Hepatic vein Doppler waveform changes in early stage (Child-Pugh A) chronic parenchymal liver disease

Application of ultrasound for the diagnosis of cirrhosis/portal hypertension

With advances in technologic approaches in patients with cirrhosis, including the improvement of management, a simple, one-step approach for advanced fibrotic state of the liver is clinically useful. Although refining the diagnosis of cirrhosis to reflect disease heterogeneity is essential, current diagnostic tests have not kept pace with the progression of this new paradigm. There are unmet needs in primary care centers with respect to patients with cirrhosis. Liver biopsy and measurement of hepatic venous pressure gradient in patients with cirrhosis are the gold standards for the estimation of hepatic fibrosis, and they have diagnostic and prognostic value. However, both approaches are invasive and cannot be used repeatedly in clinical practice. Ultrasonography (US) is safe, easy to perform, inexpensive, and yields numerical and accurate results. Conventionally, the size of the liver and spleen, bluntness of the liver edge, nodularity of the liver surface, and coarseness of the liver parenchyma have been known as useful parameters for hepatic fibrosis or portal hypertension (PHT) in chronic liver disease. Additionally, some functional US indices including Doppler and CEUS-based examination have been suggested as promising markers for diagnosing cirrhosis and PHT. Identification of the reproducibility and long-term prognostic value through further investigations can demonstrate the clinical usefulness of functional US indices, which are characterized as quantitative parameters for hepatic fibrosis and PHT.

Hepatic function predictive value of hepatic venous waveform versus portal vein velocity in liver cirrhosis

Background:

This study assessed the hepatic vein waveform (HVW) and mean maximum portal vein velocity (MM-PVV) on Doppler ultrasound in patients with liver cirrhosis (LC) and compared it with that of age and sex-matched controls. It correlated the degree of HVW abnormality and MM-PVV changes with liver function based on Child-Turcotte-Pugh (CTP) to determine which was more predictive of CTP.

Methods:

Sixty patients with LC and 60 healthy controls were consecutively recruited into this study. Each patient was classed based on the CTP system after relevant tests. Doppler evaluation of the hepatic vein (HV) and MM-PVV were performed. HVW obtained was classified either into triphasic, biphasic, or monophasic.

Results:

Sixty cirrhotic and 60 age-matched control subjects aged 19–69 and 18–69 years, respectively, completed this study. All control subjects had a normal HVW pattern while 46 (76.7%) cirrhotic subjects had abnormal HVW (P < 0.001). The MM-PVV was significantly lower in cirrhotic subjects than in controls; 22.8 cm/s versus 33.6 cm/s (P < 0.001). The degree of HVW abnormality among cirrhotics showed a significant positive correlation with CTP (r = 0.283, P = 0.029). MM-PVV on the other hand showed no correlation with CTP class (r = −0.124; P = 0.346). Linear regression showed that HVW was a significant predictor of hepatic dysfunction based on CTP.

Conclusion:

Changes in the waveform pattern of the HVs are a good predictor of the derangement of hepatic function in patients with LC than changes in PVV. HVW pattern could therefore serve as an adjunct to CTP class in hepatic function assessment.

Conventional ultrasound for diagnosis of hepatic steatosis is better than believed

BACKGROUND

Hepatic steatosis is a condition frequently encountered in clinical practice, with potential progression towards fibrosis, cirrhosis, and hepatocellular carcinoma. Detection and staging of hepatic steatosis are of most importance in nonalcoholic fatty liver disease (NAFLD), a disease with a high prevalence of more than 1 billion individuals affected. Ultrasound (US) is one of the most used noninvasive imaging techniques used in the diagnosis of hepatic steatosis. Detection of hepatic steatosis with US relies on several conventional US parameters, which will be described. US is the first-choice imaging in adults at risk for hepatic steatosis. The use of some scoring systems may add additional accuracy especially in assessing the severity of hepatic steatosis.

SUMMARY

In the presented paper, we discuss screening and risk stratification, ultrasound features for diagnosing hepatic steatosis, B-mode criteria, focal fatty patterns and Doppler features of the hepatic vessels, and the value of the different US signs for the diagnosis of liver steatosis including classifying the severity of steatosis using different US scores. Limitations of conventional B-mode and Doppler features in the evaluation of hepatic steatosis are also discussed, including those in grading and assessing the complications of steatosis, namely fibrosis and nonalcoholic steatohepatitis.

