Ch 20 Hepatoporal System Flashcards by Sarah Anderson

What is ascites?

Abnormal accumulation of fluid within peritoneal cavity

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Ascites is the m/c complication of ____?

Cirrhosis

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What is budd-chiari syndrome?

-Hepatic venous outflow obstruction at any level from the small HVs to the junction of the IVC + RA
-Due to hypercoagulable states

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Differentiate hepatopetal + hepatofugal?

Hepatopetal:
-antegrade flow towards liver
-normal direction of flow within portal-splenic venous system

Hepatofugal:
-retrograde flow away from liver
-abnormal direction of flow

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What is helical PV flow?

Spiraling/swirling helix flow pattern demonstrating hepatopetal, hepatofugal, or bidirectional flow (uncommon)

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What is helical PV flow associated with?

-Advanced chronic liver disease
-Portal hypertension
-Portosystemic shunts

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What is a hepatic arterial buffer response?

Mechanism to maintain perfusion to the liver by arterial vasodilation, when PV flow is obstructed in pt’s with advanced cirrhosis

(when PV perfusion decreases, HA flow increases)

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What is hepatic hydrothorax?

-Pleural effusion in pt’s with cirrhosis + absent cardiopulmonary disease
-Ascites from peritoneal cavity travels to pleural space via diaphragmatic defects

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What is portal hypertension?

Elevated pressure b/w the PV + IVC or HVs of >10-12mm Hg

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What are portosystemic collaterals?

Formation of abnormal blood vessels that shunt PV flow bypassing the liver to the systemic circulation, which decompresses PV pressure

(abnormal communications between the portal system and the systemic circulation)

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What is sinusoidal obstruction syndrome (SOS)?

-Aka hepatic veno-occlusive disease
-Syndrome of tender hapatomegaly, RUQ pain, jaundice + ascites

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SOS most commonly occurs after ___?

Pt’s undergo hematopoietic cell transplantation

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What is transjugular intrahepatic portosystemic shunt (TIPS)?

-Created connection within the liver b/w the HV + PV, allowing blood to bypass the liver + reduce portal pressure in pt’s with portal hypertension

-Manages variceal bleeding + ascites

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The liver receives a dual blood supply from what vessels (hepatic blood inflow)?

HA (25%) + PV (75%)

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Explain the hepatic blood outflow?

-PV enters the sinusoids to reach the central veins (start of HV drainage)

-Central veins enter interlobular veins (forms 3 HVs)

-HVs drain into IVC

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The MPV begins at the junction of ___?

SV + SMV

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___ drains into the SV prior to the portal/splenic confluence?

IMV

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___ drains into the portal system near the portal/splenic confluence?

Left gastric vein (aka coronary vein)

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What is the porta hepatis?

-TRV fissure on posterior surface of liver b/w caudate + quadrate lobes

-Where MPV + HA enters liver + hepatic duct exits liver

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Differentiate the characteristics b/w LPV + RPV?

LPV:
-Smaller, anterior, cranial
-Splits into med/lat branches

RPV:
-Larger, posterior, caudal
-Splits into ant/post branches

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List 3 characteristics of PVs?

-Intrasegmental (within liver segments)
-No valves
-Walls contain a minor amount of collagen
-Hyperechoic walls

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___ is the primary outflow route of blood from the liver?

HVs

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Which HV is the largest?

RHV

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___ joins to form a common trunk before entering the IVC?

MHV + LHV

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List 4 characteristics of HVs?

-Intersegmental (b/w lobes) -No valves -Walls composed of mostly collagen -Only hyperechoic when perpendicular to it

___ drains caudate lobe directly into IVC?

Caudate vein

___ branches off the celiac trunk towards the pt's right?

CHA

When does the CHA become the PHA?

After the gastroduodenal artery branches off

At the porta hepatis, the PHA splits into ___?

RT + LT branches

Where is the HA in the mickey mouse sign?

RT ear (lies anteromedial to PV)

HAs run with ___ veins?

Portal

What is the hepatoporal protocol?

2D images of spleen, liver, pancreas, GB + associated vasculature Spectral doppler: -HVs + IVC -Intrahepatic PVs (MPV, RPV, LPV) -Extrahepatic PVs (SV + SMV) -PHA Measure: -MPV diameter (inner to inner)

Which vessels should we use angle correct with?

MPV + PHA

What is the normal MPV diameter with quiet respiration?

< 13mm

What can the MPV diameter increase to with deep inspiration?

16mm

Normal portal venous flow is ___?

Hepatopetal

What would helical flow look like on CD?

Alternating red + blue bands

PV velocity will increase + decrease during what?

Increase: during expiration + ingestion of food Decrease: during inspiration + exercise

Normal SV diameter is ___ with quiet respiration?

