enzymes were monitored. RESULTS: Fifteen patients underwent a transjugular preoperative portal embolization without any serious complication. Mean of hospital stay was 3.3 +/- 0.6 days. (2-5 days). Portal embolization was successful in all cases; left portal branch velocity increased from 11.8 +/- 7.5 cm/s before, to 16.5 +/- 3.5 cm/s on day one, and 14.8 +/- 3.3 cm/s on day 28 after transjugular preoperative portal embolization; volume of non-embolized segments increased by 10% within the 4 weeks after transjugular preoperative portal embolization. Right hepatectomy was possible in 12 patients CONCLUSIONS: This method is safe, painless, and can be proposed in cases of impossibility to perform the standard percutaneous transhepatic portal embolization (tumor interposition, impaired hemostasis).     

Doppler hemodynamic study in portal hypertension and hepatic encephalopathy

BACKGROUND/AIMS: The aim of our study was to evaluate and compare the differences in the parameters of portal hypertension in two groups of patients with liver cirrhosis, with and without hepatic encephalopathy (HE). METHODOLOGY: 30 patients with liver cirrhosis, 17 (56.7%) of them with HE, were investigated by clinical, neurological, laboratory, endoscopic methods and with color Doppler ultrasonography (CDU) at the Institute for Digestive Diseases, Clinical Center of Serbia, Beograde. RESULTS: Significant correlation was found between the diameters of the right liver lobe and the portal vein (p=0.01), and also between the diameters of the spleen and splenic vein (p=0.0002), in both groups of patients. Mean portal vein diameter significantly increases (p=0.01) in patients with HE (14.87 +/- 1.86mm), compared to those without HE (13.2 +/- 2.31mm), while mean splenic vein diameter was not significantly different in the two groups. In patients with ascites, CDU showed significantly lower (p=0.03) portal flow velocity (11.87 +/- 6.25cm/ sec), compared to those without ascites (14.33 +/- 4.41cm/sec). Splenic flow velocity was not significantly different (16.00 +/- 6.60cm/sec with ascites and 14.61 +/- 5.29cm/sec without ascites). In patients with HE, portal flow velocity was significantly lower (9.00 +/- 5.41cm/sec) compared to those without HE (14.0 +/- 7.03cm/sec) (p=0.04). Mean splenic flow velocity was significantly lower (p=0.03) in patients with HE (12.60 +/- 4.16cm/sec), compared to those without HE (17.77 +/- 5.91cm/sec). Portal flow velocity shows linear decrease, related to the increase of the liver damage (Child-Pugh score), while splenic velocity was not related to this parameter. CONCLUSIONS: Ultrasonographic parameters of portal hypertension show significant correlation between the diameters of liver/portal vein and spleen/splenic vein. Portal hemodynamic parameter (blood flow velocity) is significantly related to the stages of liver damage, presence of ascites and HE, while splenic hemodynamics is specific and not directly related to these parameters.     

Value of portal hemodynamics and hypersplenism in cirrhosis staging

AIM: To determine the correlation between portal hemodynamics and spleen function among different grades of cirrhosis and verify its significance in cirrhosis staging. METHODS: The portal and splenic vein hemodynamics and spleen size were investigated by ultrasonography in consecutive 38 cirrhotic patients with cirrhosis (Child's grades A to C) and 20 normal controls. The differences were compared in portal vein diameter and flow velocity between patients with and without ascites and between patients with mild and severe esophageal varices. The correlation between peripheral blood cell counts and Child's grades was also determined. RESULTS: The portal flow velocity and volume were significantly lower in patients with Child's C (12.25±1.67 cm/s vs 788.59±234 mm/min, respectively) cirrhosis compared to controls (19.55±3.28 cm/s vs 1254.03±410 mm/min, respectively) and those with Child's A (18.5±3.02 cm/s vs 1358.48±384 mm/min, respectively) and Child's B (16.0±3.89 cm/s vs 1142.23±390 mm/min, respectively) cirrhosis. Patients with ascites had much lower portal flow velocity and volume (13.0±1.72 cm/s vs1078±533 mm/min) than those without ascites (18.6±2.60 cm/s vs1394±354 mm/min). There was no statistical difference between patients with mild and severe esophageal varices. The portal vein diameter was not significantly different among the above groups. There were significant differences in splenic vein diameter, flow velocity and white blood cell count, but not in spleen size, red blood cell and platelet counts among the various grades of cirrhosis. The spleen size was negatively correlated with red blood cell and platelet counts (r= -0.620 and r= -0.8.34, respectively). CONCLUSION: An optimal system that includes parameters representing the portal hemodynamics and spleen function should be proposed for cirrhosis staging.     

