Diagnosis of Budd-Chiari syndrome: three-dimensional dynamic contrast enhanced magnetic resonance angiography

Objective

To investigate the characteristics and diagnostic value of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA) in the diagnosis of Budd?CChiari syndrome (BCS).

Methods

One hundred thirty-three BCS patients underwent 3D CE-MRA, 64 patients had primary BCS, and 69 had secondary BCS.

Results

Fifty five cases (41.4%) showed a segmental stenosis of the inferior vena cava, 9 cases (6.8%) a membranous obstruction of the inferior vena cava, 5 cases (3.8%) an unobstructed inferior vena cava and hepatic veno-occlusive condition, 16 cases (12.0%) an inferior vena cava stenosis and hepatic veno-occlusive disease, and 48 cases (36.1%) an intraluminal filling defect in the inferior vena cava. In 52 cases (39.1%), collateral blood vessels were formed, with deep, medium, and shallow portal veins and intrahepatic collateral veins in 88 groups. Among these, 41 (46.6%) had deep venous collateral channels, 24 (27.3%) had medium venous collateral channels, 9 (10.2%) had superficial venous collateral channels, 5 (5.7%) had portal vein collateral channels, and 9 (10.2%) had intrahepatic venous collateral channels.

Conclusion

3D CE-MRA is important in the clinical diagnosis and treatment planning of BCS and displays hepatic veins, the inferior vena cava system, and collateral vessels.     

Experimental evaluation of portal venous pulsatile flow synchronized with heartbeat intervals: effects of vascular clamping on portal hemodynamics

Purpose

We previously showed that blood flow in the portal vein was pulsatile and influenced by both the inferior vena cava and the arterial system in a complex manner (Nihei et al., 38:141–149, 2011). The objective of the present study is to identify determinants of blood flow and to clarify the source of pulsatile flow in the portal vein.

Methods

Three-breed terminal crossbreed mini-pigs underwent general anesthesia. Pressure and flow in the portal vein, inferior vena cava, hepatic artery, and mesenteric artery were measured simultaneously. Vascular occluders were placed in the inferior vena cava, hepatic artery, and mesenteric artery to examine the effects of clamping on portal venous flow.

Results

Clamping of the mesenteric artery altered pressure and flow waves in the portal vein to waveforms similar to those in the inferior vena cava. Waves resembling those of the inferior vena cava superimposed on portal venous flow appeared later than waves of the inferior vena cava. Clamping of the inferior vena cava promptly altered portal venous pressure and flow. Because clamping of the inferior vena cava led to a sharp rise in portal venous pressure, detailed evaluations were not feasible. Clamping of the hepatic artery had no effect on flow-wave pulsation in the portal vein.

Conclusions

In the hepatic circulation, flow-wave pulsation in the portal vein is influenced by flow in the inferior vena cava via the sinusoids and by flow in the mesenteric artery via the capillary vessels of the intestine.     

多排螺旋CT血管成像技术对肝硬化门脉高压侧支循环血管的显示价值

目的探讨多排螺旋CT(MDCT)显示肝硬化门脉高压症侧支循环血管的诊断价值. 方法对肝硬化门脉高压患者23例,使用16排螺旋CT机行上腹部增强CT扫描,采用MPR、MIP、VRT等三维重建技术进行图像后处理,获得门静脉系统血管图像以显示开放的侧支循环血管. 结果显示食管胃底黏膜下静脉曲张20例,食管旁静脉曲张7例;胃左静脉曲张18 例,胃短静脉曲张16例;奇静脉、半奇静脉曲张8例;脐旁静脉与腹壁静脉曲张9例;脾肾、胃肾之间分流7例;腹膜后分流11例.结论 MDCT门静脉系统血管成像技术能良好地显示肝硬化门脉高压侧支循环血管,具有重要临床应用价值.     