KEY MESSAGES

Ultrasound is the first-line imaging examination for the screening and follow-up of patients with liver steatosis. The use of some scoring systems may add additional accuracy in assessing the severity of steatosis. Conventional B-mode and Doppler ultrasound have limitations in grading and assessing the complications of steatosis.

A sonographic Doppler study of the hepatic vein, portal vein and hepatic artery in liver cirrhosis: Correlation of hepatic hemodynamics with clinical Child Pugh score in Singapore

Objective

Liver cirrhosis has been a rising complication of chronic liver disease in Singapore. Ultrasound has been widely accepted as a non-invasive imaging modality for the evaluation of hepatic haemodynamics. This study aims to correlate the Doppler ultrasound values with the progression of liver cirrhosis to allow further understanding and possible prediction of clinical events for timely intervention.

Methods

Study sample of 56 eligible patients with liver cirrhosis was divided according to their Child-Pugh clinical score into Child's A (n = 29 patients), B (n = 19 patients) and C (n = 8 patients). The maximum portal vein velocity, maximum hepatic vein velocity, maximum hepatic artery velocity and hepatic artery resistive index were assessed by Doppler ultrasound.

Results

The incidence of ascites increases with the severity of cirrhosis. Flattening of the hepatic vein waveforms was dependant on degree of liver cirrhosis. Maximum hepatic vein velocity was higher in cirrhotic patients (where p = 0.05). Maximum portal vein velocity was found to be lower in cirrhosis (where p < 0.001) and mean maximum portal vein velocity decreases as severity of cirrhosis worsens. Hepatic artery resistive index was significantly higher in cirrhosis (where p < 0.001). Significant association was found between maximum hepatic vein velocity and maximum hepatic artery velocity and significant negative correlation was observed with the maximum portal vein velocity and hepatic artery resistive index.

Conclusion

The study demonstrated that these parameters can supplement the evaluation of liver cirrhosis and will be able to distinguish the different grades of liver cirrhosis using Doppler ultrasound.

Imaging modalities for the diagnosis of hepatic fibrosis and cirrhosis

Non-invasive methods for liver fibrosis diagnosis are now commonly used as first-intention tests for liver fibrosis diagnosis in chronic liver diseases. Even morphological parameters provided by ultrasound is now challenged by blood fibrosis tests and transient elastography, in experienced hands, it performed well and in certain situations, imaging can still be useful to detect patients with fibrosis. In parallel, to ultrasound and Doppler imaging, various methodologies have been explored. Some of them remain confined to clinical research for the moment, as perfusion, MR diffusion-weighted imaging, intravoxel incoherent motion or acoustic structure quantification; others have already taken a place in clinical practice. Regarding fast growing of new technology some methods may become available for daily practice in the near future. Ultrasound tools or automated quantification of different physical parameters of imaging data could provide an opportunity for early diagnosis of liver diseases; MRI techniques could lead to the development of a "global" liver examination.

The role of ultrasonography in the evaluation of diffuse liver disease

The use of ultrasonography (US) to detect and characterize diffuse liver disease can be challenging, but remains a useful tool for the diagnosis and management of many diffuse parenchymal liver diseases such as cirrhosis, steatosis, and malignancies. Newer techniques, such as elastography, are proving useful for earlier detection of hepatic parenchymal changes. The role of US in the assessment of possible biliary ductal obstruction is well established, and Doppler US may provide additional physiologic information regarding hepatic blood flow. US plays a central role in target selection and guidance of percutaneous liver biopsies.

Correlation between Doppler of the right hepatic vein with ultrasound transcutaneous guided biopsy in liver diseases

OBJECTIVE

To correlate chronic liver disease diagnosed by transcutaneous liver biopsy guided by ultrasound, with ultrasound findings with B-mode and Doppler of the right hepatic vein; 2) to compare the wave patterns between the study group and the control group; 3) to compare the right hepatic vein Doppler findings with histopathology findings as a possible marker of chronic liver disease.