Portosystemic shunts in a large cohort of patients with liver cirrhosis: detection rate and clinical relevance

Background  This study aimed to determine the detection rate and clinical relevance of portosystemic collaterals. Methods  We studied 326 cirrhotics. Portosystemic collaterals, portal vein diameter, and splenic area were evaluated by color Doppler sonography; esophageal varices were detected by endoscopy. Results  Of the cirrhotics, 130 had portosystemic collaterals (39.9% total, left gastric vein 11%, paraumbilical vein 7.4%, splenorenal shunts 13.8%, and combined shunts 7.7%). Cirrhotics without portosystemic collaterals or with a paraumbilical vein had a significantly narrower portal vein diameter than cirrhotics with a left gastric vein (P < 0.001). Cirrhotics with a paraumbilical vein had a significantly smaller splenic area than cirrhotics with a left gastric vein (P < 0.001), splenorenal shunts (P < 0.001), combined shunts (P < 0.001), or without portosystemic collaterals (P < 0.05). A significant association between portosystemic collaterals and Child’s classes or presence and type of esophageal varices was found (P < 0.0001 and P = 0.0004, respectively). The highest prevalence of Child’s class C and large (F-3) esophageal varices was found in cirrhotics with a left gastric vein (41.7% and 36.1%, respectively), whereas esophageal varices were absent in 47.4% of cirrhotics without portosystemic collaterals and in 58.3% of cirrhotics with a paraumbilical vein. Conclusions  The left gastric vein is associated with some sonographic and clinical markers of disease severity, whereas the absence of portosystemic collaterals or the presence of paraumbilical veins seems to identify cirrhotics with markers predictive of a more favorable clinical course.     

Value of measurement of mean portal flow velocity by Doppler flowmetry in the diagnosis of portal hypertension.

To establish the sensitivity and specificity of the mean portal flow velocity in the diagnosis of portal hypertension, a population of 304 consecutive cirrhotic patients, in whom 246 abdominal Doppler examinations were performed, was prospectively analysed between June 1988 and December 1990. To avoid equipment-related variability only examinations performed using the same equipment were considered. Further inclusion criteria were the absence of portal vein thrombosis or reversed flow in the portal vessels and the absence of spontaneous, ultrasonographically detectable, portosystemic shunts. The parameter evaluated was mean portal flow velocity calculated directly from the Doppler trace by specific, operator-independent, software. 123 patients satisfied the inclusion criteria. As a control group 60 healthy age- and sex-matched subjects were examined. Mean portal flow velocity was significantly lower in cirrhotic patients than healthy subjects (13.0 +/- 3.2 cm/s vs. 19.6 +/- 2.6 cm/s; p < 0.001). There was also a decrease in mean portal flow velocity in cirrhotics in each Child-Pugh category (13.8 +/- 2.8 cm/s in Child-Pugh A class; 12.1 +/- 3.5 cm/s in Child-Pugh B class and 11.0 +/- 2.4 cm/s in Child-Pugh C class) with a statistically significant difference between each Child-Pugh category and healthy subjects (p < 0.001), between Child-Pugh A and B (p < 0.01) and between Child-Pugh A and C (p < 0.005). The sensitivity and specificity of mean portal flow velocity in the detection of portal hypertension was then analyzed with the receiver operating characteristic curve.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of propranolol on portosystemic collateral circulation in patients with cirrhosis