Portal hypertension exacerbates intrahepatic portosystemic venous shunt and further induces refractory hepatic encephalopathy: A case report

BACKGROUNDIntrahepatic portosystemic venous shunt (IPSVS) is a rare hepatic disease with different clinical manifestations. Most IPSVS patients with mild shunts are asymptomatic, while the patients with severe shunts present complications such as hepatic encephalopathy. For patients with portal hypertension accompanied by intrahepatic shunt, portal hypertension may lead to hemodynamic changes that may result in exacerbated portal shunt and increased shunt flow.CASE SUMMARYA 57-year-old man, with the medical history of chronic hepatitis B and liver cirrhosis, was admitted to our hospital with abnormal behavior for 10 mo. He had received the esophageal varices ligation and entecavir therapy 1 year ago. Comparing with former examination results, the degree of esophageal varices was significantly reduced, while the right branch of the portal vein was significantly expanded and tortuous. Meanwhile, abdominal ultrasound presented the right posterior branch of portal vein connected with the retrohepatic inferior vena cava. The imaging findings indicated the diagnosis of IPSVS and hepatic encephalopathy. Instead of radiologic interventions or surgical therapies, this patient had only accepted symptomatic treatment. No recurrence of hepatic encephalopathy was observed during 1-year follow-up.CONCLUSIONHemodynamic changes may exacerbate intrahepatic portosystemic shunt. The intervention or surgery should be carefully applied to patients with severe portal hypertension due to the risk of hemorrhage.     

Role of percutaneous transhepatic obliteration for special types of varices with portal hypertension

The treatment of special types of varices with portal hypertension has not yet been established. We were able to control 13 cases of special types of varices by percutaneous transhepatic obliteration (PTO). These 13 cases consisted of 2 esophagojejunal varices after total gastrectomy for gastric cancer, 1 stoma varices after abdominoperineal excision for rectal cancer, 2 mesenteric varices with encephalopathy, 1 gastric variceal rupture, 1 gastrorenal and gastroazygos shunt with encephalopathy, 3 giant bar-type esophageal varices, 2 isolated gastric varices with gastropericardiac shunts, and 1 isolated gastric varices with gastrophrenic shunt. The special types of varices were successfully embolized in all cases and there were no complications. We conclude that the PTO is still an effective and safe treatment for special types of varices with portal hypertension.     

Investigating the benefit of adding a vena cava filter to anticoagulation with fondaparinux sodium in patients with cancer and venous thromboembolism in a prospective randomized clinical trial

Background

The benefit of adding a vena cava filter to anticoagulation in treating cancer patients with venous thromboembolism remains controversial. We initiated this study as the first prospectively randomized trial to evaluate the addition of a vena cava filter placement to anticoagulation with the factor Xa inhibitor fondaparinux sodium in patients with cancer.

Methods

Sixty-four patients with deep vein thrombosis (86?%) and/or pulmonary embolism (55?%) were randomly assigned to receive anticoagulation with fondaparinux sodium with or without a vena cava filter. Endpoints included rates of complications by treatment arm, recurrent thromboembolism, complete resolution of thromboembolism, and survival rates.

Results

No patient had a recurrent deep vein thrombosis; two (3?%) patients had new pulmonary emboli, one in each randomized cohort. Major bleeding occurred in three patients (5?%). Two patients on the vena cava filter arm (7?%) had complications from the filter. Median survivals were 493?days in the anticoagulation only arm and 266?days for anticoagulation?+?vena cava filter (p?Conclusions No advantage was found for placement of a vena cava filter in addition to anticoagulation with fondaparinux sodium in terms of safety, recurrent thrombosis, recurrent pulmonary embolism, or survival in this prospective randomized trial evaluating anticoagulation plus a vena cava filter in cancer patients. Favorable complete resolution rates of thrombosis were observed on both study arms.     

Esophageal varices on computed tomography and subsequent variceal hemorrhage

Purpose

Endoscopy is recommended to screen for esophageal varices in patients with cirrhosis. The objective of this study was to identify features on abdominal CT imaging associated variceal hemorrhage (VH).

Methods

A case–control study was performed among patients with cirrhosis who had a CT scan. Consecutive patients who experienced VH were included as cases, and patients without VH served as controls. Two radiologists recorded the maximal esophageal varix diameter in addition to other measures of portal hypertension at CT.

Results

The most powerful CT parameter associated with VH was the esophageal varix diameter (5.8 vs. 2.7 mm, p < 0.001; adjusted OR 1.84 per mm, p = 0.009). 63% of individuals with VH had a maximal varix diameter ≥5 mm compared to 7.5% of cirrhotic patients without VH (p < 0.001). In contrast, the proportion of individuals whose largest varix was <3 mm was 7.4% among VH cases compared to 54.7% among controls (p = 0.001). The varix diameter powerfully discriminated those with and without VH (C-statistic 0.84).

