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Abdominal > Liver Vasculature > Flashcards

Liver Vasculature Flashcards

1
Q

What is the largest organ in the human body?

A

The liver.

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2
Q

Where does the liver lie?

A

It lies in the intraperitoneal cavity.

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3
Q

What does the liver do?

A
  • It plays an essential role in all metabolic processes in the body
  • It filters and detoxifies the blood and helps regulate blood volume.
  • It helps dispose of old RBC and manufacture new ones
  • Processes blood coming from the bowel via portal system.
  • The liver produces proteins necessary for blood clotting
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4
Q

What is a major by-product of the broken red blood cells in the liver?

A

Bile.

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5
Q

What is bile?

A

It is an emulsifier of fat that aids in digestion.

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6
Q

What type of blood supply does the liver have?

A

It has a dual blood supply.

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7
Q

What does the dual blood supply in the liver consist of?

A
  • Hepatic artery supploes approx. 30% of blood flow.
  • Portal vein supplies aprox. 70% of blood flow (nutrient rich) from the gastrointestinal tract.
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8
Q

The hepatic artery and portal vein comprise the___________.

A

The hepatic inflow

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9
Q

What does the portal triad consist of?

A

It is comprised of branches of the hepatic artery, portal vein, and bile duct.

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10
Q

Where does the main portal vein begin at?

A

It begins at the confluence of the splenic vein and superior mesenteric vein.

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11
Q

Where does the portal veins lie?

A

Anterior to the IVC

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12
Q

What happens to the portal vein upon entering the porta hepatis?

A

The MPV divides into the left portal vein and right portal vein

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13
Q

What are the anatomy of the RPV (Right Portal Vein)?

A
  • Typically larger
  • Posterior and caudal
  • Divides into anterior and posterior branches
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14
Q

What is the anatomy of the LPV (Left Portal Vein)?

A
  • Anterior and cranial
  • Divides into medial and lateral branches.
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15
Q

What are the characteristics of the portal veins?

A
  • Conatins NO valves
  • Bright, echogenic walls due to thick collagenous tissue
  • Course intrasegmentally
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16
Q

What does hepatopetal mean?

A

Towards the liver.

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17
Q

What does hepatofugal mean?

A

Away from the liver

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18
Q

What are the 3 main hepatic veins?

A

Right, middle and left hepatic veins.

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19
Q

What veins are the primary outflow for the liver?

A

Hepatic veins.

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20
Q

What do the hepatic veins drain into?

A

They drain into the IVC, near the right atrium.

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21
Q

What are the characterisitics of the hepatic veins?

A
  • Contains NO valves
  • Thin-walled vessels
  • Courses intersegmentally.
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22
Q

Which is the largest of the 3 hepatic veins?

A

The right hepatic vein is typically the largest.

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23
Q

What vessels join to form a common trunk before entering the IVC?

A

MHV and LHV

24
Q

What type of waveform does the hepatic veins demonstrate?

A

Pulsatile waveform.

25
Q

Where does the common hepatic artery arise off?

A

The celiac axis

26
Q

What is it known as once the hepatic artery courses over the anterior-superior edge of the pancreas and gives rise to the gastroduodenal?

A

The proper hepatic artery

27
Q

Where does the hepatic artery terminate?

A

At the level of the porta hepatis

28
Q

What are some hepatoporta duplex indications?

A
  • Liver cirrhosis
  • Portal hypertension
  • Ascite of unknown etiology
  • Thrombosis of portal, splenic, and superior mesenteric veins.
  • Budd-Chiari syndrome
  • Pre & Post-intervention
  • TIPS evaluation
  • Acute abdominal pain
  • Elevated D-dimer
29
Q

What are some risk factors?

A
  • Chronic liver disease.
    • Viral Hep.
    • Hep B or C
    • Metabolic disorders
  • Heart disease that results in elevated right-sided heart pressures.
    • CHF
    • Tricuspid regurgitation
30
Q

What are some hepatoportal duplex vessel assesments?

A

Gray scale and color:

  • Extra- and intra-hepatic portal veins, hepatic veins, and IVC

Spectral Doppler waveforms and velocity measurements:

  • MPV, RPV, LPV
  • RHV, MHV, LHV
  • SV
  • SMV
  • IVC
  • Proper hepatic artery
31
Q

What are some addiditon assessments of a hepatoportal duplex?

A
  • Size and echogenicity of liver
    • masses, cyst
  • Spleen size (splenomegaly)
  • Presence of ascites
  • MPV diameter during quiet respiration as it crosses the IVC
32
Q

Portal Vein

A

Diameter: <13 mm

PSV: 10-30 cm/s

Flow: Towards the liver

Doppler: Repiro-phasic

33
Q

Hepatic vein:

A

Diameter: RHV <6

PSV:22-39 cm/s

Flow: Antegrade and retrograde

Doppler: Pulsatile, multiphasic

34
Q

Splenic vein

A

Diameter: up to 10 cm

PSV: 9-30 cm/3

Flow: Towards the liver (hepatopetal)

Doppler: Monophasic, slightly pulsatile.