Propranolol has been demonstrated to be effective in lowering portal pressure in cirrhotic patients. This effect is mediated by a reduction of splanchnic arterial inflow and a consequent decrease of portal vein and portocollateral blood flow. Although experimental studies suggest a direct effect of the drug on portocollateral circulation, little information exists about relative flow changes occurring in the portal vein and in collateral veins feeding esophageal varices. This study addressed the problem in 12 cirrhotic patients selected on the basis of feasibility of Doppler flowmetry in both the portal and left gastric veins. Caliber, flow velocity and flow volume in both vessels were measured by Doppler ultrasound before and at 60, 120 and 180 min after an oral dose of 40 mg propranolol, together with heart rate and mean arterial pressure. A significant decrease in heart rate (-17.6% +/- 1.1%, p less than 0.001) and mean arterial pressure (-10.6% +/- 0.9%, p less than 0.005) confirmed effective beta-blockade. Baseline flow velocity was significantly lower in the portal vein than in the left gastric vein (12.4 +/- 0.6 vs. 15.4 +/- 1.5 cm/sec, p less than 0.05). Maximal hemodynamic effect was reached at 120 min after administration of propranolol. The vessel caliber did not change significantly. Flow velocity fell from 12.4 +/- 0.6 to 10.4 +/- 0.7 cm/sec in the portal vein (p less than 0.05) and from 15.4 +/- 1.5 to 11.1 +/- 0.9 cm/sec in the left gastric vein (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler study of hepatic vein in cirrhotic patients： Correlation with liver dysfunction and hepatic hemodynamics

INTRODUCTIONThere are many studies on inflow to the liver in liver cirrhosis (LC) in relation to hepatic dysfunction and portal hypertension. In LC, there are changes in liver parenchyma as well as alteration of hepatic vasculature, including morphologica…     

Portal blood velocity and flow in aging man

The portal blood velocity and flow were measured by means of pulsed echo-Doppler in 60 normal subjects of 4 different age groups (less than or equal to 40, 41-55, 56-70, greater than or equal to 71 years). All subjects had normal routine liver function tests and no history of liver disease. Portal blood velocity decreased from 15.7 +/- 3.2 cm/s in younger subjects to 12.4 +/- 1.7 in subjects over 71 years (ANOVA: p = 0.005). Similarly portal blood flow decreased (p = 0.025). Both portal blood velocity and flow were inversely correlated with age (r = -0.583 and -0.505, respectively). No changes in portal vein diameter were observed. The age-related decline in portal flow may account for the decrease in hepatic blood flow previously documented in the elderly.     

An anomaly in persistent right umbilical vein of portal vein diagnosed by ultrasonography

AIM: To detect the anomaly in the persistent right umbilical vein (PRUV) of portal vein (PV) with deviation of the ligamentum tere and left-sided gallbladder. METHODS: A total of 5783 candidates for routine analysis were evaluated for hepatic vascular abnormalities by ultrasonography. RESULTS: Ten candidates (0.17%) had a portal vein anomaly with a rightward-deviated ligamentum tere. The blood-flow velocity in the PRUV of the portal vein (17.7±3.0 cm/s) of the 10 cases was similar to that of the right anterior portal trunk (17.6±4.1 cm/s). However, the vessel diameter of the PRUV (φ12.4±4.4 mm) was larger than the right anterior portal trunk (φ6.1?.9 mm). Therefore, flow volume in the anomalous portion (0.97±0.30 L/min) was more than that in the right anterior portal trunk (0.18±0.05 L/min). CONCLUSION: The anomaly plays an important role in intra-hepatic PV flow.     

Phased-Array intracardiac echocardiography to guide radiofrequency ablation in the left atrium and at the pulmonary vein ostium

