Non-invasive assessment of portal hypertension and liver fibrosis using contrast-enhanced ultrasonography

Portal hypertension and hepatic fibrosis are key pathophysiologies with major manifestations in cirrhosis. Although the degree of portal pressure and hepatic fibrosis are pivotal parameters, both are determined using invasive procedures. Ultrasound (US) is a simple and non-invasive technique that is available for use worldwide in the abdominal field. Because of its safety and easy of use, contrast-enhanced US is one of the most frequently used tools in the management of liver tumors for the detection and characterization of lesions, assessment of malignancy grade, and evaluation of therapeutic effects. This wide range of applications drives the practical use of contrast-enhanced US for evaluation of the severity of portal hypertension and hepatic fibrosis. The present article reviews the recent progress in contrast-enhanced US for the assessment of portal hypertension and hepatic fibrosis.     

肝硬化合并门静脉血栓致门静脉高压症治疗现状

肝硬化合并门静脉血栓(PVT)并不少见,PVT会进一步加重门静脉高压症,此时针对PVT的治疗可改善肝硬化患者的预后。目前的治疗方式包括抗凝治疗及经颈静脉肝内门体支架分流术(TIPS)。本文就此类患者的治疗现状作一综述。     

Hepatic and portal vein thrombosis in cirrhosis: Possible role in development of parenchymal extinction and portal hypertension

Obliterative lesions in portal veins (PVs) and hepatic veins (HVs) of all sizes are known to occur in cirrhotic livers. PV lesions have generally been attributed to thrombosis, but the pathogenesis of the HV (veno-occlusive) lesions is unknown. We have studied 61 cirrhotic livers removed at transplantation to clarify the prevalence, distribution, and pathogenesis of venous lesions, as well as the association of these lesions with other morphological features and clinical morbidity. Intimal fibrosis that is highly suggestive of healed HV or PV thrombosis was found in at least 70% and 36% of livers, respectively. The distribution of HV lesions was patchy and largely confined to veins between 0.1 and 3 mm in diameter, suggesting multifocal origin in small veins. PV lesions were more uniform throughout the liver, suggesting origin in large veins with propagation to the small veins. HV lesions were associated with regions of confluent fibrosis (focal parenchymal extinction), and PV lesions were associated with regional variation in the size of cirrhotic nodules and a history of bleeding varices. These observations suggest that thrombosis of medium and large PVs and HVs is a frequent occurrence in cirrhosis, and that these events are important in causing progression of cirrhosis.     

Noninvasive assessment of portal hypertension in patients with cirrhosis

Severe portal hypertension is responsible for complications and death. Although measurement of the hepatic venous pressure gradient is the most accurate method for evaluating the presence and severity of portal hypertension, this technique is considered invasive and is not routinely performed in all centers. Several noninvasive techniques have been proposed to measure portal hypertension. Certain methods evaluate elements related to the pathogenesis of portal hypertension through the measurement of hyperkinetic syndrome, for example, or they investigate the development of hepatic fibrosis through the measurement of increased intrahepatic vascular resistance. Other methods evaluate the clinical consequences of portal hypertension, such as the presence of esophageal varices or the development of portosystemic shunts. Methods evaluating increased hepatic vascular resistance are fairly accurate and mainly involve the detection of hepatic fibrosis by serum markers and transient elastography. The radiological assessment of hyperkinetic syndrome probably has value but is still under investigation. The assessment of severe portal hypertension by the presence of varices may be performed with simple tools such as biological assays, computed tomography, and esophageal capsules. More sophisticated procedures seem promising but are still under development. Screening tools for large populations must be simple, whereas more complicated procedures could help in the follow-up of already diagnosed patients. Although most of these noninvasive methods effectively identify severe portal hypertension, methods for diagnosing moderate portal hypertension need to be developed; this shows that further investigation is needed in this field.     

Assessment of portal hypertension severity using machine learning models in patients with compensated cirrhosis

1. Download : Download high-res image (255KB)
2. Download : Download full-size image

     