< 10mm

SV > 10mm indicates ___?

Portal hypertension

Normal SV flow direction is ___?

Antegrade (going towards portal-splenic confluence)

The SV will decrease in velocity during ___ + increase during ___?

Inspiration, expiration

Normal SMV diameter with quiet respiration is ___?

< 10mm

Normal SMV flow is ___?

Antegrade

What is the normal RHV diameter?

< 6mm

What is the normal RHV diameter in pt's with CHF?

< 9mm

Normal HV flow is ___?

Pulsatile

Explain the HV waveform?

S: systole, below baseline D: diastole, below baseline V: end systole, above baseline A: atrial contraction, above baseline

The HA is larger or smaller in diameter than the PV?

Smaller

Normal HA flow is ___?

Hepatopetal

What would cause the HA flow to decrease?

Ingesting food, this increases pulsatility

Normal IVC diameter?

15-25mm

SF of an obstructed IVC?

Dilated + loss of phasicity

Normal IVC flow is ___?

Antegrade (to RA), pulsatile + have respiratory phasicity

What is the normal pressure in the hepatoportal system?

5-10 mm Hg

What is the m/c cause of portal hypertension?

Sinusoidal obstruction due to cirrhosis

SFs of the 3 stages of cirrhosis?

Stage 1: liver enlarged + echogenic Stage 2: coarse + heterogeneous Stage 3: nodular, RLL atrophied + enlarged caudate

How does cirrhosis affect the PV + HV flow?

PV: increases resistance HV: obstructs

3 SFs of portal hypertension?

-Loss of phasicity -Bidirectional flow -Hepatofugal flow (severe)

What is the most specific finding of portal hypertension?

Portosystemic collateral veins (varices)

What is the most prevalent collateral vein associated with portal hypertension?

Left gastric vein (>7mm is dilated)

What causes gastroesophageal varices?

Reverse flow in the left gastric/coronary vein

Where do splenorenal varices shunt blood to?

To the LRV, then the IVC (decompresses portal circulation)

What is recanalization of the PUV?

-Fetal remnant arising from the LPV coursing along anterior edge of falciform ligament to the abdominal wall -Connects to systemic veins around umbilicus "caput medusa" sign

Where is recanalization of the PUV located?

In fissure for the ligamentum teres

What is arterialization?

PV obstruction (due to cirrhosis or PVT) which increases resistance + decreases PV flow

What happens to the HA when arterialization occurs?

-Enlarged with high velocity flow -Tortuous corkscrew appearance on CD

What is an AVF?

Abnormal connection b/w artery + vein 1) arterioportal (HA to PV) 2) portosystemic venous (PV to HV/IVC) 3) arteriosystemic (HA to HV)

PVT can be caused by what 2 things?

-Flow stasis secondary to cirrhosis + portal hypertension -Extrinsic compression from malignancy

What is cavernous transformation?

-The formation of periportal collateral veins within or around a previous PVT -Occurs if PVT goes untreated for up to 12 months

What is cardiac cirrhosis (congestive hepatopathy)?

Term used to describe liver disorders that occur due to right sided heart failure Includes: -Hepatomegaly -Portal-hepatic venous system + IVC dilation with absence of wall motion with respiration -Pulsatile PV flow (antegrade + retrograde) -HV waveform has very pulsatile "W" type pattern

What causes primary + secondary BCS?

Primary: endoluminal thrombus or webs Secondary: malignant tumor, etc

SF of BCS?

-Dilated HVs or IVC -Stenosis or occlusion of HVs or IVC -Absence of flow in HVs or IVC -Slow or reversed flow in PV -Enlarged caudate lobe (>3.5cm) -Enlarged caudate vein (>3mm)

SF of SOS?

Patent + large HVs and PVs

TIPS is done under ___ guidance?

Fluroscopic

Where does the catheter get inserted with TIPS insertion?

Enters RJV, through wall of RHV, then through liver to get to the RPV

TIPS reroutes blood from the ___ to ___?

From RPV to RHV + back to IVC

What type of flow should a functioning TIPS have?

-Hepatopetal flow in MPV -Hepatofugal flow in intrahepatic PV branches, beyond the stent

SF of TIPS?

2D: Echogenic structure around hepatic parenchyma that extends into the PV + RHV CD: -Hepatopetal flow at PV end -Hepatofugal flow at HV end

Normal velocities within a TIPS stent range from ____?

90-190 cm/s (take velocity at MPV, PV end, midstent, HV end + HV outflow)

What velocity would indicate a TIPS stenosis?

>190 cm/s

SF of a TIPS occlusion?

-Echogenic material within stent -Absent flow with spectral + CD