INTRODUCTION: We sought to evaluate the utility of a phased-array intracardiac echocardiography (ICE) device to identify left atrial (LA) and pulmonary vein (PV) anatomy; accurately guide radiofrequency ablation (RFA) to the right or left PV ostium and LA appendage (LAA); and evaluate PV blood flow before and after RFA using Doppler parameters. METHODS AND RESULTS: Twelve adult sheep were anesthetized and an Acuson 10-French, 7-MHz ICE transducer introduced via the internal jugular vein into the right atrium. The LA was imaged and PV anatomy and blood flow documented using two-dimensional and pulsed-wave Doppler. Mean LA dimensions were 4.6 +/- 0.4 x 3.5 +/- 0.5 cm; mean single right and left main PV ostium diameters were 1.5 +/- 0.2 and 1.3 +/- 0.3 cm; and mean right and left PV first-order branch diameters were 0.8 +/-0.2 and 0.6 +/- 0.1 cm. Mean PV maximum inflow velocity for the right PV were 0.30 +/- 0.05 m/sec and for the left PV were 0.35 +/- 0.04 m/sec. The PV ostia and LAA could be targeted accurately for RFA using ICE guidance. At pathologic evaluation, the mean distance of the lesion center to the right or left PV-LA junction was 3.0 +/- 2.0 mm. The mean distance of the lesion center to the posterior margin of the LAA was <4 mm in all cases. There was no significant increase in PV maximum inflow velocity or decrease in PV diameter following RFA at the PV ostium. Absence of PV obstruction was confirmed at pathology. CONCLUSION: Phased-array ICE allows detailed assessment of LA and PV anatomy when imaged from the right atrium; accurate guidance of RFA to the PV ostium and LAA; and immediate evaluation of PV patency after RFA.     

Effect of metoclopramide on portal blood flow in patients with liver cirrhosis, measured by the pulsed Doppler system

The effect of metoclopramide on portal blood flow, the maximal diameter of the portal vein, and some cardiovascular haemodynamic variables was studied in 10 patients with cirrhosis of the liver and portal hypertension. Portal vein haemodynamics were studied by the pulsed Doppler system. Within 15 min of intravenous administration of 20 mg metoclopramide, portal blood velocity and portal blood flow decreased significantly, from 11.2 +/- 1.1 to 10.8 +/- 1.2 cm/sec and from 769.0 +/- 87.7 to 707.9 +/- 84.2 ml/min, respectively (p less than 0.001). Within about 30 min portal blood velocity and portal blood flow returned to basal values (p greater than 0.05). The maximal diameter of the portal vein, systolic and diastolic blood pressure, and heart rate remained unchanged. These results support the hypothesis that metoclopramide, which raises lower oesophageal sphincter pressure and reduces intravariceal blood flow, significantly decreases the portal blood flow in cirrhotic patients with portal hypertension.     

Different hemodynamic patterns of alcoholic and viral endstage cirrhosis: analysis of explanted liver weight, degree of fibrosis and splanchnic Doppler parameters

OBJECTIVE: In cirrhosis, portal hemodynamics is usually considered independently of the disease etiology. The objective of this study was to investigate the role of the etiology of liver disease on the relationship between liver blood flow and liver pathology in endstage cirrhosis. MATERIAL AND METHODS: Portal blood velocity and volume, congestion index of the portal vein, and hepatic and splenic pulsatility indices were evaluated with echo-Doppler in cirrhotic patients immediately before liver transplantation. When a patent paraumbilical vein was present, its blood flow was measured and effective portal liver perfusion was calculated as portal blood flow minus paraumbilical blood flow. The hemodynamic parameters were correlated with liver weight and the pattern of the liver fibrosis morphometrically assessed in explanted livers. A total of 131 patients with alcoholic or viral cirrhosis were included in the study. RESULTS: In alcoholic cirrhosis, liver weight was higher than that in viral disease (1246+/-295 g versus 1070+/-254 g, p=0.001), portal liver perfusion per gram of liver tissue was lower (0.49+/-0.36 ml g(-1) min(-1) versus 0.85+/-0.56 ml g(-1) min(-1), p=0.004) and hepatic pulsatility indices were higher (1.45+/-0.31 versus 1.26+/-0.30, p=0.018). The degree of liver fibrosis was similar in alcoholic and viral cirrhosis (11.7+/-5.5% versus 11.0+/-4.4%, p=NS). An inverse relationship between liver weight and Child-Pugh score was disclosed in viral (p<0.001) but not in alcoholic disease. CONCLUSIONS: A different hemodynamic pattern characterizes the advanced stage of cirrhosis of alcoholic and viral origin. A more severe alteration of intrahepatic portal perfusion, probably coexisting with a more severe hepatocyte dysfunction, and a higher liver weight can be detected in alcoholic cirrhosis.     