METHODS

Were studied 38 patients with chronic liver disease diagnosed by biopsy and serology (study group) and 10 persons without serologic liver disease (control group), assessed only by ultrasound B-mode and Doppler. The criteria were based on histology classification of the Brazilian Society of Pathology for chronic hepatitis. Chi-square, Fisher's exact and Student t tests were used.

RESULTS

The B-mode and Doppler ultrasound were useful in inferring the differentiation between individuals with chronic liver disease from normal. There were significant differences between the study group and the controls when comparing the histopathology findings, ultrasound B-mode and Doppler in relationship to the wave patterns of the right hepatic vein.

CONCLUSION

The correlation of liver biopsies with ultrasound B-mode and Doppler of hepatic vein was positive; 2) individuals with liver disease showed alterations in the flow of the right hepatic vein and normal subjects not, being the wave pattern in normal triphasic and in patients with chronic liver disease monophasic or biphasic; 3) Doppler of the right hepatic vein is useful marker for chronic liver disease.

Relationship between hepatic haemodynamics assessed by Doppler ultrasound and liver stiffness

AIM

We tested the relationship between hepatic haemodynamics assessed by Doppler ultrasonography and liver stiffness assessed by Transient Elastography in hepatitis C related chronic liver disease.

METHODS

Three liver Doppler ultrasound parameters (hepatic artery resistance index, splenic artery resistance index and waveform pattern in hepatic veins) and liver stiffness measured by Transient Elastography were analysed in one hundred consecutive patients affected by hepatitis C related chronic liver disease.

RESULTS

Hepatic and splenic arteries resistance indexes correlate significantly (p<0.0001 for both) with liver stiffness. A hepatic artery resistance index cut-off value of 0.64 provided sensitivity and specificity respectively of 84.4% and 69.1% for predicting liver stiffness ≤or >13 kPa, whereas a splenic artery resistance index cut-off value of 0.56 provided sensitivity and specificity respectively of 81.3% and 48.5%. The coincidental finding of both resistance indexes above the respective cut-off values showed a good accuracy in identifying patients with liver stiffness values >13 kPa (accuracy=78%, +LR=2.90, -LR=0.31). A significant difference in liver stiffness values was evident between patients with triphasic and bi- or monophasic waveform pattern (p=0.005).

CONCLUSIONS

Hepatic and splenic arteries resistance indexes and the hepatic veins waveform pattern assessed by Doppler ultrasound may provide information similar to that of Transient Elastography in hepatitis C related chronic liver disease.

Assessment of intrahepatic blood flow by Doppler ultrasonography: relationship between the hepatic vein, portal vein, hepatic artery and portal pressure measured intraoperatively in patients with portal hypertension

BACKGROUND

Abnormality of hepatic vein (HV) waveforms evaluated by Doppler ultrasonography has been widely studied in patients with chronic liver disease. We investigated the correlation between changes in HV waveforms and portal vein velocity (PVVel), the hepatic artery pulsatility index (HAPI), and also the extent of abnormal Doppler HV waveforms expressed as damping index (DI), severity of portal hypertension expressed as Child-Pugh scores and portal pressure (PP) measured directly from patients with portal hypertension (PHT) to evaluate the indicative value of abnormal HV waveforms and discuss the cause of abnormal HV waveform.

METHODS

Sixty patients who had been diagnosed with PHT and accepted surgical therapy of portosystemic shunts were investigated. PP was measured intraoperatively. Thirty healthy volunteers with no history of chronic liver disease were enrolled as the control group. HV waveforms were categorized as triphasic, biphasic or monophasic. DI was compared as the quantitative indicator of abnormal HV waveforms. Another two Doppler parameters, PVVel and HAPI were also measured. These Doppler features were compared with PP, Child-Pugh scores and histological changes assessed by liver biopsy.

RESULTS

In the patient group, the Doppler flow waveforms in the middle HV were triphasic in 31.6%, biphasic in 46.7%, and monophasic in 21.6% of subjects. These figures were 86.7%, 10.0%, and 3.3%, respectively, in healthy subjects. With the flattening of HV waveforms, the HAPI increased significantly (r = 00.438, p < 0.0001), whereas PVVel decreased significantly (r = -0.44, p <0.0001). Blood flow parameters, HAPI, PVVel and HV-waveform changes showed no significant correlations with Child-Pugh scores. The latter showed a significant correlation with PP (r = 0.589, p = 0.044). Changes of HV waveform and DI significantly correlated with PP (r = 0.579, r = 0.473, p <0.0001), and significant correlation between DI and Child-Pugh scores was observed (r = 0.411, p = 0.001). PP was significantly different with respect to nodule size (p < 0.05), but HV-waveform changes were not significantly correlated with pathological changes.