Conclusions

A large esophageal varix diameter is strongly associated with subsequent VH. A threshold of <3 and ≥5 mm appears to identify patients with cirrhosis at low and high risk for hemorrhage.     

A case of Castleman's disease with "downhill" varices in the absence of superior vena cava obstruction

Downhill esophageal varices", classically defined as those that develop in the upper region of the esophagus, are less common than the "uphill" type, which is usually produced by portal hypertension. Various causes of downhill varices have been reported, but mediastinal tumor is the most common responsible lesion. Castleman's disease, or angiofollicular lymph node hyperplasia, is a rare pathological process of unknown etiology that usually develops in the mediastinum. We report the case of a 60-year-old woman whose large esophageal varices were detected incidentally. The cause was a mediastinal mass which was diagnosed as Castleman's disease on histopathological examination of a surgical specimen. This patient's varices most likely formed as a result of copious blood drainage from the tumor into the esophageal veins. Evidence for this was the lack of the classic downhill pattern, the absence of superior vena cava obstruction, and the fact that the varices resolved after the tumor was removed. It is our opinion that this type of varices should be renamed, and we suggest that "overflow varices" would be an appropriate term.     

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.     

Portal hypertension. A new beginning for an old problem.

There are two types of shunts for the treatment of esophageal varices: total shunts or selective shunts. The various total shunts are designed to "decompress" both the portal and the variceal venous systems. In contrast, a selective shunt decompresses the varices only, and the portal pressure and presumably portal flow are not affected. The very purpose of the total shunt is the total or partial diversion of portal flow. This is the case no matter which branches of the portal and systemic venous systems are connected and whether the anastomosis is a direct one or is through a graft. In an ongoing prospective, randomized clinical trial, which now includes 46 patients, a total shunt (mesorenal H graft) and the selective distal splenorenal (Warren) shunt are compared. The operative mortality rate and the frequency of postoperative bleeding are the same. However, encephalopathy is more frequent after the total shunt (P less than 0.05), and a trend is developing which suggests a better long-term survival rate after the Warren shunt. If these trends continue, then the superiority of the Warren shunt is established in a selected group of patients who have bled at least once from their varices. If these patients continue to remain free of encephalopathy and hemorrhage will not recur, then it is probable that the Warren shunt could improve the chances of survival of cirrhotic patients with esophageal varices who did not bleed yet. The "prophylactic" value of the Warren shunt will require a multicenter, cooperative, controlled clinical trial.     

微探头超声评估食管周围侧支血管在套扎治疗后食管曲张静脉复发中作用的临床研究

目的利用微探头超声(UMP)研究食管周围侧支血管在套扎治疗后食管曲张静脉复发中的作用,以及对食管曲张静脉套扎术所需套扎点数及次数的影响.方法对20例门静脉高压症食管静脉曲张患者在食管曲张静脉套扎术前进行常规胃镜检查,记录食管曲张静脉分级;然后用UM-3R超声成像系统中的20 MHz微探头进行食管下段超声检查,记录食管周围静脉和旁静脉的曲张程度.行根治性食管曲张静脉套扎术后6个月进行内镜检查,观察食管曲张静脉是否复发并判断曲张程度.结果 20例追踪观察,5例食管曲张静脉复发,1例在观察期间再出血;重度旁静脉和重度周围静脉共存时,食管曲张静脉复发率达75%,较其他组合类型的复发率高.周围静脉为轻度时需套扎2次左右,18～20个套扎点即可根治,而周围静脉和旁静脉均为重度时则需套扎3次左右,29～31个套扎点.结论食管周围侧支静脉对食管静脉曲张复发起作用,当UMP检测到重度旁静脉和重度周围静脉共存,则预示高复发率.食管曲张静脉套扎根治术所需套扎次数及套扎点数受旁静脉和周围静脉曲张程度影响.     

Portal vein branching pattern in anomalous right-sided round ligament

Objective

To study the relationship of anomalous right-sided round ligament with respect to branches of the portal vein.

Methods

We studied four patients of right-sided round ligament diagnosed radiologically in the last 5 years. 3-D volume rendered CECT abdominal images were analyzed for attachment of the round ligament in the liver in relation to portal venous anatomy and position of gallbladder.

Results

In all cases, a trifurcate pattern of portal venous branching was observed. Right-sided round ligament was attached at the point of divergence of the right anterior portal vein. The region to the left of the point of its attachment drained into the middle hepatic vein while the region to the right of the point of attachment drained into the right hepatic vein. The left portal vein branched into posterior and paramedian branches. Right, middle, and left hepatic veins were visualized having normal course in all cases. In all, the gallbladder was present to the left of the round ligament.