肝硬化脾切除术后门静脉血栓形成的危险因素分析

目的探讨肝硬化脾脏切除后门静脉系统血栓形成的原因,并且对各种可能的影响因素进行分析总结。方法回顾性分析本院于2009年2月-2012年2月收治的216例肝硬化脾脏切除术后患者的临床资料,分别对患者的性别、年龄、门静脉和脾静脉的直径、脾脏的大小、肝功能分级、术后并发症、手术前后的门静脉血液流速和压力、手术前后的血小板数量和凝血酶原延长时间等因素进行考察和分析。结果脾切除术后发生门静脉血栓(portal vein thrombosis,PVT)36例,未发生PVT 180例。术后发生PVT患者的门静脉和脾静脉的直径、脾脏的大小、术后门静脉血液流速、手术前后门静脉的压力以及术后并发症的情况与发生门静脉血栓有显著性关联,差异有统计学意义(P<0.05),但是患者的性别、年龄、肝功能分级、手术前后的血小板数目、术前门静脉血液流速和手术前后的凝血酶原延长时间与门静脉血栓的形成无显著性关联,差异无统计学意义(P>0.05)。结论门静脉和脾静脉直径较粗、脾脏较大、手术后门静脉血液流速较慢、手术前后门静脉压力较小以及手术后并发症较多是肝硬化脾切除术后PVT形成的主要危险因素,因此可针对上述指标及时对患者的术后情况进行检测,减少肝硬化脾切除术后PVT的形成,促进患者术后康复。     

Predictive value of D-dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus-related cirrhosis

AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS: A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specifi city, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed. RESULTS: The D-dimer levels in the group developing postoperative PVT was signifi cantly higher than those in the group not developing PVT (P = 0.001), and the ROC semi-quantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi- quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001). CONCLUSION: Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 μg/mL, the possibility of PVT is very high.     

肝硬化门静脉高压患者门静脉压力与血流动力学的关系

通过多普勒超声技术，检测肝硬化门静脉高压患者门静脉系统血流动力学状态并分析其与门静脉压力的关系，旨在探讨多普勒超声技术对肝硬化门静脉高压患者门静压力的诊断意义。     

A comparison study of local injection and radiofrequency ablation therapy for traumatic portal vein injure guided by contrast-enhanced ultrasonography

Background. To compare local injection of hemostatic agents and radiofrequency (RF)-assisted hemostasis in the management of bleeding from the portal vein with varying diameters and blood flow velocities.Material and methods. Sixteen Bama pigs were used. Laparotomy was performed to expose the liver and inner diameters and blood flow velocities of the pre-injured portal vein in the hepatic segments and subsegments were measured. Vascular injuries in the portal vein were produced (4 in each pig). The pigs were randomly divided into two groups and local injection of hemostatic agents was performed in one group and RF-assisted hemostasis in the other, both techniques monitored by contrast-enhanced ultrasonogra-phy (CEUS). Time to hemostasis was measured, and the extent of liver injury was determined 2 h after treatment.Results. In the local injection group, the rates of successful hemostasis were 100, 88.9, and 50% with portal veins with inner diameters of < 1 mm, 1-2 mm, and 2-3 mm, respectively, and the maximum time to achieve hemostasis was 24.0 ± 7.2 s. Hemostasis was not successful when the diameter was > 3 mm. In the RF-assisted group, hemostasis was successfully at all sites regardless of vessel diameter; however, the maximum time to achieve hemostasis was 156.8 ± 31.2 s. Injury to surrounding tissue was significantly greater in the RF-assisted group.Conclusion. Both methods can achieve hemostasis with small diameter portal vein injuries; however, RF-assisted hemostasis is necessary for larger vessels, though it is associated with greater damage to surrounding tissue.     

超声检查诊断肝硬化门静脉高压症临床价值研究

目的 研究超声检查在肝硬化门静脉高压症诊断中的临床价值。方法 选择2008年1月~2015年9月我院诊治的肝硬化门静脉高压症患者80例和体检健康者75例,使用纤维内镜进行胃镜检查,判断食管胃底静脉曲张程度,使用意大利百胜Mylab60全数字化多普勒超声诊断仪测量门静脉内径、脾静脉内径、门静脉血流量和脾静脉血流量。结果 肝硬化患者门静脉内径、脾静脉内径、门静脉血流量和脾静脉血流量分别为（1.4±0.6） cm、（1.2±0.3） cm、（1023.2±653.4） mL/min和（593.3±112.3） mL/min,均明显高于健康人【（0.9±0.2） cm、（0.6±0.4） cm、（916.3±254.2） mL/min和（325.6±96.4） mL/min,P<0.05】;46例门静脉内径≥1.4 cm组轻度曲张发生率为19.6%,明显低于34例门静脉内径<1.4 cm组的52.9%（P<0.05）,门静脉内径≥1.4 cm组重度曲张发生率为52.2%,明显高于门静脉内径<1.4 cm组的20.6%（P<0.05）;49例脾静脉内径≥1.0 cm组轻度曲张发生率为20.4%,明显低于31例脾静脉内径<1.0 cm组的51.6%（P<0.05）,脾静脉内径≥1.0 cm组重度曲张发生率为51.0%,明显高于脾静脉内径<1.0 cm组的22.6% （P<0.05）。结论 超声检查诊断肝硬化门静脉高压症具有较高的敏感性和特异性,对食管胃底静脉曲张的轻重程度也具有良好的诊断价值,能为评价患者的肝功能和选择治疗方案提供重要的参考依据。     

