Sonographic demonstration of a patent umbilical vein in portal vein tumor thrombosis

A patent umbilical vein is a well-known sonographic sign of portal hypertension. We here describe this finding in a patient with extensive tumor thrombosis of the portal vein and its branches.     

Acute portal vein thrombosis

The findings in acute portal vein thrombosis in a patient with chronic calcific pancreatitis and two episodes of pancreatic surgery are described. The diagnosis was made by ultrasound, which showed a dilated portal vein filled with low-level echoes, surrounding hepatic oedema, hypertrophy of the hepatic artery, splenomegaly, collateral vessels and ascites. This was confirmed by computed tomography. The ultrasonic differences in appearance between acute and chronic portal vein thrombosis are discussed, in the context of portal hypertension. The diagnosis of acute portal vein thrombosis should be considered in patients in the appropriate situation who suffer a sudden clinical deterioration with right upper quadrant or abdominal pain. Ultrasound is recommended as the imaging modality of first choice because of the flexibility of its scanning plane and its real time and Doppler capabilities. Computed tomography is valuable in patients with an ileus or heavy pancreatic calcification and for its ability to demonstrate patent vessels on intravenous injection of contrast medium.     

MR imaging of portal vein thrombosis

MR imaging is emerging as a potential means of detecting portal venous thrombosis (PVT). Therefore, we attempted to establish specific criteria with which to diagnose PVT on conventional spin-echo images. In a retrospective review of 342 consecutive abdominal MR scans performed with a 0.5-T magnet, we identified nine patients with persistent signal in the portal vein and used the findings in these patients to establish criteria with which to diagnose PVT. We subsequently applied these criteria to 109 additional consecutive abdominal MR scans performed with the same magnet. Fifteen cases were found in which all images showed either (1) signal involving the entire width of the portal vein lumen, which approximated (with T1 weighting) and exceeded (with T2 weighting) the intensity of the hepatic parenchyma in images in which the hepatic veins showed a complete flow void or (2) complete nonvisualization of the portal vein and its major branches in images that showed a flow void in portal venous collaterals and hepatic veins. All patients had unequivocal findings of PVT on at least one other imaging study (CT or sonography) or at surgery. Although the sensitivity of these signs could not be calculated, their specificity was 100%. We conclude that in the presence of these signs, the diagnosis of PVT can be made with confidence.     

Ultrasonographic demonstration of portal vein thrombosis.

For screening patients suspected of having portal vein thrombosis, the ultrasound examination is simple to perform, noninvasive, and can be accomplished rapidly. Three patients were studied in whom ultrasound examination revealed portal vein thrombosis that was subsequently confirmed by angiography or surgery. Ultrasonic findings in a series of 100 randomly selected patients are summarized.     

门静脉癌栓合并门脉高压症的TIPS姑息治疗

目的 评价门静脉癌栓（portal vein tumor thrombosis,PVTT) 合并门脉高压症患者行经颈静脉肝内门体静脉分流术（transjugular intrahepatic portosystemic shunt,TIPS)姑息治疗的疗效，并讨论其技术特点。方法 本组报告14例终末期肝癌合并门静脉癌栓及门静脉高压症患者，平均年龄53．6％。8例门静脉主干完全堵塞，6例门静脉主干及分支有不同程度栓塞，5例合并门静脉海绵样变。1例单纯上消化道大出血，3例单纯顽固性腹水，10例上消化道大出血合并顽固性腹水。结果 14例中10例患者成功行TIPS治疗，门静脉压力平均从术前37.2mmHg(1mmHg=0.133kPa)降至术后18.2mmHg，平均降低19.0mmHg；腹水减少或消失，消化道出血，腹胀，腹泻等症状缓解，平均生存32.3d。4例失败。结论 TIPS是姑息治疗肝癌合并门静脉癌栓引起的上消化道大出血和顽固性腹水的有效方法。     

Gradient echo MRI of portal vein thrombosis.

The MR appearance of thrombosis of the portal vein and its branches using gradient echo (GRE) sequences is described. The study consists of two separate parts. In the first part, five normal volunteers were examined to select the optimal section plane for each portal vessel to be studied. Given the "time of flight" effect of GRE sequences, a scan plane perpendicular to the direction of flow was used to obtain maximal signal enhancement of flowing blood. In the second part of the study, 13 patients with thrombosis of the portal system diagnosed by Doppler sonography, CT, and digital subtraction angiography were examined with the GRE technique. Gradient echo MR confirmed the presence and defined the extent of vessel thrombosis with high diagnostic accuracy. In addition, it proved accurate in detecting portosystemic collaterals. We concluded that the GRE technique can be effectively used as a complement to conventional SE MR to further delineate portal vessels.     

Imaging and radiological interventions of portal vein thrombosis

Portal vein thrombosis (PVT) is diagnosed by imaging methods. Once diagnosed by means of ultrasound, Doppler ultrasound can be performed to distinguish between a benign and malignant thrombus. If further information is required, magnetic resonance angiography or contrast-enhanced computed tomography is the next step, and if these tests are unsatisfactory, digital subtraction angiography should be performed. Many papers have been published dealing with alternative methods of treating PVT, but the material is fairly heterogeneous. In symptomatic non-cavernomatous PVT, recanalization using local methods is recommended by many authors. Implantation of transjugular intrahepatic portosystemic shunt is helpful in cirrhotic patients with non-cavernomatous PVT in reducing portal pressure and in diminishing the risk of re-thrombosis. In non-cirrhotic patients with recent PVT, some authors recommend anticoagulation alone. In chronic thrombotic occlusion of the portal vein, local measures may be implemented if refractory symptoms of portal hypertension are evident.     