Effects of different octreotide dosages on splanchnic hemodynamics and glucagon in patients with TIPS

OBJECTIVE: The aim of this study was to evaluate the hemodynamic effects of octreotide in patients treated with transjugular intrahepatic portosystemic stent shunt in relation to plasma levels of octreotide and glucagon and the correlation between portal pressure and noninvasive Doppler parameters. METHODS: In 15 fasting patients, we i.v. administered isotonic sodium chloride followed by octreotide 25 microg/h and 100 microg/h, each over 1 h. We measured portal pressure (PP) directly and portal vein blood flow velocity by Doppler ultrasound simultaneously and calculated portal vascular resistance (PVR) and portal venous flow (PVF). Blood samples were taken for glucagon and octreotide (mean +/- SE). RESULTS: Octreotide reduced PP (120': -7.7+/-2.2%, p < 0.01 vs baseline; 180': - 11.4+/-2.1%, p < 0.01 vs baseline) and PVF (120': -21.7+/-31.7%, p < 0.01 vs baseline; 180': -11.6+/-18.1%, p < 0.05 vs baseline). Glucagon decreased with the increase in octreotide levels and showed a correlation with the decrease in PP and with PVF. In patients with a high PVR, we found a close inverse correlation between PP and portal vein blood flow velocity (r = -0.83, p = 0.03) as well as Cl (r = 0.81, p = 0.05), whereas poor correlation was found in patients with low PVR. CONCLUSIONS: Octreotide caused a dose-related, moderate but sustained reduction in PP in patients with transjugular intrahepatic portosystemic stent shunt. PVR seems to be an important parameter that influences the efficacy of octreotide and the relation between PP and noninvasive Doppler parameters.     

Hemodynamic analysis of esophageal varices in patients with liver cirrhosis using color Doppler ultrasound

AIM: To study the portal hemodynamics and their relationship with the size of esophageal varices seen at endoscopy and to evaluate whether these Doppler ultrasound parameters might predict variceal bleeding in patients with liver cirrhosis and portal hypertension. METHODS: One hundred and twenty cirrhotic patients with esophageal varices but without any previous bleeding were enrolled in the prospective study. During a 2-year observation period, 52 patients who had at least one episode of acute esophageal variceal hemorrhage constituted the bleeding group, and the remaining 68 patients without any previous hemorrhage constituted the non-bleeding group. All patients underwent endoscopy before or after color Doppler-ultrasonic examination, and images were interpreted independently by two endoscopists. The control group consisted of 30 healthy subjects, matched to the patient group in age and gender. Measurements of diameter, flow direction and flow velocity in the left gastric vein (LGV) and the portal vein (PV) were done in all patients and controls using color Doppler unit. After baseline measurements, 30 min after oral administration of 75 g glucose in 225 mL, changes of the diameter, flow velocity and direction in the PV and LGV were examined in 60 patients with esophageal varices and 15 healthy controls. RESULTS: The PV and LGV were detected successfully in 115 (96%) and 105 (88%) of 120 cirrhotic patients, respectively, and in 27 (90%) and 21 (70%) of 30 healthy controls, respectively. Among the 120 cirrhotic patients, 37 had F1, 59 had F2, and 24 had F3 grade varices. Compared with the healthy controls, cirrhotic group had a significantly lower velocity in the PV, a significantly greater diameter of the PV and LGV, and a higher velocity in the LGV. In the cirrhotic group, no difference in portal flow velocity and diameter were observed between patients with or without esophageal variceal bleeding (EVB). However, the diameter and blood flow velocity of the LGV were significantly higher for EVB (+) group compared with EVB (-) group (P < 0.01). Diameter of the LGV increased with enlarged size of varices. There were differences between F1 and F2, F1 and F3 varices, but no differences between F2 and F3 varices (P = 0.125). However, variceal bleeding was more frequent in patients with a diameter of LGV >6 mm. The flow velocity in the LGV of healthy controls was 8.70+/-1.91 cm/s (n = 21). In patients with liver cirrhosis, it was 10.3+/-2.1 cm/s (n = 12) when the flow was hepatopetal and 13.5+/-2.3 cm/s (n = 87) when it was hepatofugal. As the size of varices enlarged, hepatofugal flow velocity increased (P < 0.01) and was significantly different between patients with F1 and F2 varices and between patients with F2 and F3 varices. Variceal bleeding was more frequent in patients with a hepatofugal flow velocity >15 cm/s (32 of 52 patients, 61.5%). Within the bleeding group, the mean LGV blood flow velocity was 16.6+/-2.62 cm/s. No correlation was observed between the portal blood flow velocity and EVB. In all healthy controls, the flow direction in the LGV was hepatopetal, toward the PV. In patients with F1 varices, flow direction was hepatopetal in 10 patients, to-and-fro state in 3 patients, and hepatofugal in the remaining 18. The flow was hepatofugal in 91% patients with F2 and all F3 varices. Changes in diameter of the PV and LGV were not significant before and after ingestion of glucose (PV: 1.41+/-1.5 cm before and 1.46+/-1.6 cm after; LGV: 0.57+/-1.7 cm before and 0.60+/-1.5 cm after). Flow direction in the LGV was hepatopetal and to-and-fro in 16 patients and hepatofugal in 44 patients before ingestion of glucose. Flow direction changed to hepatofugal in 9 of 16 patients with hepatopetal and to-and-fro blood flow after ingestion of glucose. In 44 patients with hepatofugal blood flow in the LGV, a significant increase in hepatofugal flow velocity was observed in 38 of 44 patients (86%) with esophageal varices. There was a relationship between the percentage changes in flow velocity and the size of varices. Patients who responded excessively to food ingestion might have a high risk for bleeding. The changes of blood flow velocity in the LGV were greater than those in the PV (LGV: 28.3+/-26.1%, PV: 7.2+/-13.2%, P < 0.01), whereas no significant changes in the LGV occurred before and after ingestion of glucose in the control subjects. CONCLUSION: Hemodynamics of the PV is unrelated to the degree of endoscopic abnormalities in patients with liver cirrhosis. The most important combinations are endoscopic findings followed by the LGV hemodynamics. Duplex-Doppler ultrasonography has no value in the identification of patients with cirrhosis at risk of variceal bleeding. Hemodynamics of the LGV appears to be superior to those of the PV in predicting bleeding.     