Hepatic hemodynamics in patients with chronic hepatitis or cirrhosis as assessed by organ-reflectance spectrophotometry

Hepatic hemodynamics in patients with chronic liver disease has been studied by reflectance spectrophotometry of the liver in situ during peritoneoscopy. An organ-reflectance spectrophotometer used in this study was equipped with a branched optic fiber bundle, which coupled the liver surface with the spectrophotometer. The spectrophotometry could measure qualitatively and quantitatively the absorption of hemoglobin in the liver in situ, thus estimating the regional hepatic tissue blood hemoglobin concentration and the saturation level of hemoglobin in the regional tissue blood. The analysis of 42 cases has shown that the estimated regional hepatic tissue blood hemoglobin concentration and saturation level of hemoglobin decreased in most cirrhotic livers, suggesting that even in cirrhotic livers the hepatic oxygen extraction increased, concomitant with a decrease in the regional hepatic tissue blood hemoglobin concentration. The hepatic blood hemoglobin concentration estimated on the surface layer of the liver was positively correlated with the regional hepatic blood flow measured by radioisotope clearance technique. The estimated hepatic blood hemoglobin concentration was also correlated positively with serum albumin level and prothrombin time, and negatively correlated with plasma retention of indocyanine green at 15 min. It is concluded that the hepatic tissue blood hemoglobin concentration decreases significantly with progress of chronic hepatitis to cirrhosis. This decrease in hepatic blood hemoglobin concentration and flow is concomitant with a decrease in metabolic functions, which is not compensated by an increased hepatic oxygen extraction.     

Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis

OBJECTIVES: We aimed to develop a model based on noninvasive variables for the prediction of clinically significant portal hypertension (CSPH) and of esophageal varices (EV) in patients with compensated liver disease.
METHODS: Sixty patients with compensated liver cirrhosis diagnosed by histology were included in the training set. All patients had physical examination, laboratory tests, abdominal color-Doppler ultrasound, upper digestive tract endoscopy, and measurement of hepatic venous pressure gradient. Predictive models for the presence of CSPH and of EV were calculated. The models were validated in an independent series of 74 patients with compensated liver disease.
RESULTS: Clinical and laboratory variables were selected in the final models, while ultrasonography did not add statistical power for the prediction of CSPH and EV. The model for prediction of CSPH included albumin, INR, and ALT. The best cutoff had 93% sensitivity and 61% specificity in the training set, and correctly classified 77% of patients in the validation set. Spider angiomas, ALT, and albumin predicted EV. The best cutoff of the model in the training set had a sensitivity of 93% and a specificity of 37% and correctly classified 72% of cases in the validation set.
CONCLUSIONS: Noninvasive prediction of EV in well-compensated cirrhotic patients is not accurate. However, a model obtained by combining simple laboratory variables has a high sensitivity to predict CSPH in this population and may be useful to select the subset of patients requiring screening endoscopy. By this method, endoscopic screening could be obviated in about 40% of patients.     

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.     

Doppler ultrasonography for postoperative hepatofugal portal blood flow of the intrahepatic portal vein

BACKGROUND/AIMS: The clinical significance of the hepatofugal portal blood flow after abdominal surgery involving other than portosystemic shunt was investigated in our hepatobiliary pancreatic surgical division. METHODOLOGY: Preoperative and postoperative Color and pulsed Doppler ultrasonography was performed on 101 consecutive patients who underwent abdominal surgery. Preoperative Doppler ultrasonography was performed within one week before surgery. Basically, postoperative Doppler ultrasonography was performed every other day within one week after surgery and once a week 2 weeks after surgery. The portal flow direction was assessed in the right portal branch or the umbilical portion of the left portal branch. RESULTS: Of the 101 patients, 9 showed a hepatofugal flow in the intrahepatic portal vein, 5 of which showed a total hepatofugal flow, and 4 of these 5 patients died of hepatic failure. The remaining 4 patients showed a partial hepatofugal flow and postoperative hyperbilirubinemia, but all 4 survived. CONCLUSIONS: Postoperative total hepatofugal flow indicated a serious prognostic sign of critical liver damage. Postoperative partial hepatofugal flow induced postoperative hyperbilirubinemia which was not critical.     

Noninvasive assessment of portal hypertension in cirrhosis: Liver stiffness and beyond

Liver stiffness measurement(LSM)is a good,but still limited tool to noninvasively assess complications and prognosis in patients with advanced liver disease.This review aims to consider the role of LSM for the diagnosis of portal hypertension-related complications and for assessment of prognosis in cirrhotic patients,and to highlight the drawbacks as well as some alternatives for improving the performance.Hence,this field is far from being closed,and deserves more attention.There is still a place for more carefully designed studies to find new,innovative and reliable approaches.