CONCLUSION

In patients with PHT, a monophasic HV waveform indicates higher portal pressure. Furthermore, quantitative indicator DI can reflect both higher portal pressure and more severe liver dysfunction. Flattening of HV waveforms accompanied by an increase in the HAPI and decrease in PVVel support the hypothesis that histological changes reducing HV compliance be the cause of abnormality of Doppler HV waveforms from the hemodynamic angle.

Value of duplex doppler ultrasonography in non-invasive assessment of children with chronic liver disease

AIM: To investigate the value of duplex Doppler ultrasonography (US) in the assessment of the hemodynamics of the portal and hepatic veins in a cohort of children with chronic liver disease (CLD) and to detect any relationship between the US changes, etiology and severity (or stage) of CLD.

METHODS: We prospectively enrolled 25 children with biopsy-proven CLD. Thirteen had cirrhosis (aged 8.9 ± 2.0 years) and 12 had chronic hepatitis (aged 9.3 ± 2.3 years). Gray scale and color-coded duplex Doppler US were performed for all, as well as 30 healthy age and sex-matched controls. Findings were correlated with clinical, laboratory and histopathological characteristics.

RESULTS: Prominent caudate lobe was detected in 100% of cirrhotics, but none of the chronic hepatitis or controls. Thickened lesser omentum and loss of the triphasic waveform of the hepatic vein were present in 69.2% and 53.8% of cirrhotics vs 33.3% and 8.3% of chronic hepatitis respectively. Portal vein flow velocity was significantly lower (P < 0.0001) and the congestion index was significantly higher (P < 0.005) in both patient groups compared to controls. Child-Pugh’s staging showed a positive correlation with both abnormal hepatic vein waveform and direction of portal blood flow; and a negative correlation with both hepatic and portal vein flow velocities. No correlation with the etiology of CLD could be detected.

CONCLUSION: Duplex Doppler added to grayscale US can detect significant morphologic and portal hemodynamic changes that correlate with the severity (stage) of CLD, but not with etiology.

Hepatic vein waveforms in liver cirrhosis re-evaluated

OBJECTIVE

There are many studies on changes in Doppler waveforms of hepatic veins in cirrhotic liver. It is postulated that dampening of phasic oscillations appears with worsening of liver function. Our aim was to reevaluate the significance of Doppler waveforms of hepatic vein in cirrhotic patients and to correlate with hepatic blood flow.

PATIENTS AND METHOD

One hundred and thirty-five consecutive patients of liver cirrhosis and 60 age and sex matched non-cirrhotic controls were enrolled in this study. Doppler waveforms were obtained from right hepatic vein during normal respiration. Other parameters measured were flow volume of portal trunk, right portal vein and proper hepatic artery.

RESULT

Waveforms of the hepatic vein were classified into triphasic, biphasic and flat patterns. Flat waveform was rare and appeared in only 3% cases. There was no correlation between liver dysfunction and patterns of waveforms. Inflow, particularly to the right lobe, was significantly elevated in cases associated with the non-triphasic waveforms.

CONCLUSION

This study shows that the flat waveforms have no diagnostic value. Role of hepatic blood flow seems to be important suggesting hemodynamic changes rather than liver dysfunction as a plausible cause of change in waveforms.

Pearls and pitfalls in hepatic ultrasonography

Ultrasonography is often the initial imaging study in patients who present with right upper quadrant abdominal complaints. However, due to its intrinsic technical limitations, ultrasonography generally has a lower sensitivity than contrast-enhanced computed tomography or magnetic resonance imaging in detecting hepatic lesions. In this review, we describe several subtle sonographic signs that suggest the presence of an otherwise inconspicuous focal liver lesion, including disease in the pleural space or the lung parenchyma, refractive edge shadows, distorted or absent venous landmarks, abnormal Doppler patterns, and venous thrombosis. When encountered, these features should trigger careful evaluation of the adjacent areas for abnormalities and may warrant further studies with computed tomography, magnetic resonance imaging, or positron emission tomography. We also summarize common sonographic findings of diffuse liver diseases, including fatty infiltration and cirrhosis.