35
Q

SMA

A

Diameter: Up to 10 cm

PSV: 8-40 cm/sec

Flow: towards the liver (hepatopetal)

Doppler: Monophasic, slightly pulsatile.

36
Q

Hepatic artery

A

Diameter: smaller than PV

Flow: hepatopetal

Doppler: Low resistance

37
Q

IVC

A

Diameter: 15 mm to 25 mm

PSV: 44-118 cm/s

Flow: Toward the right atrium

Doppler: Pulsatile, multiphasic, respiro-phasic

38
Q

What is the respiration variation associated with the portal vein?

A

Diameter: increases with inspiration

Velocity: decreases with inspiration, increases with expiration.

39
Q

What is the respiration variation associated with the splenic vein?

A

Diameter: increases by 20-100% with inspiration,

Velocity: decreases with inspiration, increases with expiration.

40
Q

What is the respiration variation associated with the SMV?

A

Diameter: increases by 20-100% with inspiration.

Velocity: decreases with inspiration, increases with expiration.

41
Q

What is ascites?

A

It is effusion and accumulation of serous fluid in the abdominal cavity.

Legs are usually swollen as well due to increase abdominal pressure.

42
Q

What is portal hypertension?

A

It is elevated portal venous pressure due to impedance of blood flow through the liver.

Causes divided in 3 categories:

  1. Prehpatic (inflow)
  2. Intraphepatic (liver, sinusoids, and hepatocytes)
  3. Posthepatic (outflow)
43
Q

What is the most commong etiology of portal hypertension in north america?

A

Cirrhosis caused by hep. C

44
Q

What is the primary complication of portal hypertension?

A

Gastrointensional bleeding from ruptured esophageal and gastric varices.

45
Q

What are the abnormal duplex findings in portal hypertension?

A
  • Increased portal diameter (>13 mm)
  • Increased SV and SMV diameteres (>10 mm)
  • <20% increase in SMV and SV diameteres with inspiration
  • Decreased respiratory variation
  • Decreased PV flow velocity
  • Hepatofugal flow in the portahepatic veins
46
Q

What is TIPS?

A

It stands for transjugular intraheptic portosystemic shunt.

It is a treatment for portal hypertenson.

47
Q

What does TIPS do?

A
  • It decreases pressure or decompresses the portal venous system.
  • A stent is deployed to connect one of the portal veins with one of the hepatic veins (often the right)
  • Re-routes blood away from the liver, to the hepatic vein, and back to the heart.
48
Q

How should you asses TIPS?

A

Obtain velocities and flow direction:

  • MPV
  • PV end of shunt
  • Mid shunt
  • HV end of shunt
  • IVC or outflow hepatic vein
49
Q

What are normal TIPS duplex findings?

A
  • Hepatofugal flow may be present in intrahepatic portal veins
  • MPV= hepatopetal flow.
  • Flow should be directed towards the hepatic vein
  • Color fil wall-to-wall within stent
  • Stent velocities=90-190 cm/s
  • MPV and hepatic artery velocities increase from pre-TIPS
50
Q

How do you indentify a stenosis in TIPS?

A
  • PSV <50 cm/s within stent
  • PSV <30 cm/s within MPV
  • A focal increase in stent velocities measuring >200 cm/s
  • A velocity change of >50 cm/s within stent , as compared to previous exams.
  • >50 cm/s difference in stent velocities from one segment to another
  • Reccurent ascite, varices, or splenomegaly
  • Retrograde flow in hepatic vein serving as outflow
51
Q

What does thrombosis of the portal, splenic or superior mescenteric vein result from?

A
  • Statis due to cirrhosis and portal hypertension
  • Pancreatitis, appendicitis, and diverticulitis
  • Hypercoaguable state
  • Surgery
  • Trauma
  • Abdominal malignancy
52
Q

What are the portal venous trhombosis duplex findings?

A
  • Increased PV diameter with intraluminal echoes
    • >15 mm suggest acute thrombosis
    • >23 mm with intraluminal echoes suggest tumor thrombosis
  • Non-visualization of PV
  • Gallbladder varices
  • Increased hepatic arterial flow.
53
Q

What is Budd-Chiari Syndrome?

A

It is hepatic venous outflow obstruction caused by a thrombosis or tumor.

Can also be caused by IVC stenosis or occlusion cephalad to hepatic veins

54
Q

What is the clinical presenation of Budd-Chiari?

A
  • RUQ pain
  • Jaundice
  • Ascites
  • Hepatomegaly
  • Liver function abnormalities
55
Q

What are the duplex findings in Budd-Chiari?

A
  • IVC dialation with intraluminal echoes
  • Absence of flow in IVC or HV
  • Hepatomegaly
  • HV dilation with intraluminal echoes
  • Sluggish or retrograde flow in PV
  • Splenomegaly
  • Stenosis or occlusion of HV or IVC
  • Ascites
  • Collaterals
56
Q

What is the cause of CHF?

A

DIlation within hepatoportal venous system and IVC

57
Q

What are the characterisitcs of CHF?

A
  • PV flow will be marked pulsatile
  • HV=highly pulsatile and demonstrates flow reversal during diastole.
  • RHV diameter may increase to >9 mm in patients with CHF

Abdominal (6 decks)

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