Portal venous system after endoscopic sclerotherapy of esophageal varices in patients with liver cirrhosis--prospective study with Doppler sonography

BACKGROUND/AIMS: The aim of this prospective, clinical study was an ultrasonographic color Doppler evaluation of morphological and hemodynamic changes in the portal system prior to and after repeated, endoscopic injection sclerotherapy in patients with liver cirrhosis and hemorrhage from esophageal varices. METHODOLOGY: Twenty-six patients before and after complete eradication of esophageal varices by repeated sclerotherapy with 5% ethanolamine oleate as obliterating agent were examined. The diameter of the portal and splenic veins, the patency of the veins, the direction of the blood flow, the mean and maximal velocity of blood flow, spleen size and presence and number of collateral circulation pathways were determined. Hemodynamic examinations of the portal system were performed with duplex Doppler method with color imaging of blood flow. RESULTS: The study revealed no statistically significant differences between diameters of the portal and the splenic vein or between the size of the spleen prior to and after sclerotherapy. The blood flow was intrahepatic and portal vein thrombosis was not detected in any of the patients. The mean velocity blood flow in the portal vein prior to and after sclerotherapy did not reveal any changes. The maximal velocity of blood flow in the portal vein increased from 23.7 +/- 2.5 cm/s to 27.2 +/- 2.8 cm/s, but it was not statistically significant. Prior to the commencement of sclerotherapy collateral portal-systemic circulation was detected in 17 out of 26 patients (65%), with a total of 25 collateral circulation pathways. After completion of sclerotherapy collaterals were detected in 19 out of 26 patients (73%) and number of pathways was increased by 7. CONCLUSIONS: Endoscopic sclerotherapy of esophageal varices does not affect the direction of blood flow in the portal vein and causes no thrombosis of the portal system. Effective sclerotherapy and complete eradication of esophageal varices results in closure of collateral circulation pathways through submucosal esophageal varices as well as development of new pathways of collateral circulation.     

Pulmonary venous flow dynamics before and after balloon mitral valvuloplasty as determined by transesophageal Doppler echocardiography.

