45 year old female with cirrhosis, hepatitis B and C.

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Portal Hypertension

  • Image findings: Ultrasound shows hepatofugal blood flow in the portal vein. MR image #1 shows prominent replaced hepatic artery from left gastric artery. MR image #2, venous phase, shows large collateral vessels
  • Portal hypertension is defined as portal pressure > 5-10mm Hg. Most commonly is caused by hepatic cirrhosis. Clinical manifestation occur because of altered flow dynamics. GI variceal bleeding is the most common presentation
  • Causes:
    • Presinusoidal: portal vein obstruction (thrombosis, tumor), Schistosomiasis
    • Sinusoidal: Cirrhosis
    • Postsinusoidal: Budd-Chiari syndrome, Hepatic vein or IVC occlusion
  • Physiology: Elevated portal pressure, Increased hepatic arterial flow to liver, biphasic or hepatofugal portal flow, decompression of portal venous system via systemic collaterals
  • Collaterals:
      1. Coronary vein to azygous or hemiazygous veins (esophageal varices),
      2. SMV/IMV to iliac veins (mesenteric varices, stomal varices),
      3. IMV to inferior hemorrhoidal veins (hemorrhoids),
      4. Umbilical vein to epigastric veins (caput medusa),
      5. Splenic vein to azygous veins(gastric fundal varices),
      6. Splenic vein to retroperitoneal veins (duodenal/retroperitoneal varices)
        • Radiographic Features:
          • US: Recanalized umbilical vein or hepatofugal flow is diagnostic. Always determine portal and splenic vein patency for determining treatment options. Portal collaterals. Splenomegaly. Ascites.
          • Angiography: Elevated portal pressure (Corrected sinusoidal pressure=hepatic wedge pressure IVC pressure), CSP < 5mm Hg is normal. Portal flow away from liver. Portosystemic collaterals or varices. Corkscrew hepatic arteries. Always exclude presinusoidal and postsinusoidal etioligies
        • Treatment:
          • TIPS is the treatment of choice after conventional endoscopic teaching fail to control bleeding
          • Variceal embolization is adjunctive
          • Sugical portosystemic shunts
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