Effects of respiratory manoeuvres on hepatic vein Doppler waveform and flow velocities in a healthy population

OBJECTIVE

This study was performed to determine the variations in Doppler waveforms and flow velocity during respiratory manoeuvres in healthy individuals with no liver disease.

MATERIALS AND METHODS

In total, 100 individuals (75 women and 25 men) without known cardiac or liver disease were examined prospectively with duplex Doppler ultrasonography (US). We recorded the Doppler waveforms and peak systolic velocities (V(max)) of the middle hepatic vein during normal respiration, during breath-holding after quiet expiration and also during deep inspiration. Doppler waveforms are categorised as triphasic, biphasic or monophasic.

RESULTS

During normal respiration, hepatic venous waveforms were triphasic in 93% of subjects, monophasic in 6% and biphasic in 1%. During breath-holding after quiet expiration, the percentages were 91%, 6% and 3%, respectively. During deep inspiration, they were 80%, 18% and 2%, respectively. Although significant differences were noted between rates during deep inspiration and normal respiration, they were quite similar during normal respiration and breath-holding after quiet expiration (P<0.05). The values of V(max) were significantly higher during normal respiration compared to quiet expiration and during quiet expiration compared to deep inspiration (P<0.05).

CONCLUSION

The velocities and waveforms of hepatic veins varied during respiratory manoeuvres. The status of respiration must be taken into consideration whilst examining the hepatic vein waveforms and velocities with duplex Doppler US.

Can imaging modalities diagnose and stage hepatic fibrosis and cirrhosis accurately?

The accurate diagnosis and staging of hepatic fibrosis is crucial for prognosis and treatment of liver disease. The current gold standard, liver biopsy, cannot be used for population-based screening, and has well known drawbacks if used for monitoring of disease progression or treatment success. Our objective was to assess performance and promise of radiologic modalities and techniques as alternative, noninvasive assessment of hepatic fibrosis. A systematic review was conducted. Six hundred twenty-eight studies were identified via electronic search. One hundred fifty-three papers were reviewed. Most described techniques that could differentiate between cirrhosis or severe fibrosis and normal liver. Accurate staging of fibrosis or diagnosis of mild fibrosis was often not achievable. Ultrasonography is the most common modality used in the diagnosis and staging of hepatic fibrosis. Elastographic measurements, either ultrasonography-based or magnetic resonance-based, and magnetic resonance diffusion weighted imaging, show the most promise for accurate staging of hepatic fibrosis. Most currently available imaging techniques can detect cirrhosis or significant fibrosis reasonably accurately. However, to date only magnetic resonance elastography has been able to stage fibrosis or diagnose mild disease. Utrasonographic elastography and magnetic resonance diffusion weighted appear next most promising.

Liver involvement in a large cohort of patients with hereditary hemorrhagic telangiectasia: echo-color-Doppler vs multislice computed tomography study

BACKGROUND/AIMS

Hepatic arterio-venous malformations (HAVMs) have been found in 74% of hereditary hemorrhagic telangiectasia (HHT) patients with multislice CT (MSCT). This single-blind study aimed to compare the diagnostic accuracy of echo-color-Doppler with MSCT and identify the most sensitive ultrasound criteria indicating hepatic shunts.

METHODS

One hundred and fifty-three HHT patients were systematically screened for HAVMs by biological tests, abdominal MSCT and echo-color-Doppler. Twenty-five normal subjects and 15 cirrhotic patients were also included as control groups. Both intrahepatic ("color spots" and hypervascularization) and extrahepatic parameters (diameter, flow velocity and tortuosity of hepatic artery and diameter and flow velocity of portal/hepatic vein) were utilized. "Color-spots" are defined as subcapsular vascular spots with a high-velocity arterial blood flow and low resistivity index and can identify extremely small HAVMs.