Conclusions

Trifurcate pattern of portal vein branching in all four cases. Right-sided round ligament was attached to the bifurcation of the right anterior portal vein in all the cases. The left portal vein branched into posterior and paramedian branches.     

Unusual hepatic-portal-systemic shunting demonstrated by Doppler sonography in children with congenital hepatic vein ostial occlusion

PURPOSE: This report describes unusual changes in the hepatic vasculature in 3 children presenting with upper gastrointestinal hemorrhage. METHODS: The study included 3 children (ages 5-8 years) who presented with hematemesis. All had mild hepatosplenomegaly and normal liver function. Esophageal varices were demonstrated in all on upper endoscopy. Color and spectral Doppler sonography was performed to assess the hepatic vasculature, including the hepatic veins (HVs), portal vein (PV), hepatic artery (HA), and inferior vena cava (IVC). RESULTS: The HVs were all patent but with ostial occlusion at the point of their communication with the IVC. Complete flow reversal was shown inside the HVs, with blood draining into collateral vessels at the liver surface and paraumbilical vein. In one patient, the paraumbilical vein could be traced to its communication with the right external iliac vein. In all children, the direction of flow in the PV, HA, and IVC was normal. After endoscopic sclerotherapy, all children were shown to be in good general condition and to have normal liver function for a follow-up period of 15-36 months. CONCLUSIONS: Ostial occlusion of the HV is a rare cause of hepatic outflow obstruction in children. Doppler sonography is a valuable, noninvasive imaging technique for evaluation of the hepatic vasculature and the accompanying shunting pathways in such cases.     

Intrahepatic spontaneous portosystemic venous shunt: value of color and power Doppler sonography

Spontaneous portosystemic venous shunts (SPVSs) within the hepatic parenchyma are rare. Fewer than 50 cases have been reported, and most of them were diagnosed by angiography. We present a case of SPVS diagnosed by color Doppler sonography in a 5-year-old boy admitted for bleeding due to rupture of esophageal varices. Conventional color and power Doppler sonography as well as CT showed a large shunt between the posterior branch of the right portal vein and the inferior vena cava. We believe that accurate diagnosis and follow-up of SPVS can be done with color Doppler sonography without resorting to angiography.     

Percutaneous ultrasound-guided fine-needle aspiration of portal vein thrombi as a diagnostic and staging technique for hepatocellular carcinoma

Background

Detection of portal vein tumor invasion in hepatocellular carcinoma (HCC) is important in determining therapy and prognosis. Patients with portal vein thrombus (PVT) due to tumor are considered to have advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately differentiate benign from malignant PVT.

Methods

In this study, 20 patients presenting to the out-patient department with a PVT and a diagnosis/diagnostic suspicion of HCC were subjected to FNAC of PVT. Clinical, cytological, and histopathological data for these patients were analyzed.

Results

The patients had a median age of 58 years, with majority being cirrhotic (80%) and males (80%). Thirteen patients had a prior radiological diagnosis of HCC at the time of FNAC. In three patients without any mass on imaging, FNAC made the initial diagnosis and staged the disease simultaneously. 50% of the thrombi were limited to 1st-order portal vein branches (vp3). Sixteen of the aspirates were positive for malignancy with 50% of the tumors being moderately differentiated. On histologic follow-up, three of the patients with negative aspirates had bland thrombi in their portal veins. No complications resulted from the procedure.

Conclusions

FNAC of PVT is a simple, safe, effective, well-tolerated, and economical method for staging of patients with HCC. When used as the initial diagnostic procedure, in selected patients, it can provide the diagnosis and staging information simultaneously.     

Usefulness of endoscopic ultrasound in esophagogastric varices

Endoscopic ultrasound (EUS) is a useful diagnostic tool for evaluation of esophagogastric varices and guidance of endoscopic therapy. EUS can visualize not only collateral veins around the esophagus but also perforating veins that connect esophageal varices with collateral veins. They are associated with high risk of bleeding and early recurrence after initial variceal eradication. Isolated gastric varices can be easily diagnosed using EUS that mimic thickened gastric folds or subepithelial tumors. EUS-guided endoscopic therapy is a challenging field of variceal bleeding. It has a potential role for assistance of interventions and evaluation of treatment outcome.     