The pattern of left atrial filling was studied in 14 patients with severe mitral stenosis in sinus rhythm before and immediately after successful balloon mitral valvuloplasty by transesophageal pulsed Doppler echocardiography of the left superior pulmonary vein. Mean mitral valve orifice area increased from 0.8 +/- 0.1 to 2.2 +/- 0.3 cm2 (p less than 0.0001), and left atrial mean pressure decreased from 30 +/- 5 to 12 +/- 4 mm Hg (p less than 0.0001) after the procedure. After balloon mitral valvuloplasty, significant increases in peak systolic pulmonary velocity (35 +/- 16 to 44 +/- 10 cm/s; p less than 0.01), systolic flow velocity time integral (3.3 +/- 1.5 to 5.9 +/- 2.0 cm; p less than 0.001) and the ratio of systolic/diastolic pulmonary venous flow velocity time integrals (0.8 +/- 0.4 to 1.4 +/- 0.5; p less than 0.001) were observed. An acute increase in mitral valve orifice area caused no significant changes in peak diastolic forward flow velocity (40 +/- 7 to 41 +/- 9 cm/s; p = not significant [NS]), diastolic forward flow velocity time integral (4.3 +/- 1.7 to 4.6 +/- 1.8 cm; p = NS) and atrial flow reversal velocity (30 +/- 3 to 35 +/- 3 cm/s; p = NS) compared with at baseline. The results suggest that in patients with severe mitral stenosis and sinus rhythm, left atrial filling is biphasic with a diastolic preponderance, and successful mitral valvuloplasty is associated with an immediate increase in pulmonary venous systolic forward flow.     

Assessment of portal blood flow by isotope splenoportography. Methodology and 1st results in cirrhosis

The authors report a new non-invasive method of portal blood flow (PBF) measurement, after injection of a radiotracer into the spleen. PBF was equal to the product of the radiotracer bolus velocity and the cross-section area of the portal vein as measured by ultrasonography. In 16 patients with cirrhosis, the velocity of the portal blood flow (V) and PBF were determined in 11 cases. In the remaining 5 patients, failures were explained by either a total extrahepatic shunt (3 cases) or difficulties of scanning view analysis (2 cases). Mean values of V and PBF were 8.8 +/- 2.5 cm/s and 579 +/- 193 ml/min respectively, which represent a reduction of 50 p. 100 compared to estimated normal values. This method was also useful to appreciate the fraction of PBF which is supposed to reach the liver cells called the "actual portal blood flow" (APBF). APBF was equal to PBF minus the fraction of blood flowing through intrahepatic shunts and/or the recanalized umbilical vein. In the 16 cases, mean values were 528 +/- 184 ml/min for APBF, 11.9 +/- 1.7 cm for the portal vein diameter, and 53 +/- 34 p. 100 for spleen blood flow fraction going through porto-systemic collateral veins. Significant intrahepatic shunt was observed in one patient only out of 13 without total extrahepatic shunt, i. e., in 8 p. 100 of the cases. The impossibility of measuring PBF when a total extrahepatic shunt is present is a drawback in the use of this new technique.(ABSTRACT TRUNCATED AT 250 WORDS)     

Favorable effect of pulmonic vein isolation by partial circumferential ablation on ostial flow velocity

OBJECTIVES: The aim of this study was to determine the effect of electrical isolation of pulmonic vein (PV) on flow velocity. BACKGROUND: We report our experience with electrical isolation of PV by partial circumferential ablation and its effect on ostial peak flow velocity as assessed by phased-array ultrasound catheter imaging. METHODS: Sixty-two patients participated in the study. Magnetic electroanatomic mapping, ultrasound catheter imaging, and Lasso mapping catheter were used. Electrical isolation was achieved by delivering radiofrequency ablation (RFA) lesions proximal to Lasso mapping catheter bipoles showing PV entry. Following this, the number of RFA lesions/PV and their segment-wise distribution (maximum 4/PV) were assessed. RESULTS: Fifty right superior, 51 left superior, 32 left inferior, and 17 right inferior PVs were isolated. RFA involved 4 segments in 42 PVs, 3 segments in 61 PVs, and 90% reduction in AF burden, either with or without previously ineffective antiarrhythmic agents, was achieved in 54 patients (87%). CONCLUSIONS: In the majority of PVs (72%), electrical isolation can be achieved by partial circumferential ablation (targeting 相似文献