Macronodular hepatic tuberculosis associated with portal vein thrombosis and portal hypertension

Tuberculosis (TB) of the liver is usually associated with miliary spread. Macronodular TB of the liver is rare. A case of macronodular TB of the liver in a 31-year-old woman causing portal vein thrombosis and portal hypertension is presented. Ultrasound and CT appearances are described. There was coexistent ileo-caecal TB with extensive mesenteric and retroperitoneal lymphadenopathy. Macronodular TB should be considered in the differential diagnosis when a patient presents with multiple calcified masses in the liver with portal vein thrombosis and portal hypertension.     

A rare pediatric case of portal vein aneurysm thrombosis

Portal vein aneurysm (PVA) is rarely encountered, and published papers describing this etiology in adults and children typically include only case reports or small case series. We present a clinical case of PVA in a child associated with severe complications, including diffuse thrombosis of the portal venous system. A 10-year-old boy presented with abdominal pain and vomiting, resulting in an initial diagnosis of pancreatic head tumor based on suspicious images on abdominal grayscale ultrasound. Contrast-enhanced computed tomography confirmed a diagnosis of occlusive PVA thrombosis (36 × 37 × 95 mm). Lacking drastic symptoms, the patient was treated with conservative anticoagulant therapy. On follow-up, the thrombosis appeared to shrink gradually and disappeared at 6 months based on Doppler ultrasound imaging. The PVA was reduced in size, and hepatopetal flow was restored. Surgeons and radiologists should be aware of this rare entity to ensure that a precise diagnosis can be established and to provide suitable treatment.     

TIPSS技术在门脉癌栓性门脉高压中的应用

目的 探讨TIPSS技术在治疗门静脉癌栓合并门脉高压中的技术特点及禁忌证。方法 16例门静脉癌栓合并门脉高压症患者,9例门静脉主干完全堵塞,7例门静脉主干及分支有不同程度栓塞;6例合并门脉海绵样变;1例单纯上消化道大出血;4例单纯顽固性腹水;11例上消化道大出血合并顽固性腹水。结果 16例中11例患者成功行TIPSS治疗,技术成功率约68.8%,门脉压力从术前4.9kPa降至2.4kPa,平均降低2.5kPa,腹水减少或消失,症状缓解。平均生存136d。5例失败。结论 TIPSS是治疗门脉癌栓引起的上消化道大出血和顽固性腹水的有效方法,门脉海绵样变是该术的禁忌证。     

Hepatopetal collaterals after portal vein thrombosis following liver transplantation

Two liver transplant patients with hepatopetal collaterals after portal vein thrombosis are described. Angiographically, the appearance is similar to cavernous transformation of the portal vein. The demonstration of hepatopetal collaterals is diagnosic of portal vein occlusion from whatever cause. After portal vein occlusion, collaterals develop from preexisting periportal vessels which undergo compensatory enlargement and reconstitute the intraheptic portal vessels. In liver transplant patients, the collateral communications must arise de novo, since all potential collateral pathways are severed at the time of transplantation.     

Conformal radiation therapy for hepatoma with portal vein thrombosis

A 43-year-old male patient was diagnosed as having hepatocellular carcinoma with portal vein thrombosis and arterioportal shunts. Three-dimensional conformal radiation therapy (3DCRT) with high focal dose was given to the left portal venous area. Shrinkage of the tumour and thrombus, disappearance of the arterioportal shunts and restoration of the hepatopedal flow of the portal vein was noted 3 months after treatment. The patient received further transarterial embolisation and achieved successful tumour control. No serious complications were encountered. 3DCRT is technically feasible and effective to treat a small volume of liver tissue with a high dose of radiation in this advanced disease.     

Contrast-enhanced color Doppler US in malignant portal vein thrombosis

Purpose: To assess the role of contrast-enhanced color Doppler US in the differential diagnosis of benign and malignant portal vein thrombosis.Material and Methods: Fifty-six patients with portal vein thrombosis underwent color and power Doppler US examination before and after i.v. injection of galactose-palmitic acid suspension. The criterion for diagnosing the presence and extension of thrombosis was the lack of visualization of portal vein flow in a segment of the portal vein. The criterion for diagnosing malignant portal vein thrombosis was the detection of pulsatile arterial flow, either hepatopetal or hepatofugal, in the thrombus. The US data were correlated with the types of portal vein thrombosis.Results: Among the 56 patients, there were 40 benign and 16 malignant portal thromboses. Unenhanced Doppler US detected continuous blood flow in 24 benign thromboses and pulsatile in 3 malignant thromboses. No flow, either continuous or pulsatile, was detected in 16 cases with benign thrombosis and in 13 cases with malignant thrombosis. Contrast-enhanced Doppler US allowed to assess pulsatile flow in 15 cases with malignant thrombosis (94%). The use of pulsatile flow as diagnostic criterion of malignant thrombosis yielded a sensitivity of 57% and a specificity of 95% with conventional Doppler US, whereas contrast-enhanced US achieved a sensitivity of 94% and a specificity of 100%.Conclusion: Contrast-enhanced Doppler US is a reliable diagnostic tool for assessing malignant portal vein thrombosis.     

Transsplenic endovascular therapy of portal vein stenosis and subsequent complete portal vein thrombosis in a 2-year-old child

A complex catheter intervention for portal vein stenosis and subsequent complete thrombosis after split-liver transplantation was performed using transsplenic access to the portal vein circulation. The combination of intrahepatic, local thrombolysis and extrahepatic portal vein angioplasty performed twice on 2 consecutive days followed by anticoagulation with a high dose of heparin and clopidogrel completely resolved portal vein stenosis and thrombosis. Postinterventional angiographic and serial ultrasound examinations confirmed that the endovascular therapy was successful. In selected patients, percutaneous transsplenic access to the portal vein circulation may be used for diagnostic and therapeutic interventions even in early childhood.