内镜下套扎、硬化剂及组织胶栓塞联合治疗食管胃底静脉曲张出血的临床研究

目的研究内镜下套扎、硬化剂及组织胶栓塞联合治疗食管胃底静脉曲张出血的临床效果。方法采用回顾性分析方法,研究对象为2018年1月至2019年6月西安交通大学第一附属医院收治的220例食管胃底静脉曲张出血患者。根据不同治疗方式分为对照组(n=100)和研究组(n=120)。对照组单用内镜下套扎治疗,研究组联用内镜下套扎、硬化剂及组织胶栓塞联合治疗。比较2组患者术前、术后3 d静脉曲张严重程度、疼痛评分、食管静脉曲张直径、门静脉宽度、脾静脉宽度与治疗后止血成功率、早期再出血率和迟发性再出血率。结果2组患者术前静脉曲张严重程度、疼痛评分、食管静脉曲张直径、门静脉宽度、脾静脉宽度比较,差异无统计学意义(P>0.05);2组患者术后3 d中重度静脉曲张率、疼痛评分、食管静脉曲张直径、门静脉宽度、脾静脉宽度较术前明显降低(P<0.05);研究组术后3 d中重度静脉曲张率、疼痛评分、食管静脉曲张直径、门静脉宽度、脾静脉宽度、早期再出血率、迟发性再出血率较对照组更低,止血成功率较对照组更高,差异有统计学意义(P<0.05)。结论食管胃底静脉曲张出血治疗中内镜下套扎、硬化剂及组织胶栓塞联合应用效果显著,可有效减轻患者静脉曲张严重程度及疼痛,降低再出血率。     

Subtypes and clinical significance of common bile duct varices in portal vein thrombosis: diagnosis and follow-up by Doppler US and EUS

Purpose

To investigate (1) diagnostic performance of transabdominal color doppler ultrasound (US) and endoscopic ultrasound (EUS) for detection and sub-classification of common bile duct varices (CBDV) in patients with portal vein thrombosis (PVT), and (2) clinical significance and natural history of CBDV subtypes.

Patients and Methods

During a 4-year period, 56 patients with PVT underwent US and EUS for the presence and subtypes of CBDV. Natural history was analyzed for patients who attended control visits.

Results

CBDV were diagnosed in 57 and 59 % of patients with US and EUS, respectively. In 19 % of patients, EUS revealed different CBDV subtypes than previously seen by US. The most common were paracholedochal (PCV), while the least common were epicholedochal (ECV) and Submucosal varices (SMV). Nine patients had obstructive jaundice and underwent ERCP which was complicated by hemobilia in two patients with SMV. Among eight patients who underwent control EUS (median follow-up 60 months), the form of CBDV remained unchanged. Two patients bled from esophageal varices, both with ECV.

Conclusion

While abdominal US and EUS are equally sensitive for detection of CBDV, EUS allows more precise determination of CBDV subtype. Patients with SMV might be at increased risk of bleeding upon ERCP.

     

Imaging of patients after the Lap-Band System application

Objective

We describe the use of imaging in the management of adjustable gastric-banding patients, and describe complications of banding that are diagnosed by imaging.

Materials &; Methods

Using a four-year period as an example of complications of this type of laparoscopic approach, we have retrospectively identified all patients with laparoscopic bands who were imaged in the radiology department at our large multispecialty hospital. Included are patients who had their bands placed by the hospital’s surgeons as well as patients referred for consultation from other practices.

Results

Twenty-two of 165 patients who had banding as their sole weight loss surgery had 23 complications diagnosed by imaging. Complications included band slip (3), device issues (4), esophageal dilation (8), esophageal dysmotility (5), symptomatic gallstones (2) and a gastroesphageal diverticulum (1). Complications were detected by fluoroscopy (17), CT (4) or ultrasound (2). 17 patients had banding as one of multiple bariatric surgeries, with 13 complications: band slip (4), port infection (1), esophageal dilation (1), esophageal dysmotility (5), anastomotic leak (1) and internal hernia (2). Complications were detected with fluoroscopy (12) and CT (1).

Conclusions

Fluoroscopy is generally the primary imaging modality used to diagnose complications of gastric banding. Esophageal dilation and dysmotility, which appear to be long-term sequelae of banding, were the most common complications identified by imaging.