RESULTS

CT was positive in 128/153 (84%) patients and Doppler color spots were found in 131/153 (86%) patients. The sensitivity, specificity and diagnostic accuracy of "color spots" compared to MSCT were 95.3%, 68.0% and 91.8%, respectively. The "color-spot" showed a greater correlation to CT (V(index)=0.655; p<0.0001) than extrahepatic criteria (V=0.317). In 20/29 (69%) subjects, echo-color-Doppler, confirmed by CT, identified the third criterion for definite HHT diagnosis.

CONCLUSIONS

Intrahepatic criteria was superior to extrahepatic criteria for identification of HAVMs. A new Doppler parameter ("color-spots") with an optimal accuracy for detecting HAVMs is proposed for easy periodic screening of HHT patients.

Portalsystemic hemodynamic changes in chronic severe hepatitis B: An ultrasonographic study

AIM: To evaluate portalsystemic hemodynamic changes in chronic severe hepatitis B.

METHODS: Hemodynamic parameters included portal vein diameter (PVD), portal vein peak velocity (PVPV), portal vein volume (PVV), spleen length (SPL), spleen vein diameter (SPVD), spleen vein volume (SPVV) and umbilical vein recanalization. They were measured by Color Doppler ultrasonography in 36 patients with chronic severe hepatitis B, compared with 51 normal controls, 61 patients with chronic hepatitis B, 46 patients with compensable cirrhosis, and 36 patients with decompensable cirrhosis.

RESULTS: In the group of chronic severe hepatitis B, PVD (12.38 ± 1.23 mm) was significantly different from the normal control, compensable cirrhosis and decompensable cirrhosis groups (P = 0.000-0.026), but not significantly different from the chronic hepatitis group. PVPV (16.15 ± 3.82 cm/s) dropped more significantly in the chronic severe hepatitis B group than the normal control, chronic hepatitis B and compensable cirrhosis groups (P = 0.000-0.011). PVV (667.53 ± 192.83 mL/min) dropped significantly as compared with the four comparison groups (P = 0.000-0.004). SPL (120.42 ± 18.36 mm) and SPVD (7.52 ± 1.52 mm) were longer in the normal control and chronic hepatitis B groups (P = 0.000-0.009), yet they were significantly shorter than those in the decompensable cirrhosis group (P = 0.000). SPVV (242.51 ± 137.70 mL/min) was also lower than the decompensable cirrhosis group (P = 0.000). The umbilical vein recanalization rate (75%) was higher than the chronic hepatitis B and compensable cirrhosis groups. In the course of progression from chronic hepatitis to decompensable cirrhosis, PVD, SPL and SPVD gradually increased and showed significant differences between every two groups (P = 0.000-0.002).

CONCLUSION: Patients with chronic severe hepatitis B have a tendency to develop acute portal hypertension, resulting in significantly reduced portal vein perfusion. Observation of the portalsystemic hemodynamic changes may be contributed to the disease progression of chronic liver disease.

Doppler study of hepatic vein in cirrhotic patients: Correlation with liver dysfunction and hepatic hemodynamics

AIM: To elucidate the significance of Doppler measurements of hepatic vein in cirrhotic patients and to correlate with liver dysfunction and hepatic hemodynamics.

METHODS: One hundred patients with liver cirrhosis and 60 non-cirrhotic controls were studied. Doppler waveforms were obtained from right hepatic vein and flow velocity measured during quiet respiration. Doppler measurements were also obtained from portal trunk, right portal vein and proper hepatic artery.

RESULTS: Hepatic vein waveforms were classified into three classical patterns. Flat waveform was uncommon. Mean hepatic vein velocity was significantly higher in cirrhotic patients (12.7 ± 6.4 vs 5.1 ± 2.1 and 6.2 ± 3.2 cm/s; P < 0.0001). The poorer the grade of cirrhosis, the higher was the mean velocity. Maximum forward velocity was never greater than 40 cm/s in controls. Degree of ascites was found to be highly correlated with mean velocity. “Very high” group (≥ 20 cm/s) presented clinically with moderate to massive ascites. Correlations between right portal flow and mean velocity was significant (P < 0.0001, r = 0.687).

CONCLUSION: Doppler waveforms of hepatic vein, which is independent of liver dysfunction, should be obtained during normal respiration. Mean hepatic vein velocity reflects the change in hepatic circulation associated with progression of liver cirrhosis. It can be used as a new parameter in the assessment of liver cirrhosis.

Hepatic vein Doppler waveform in patients with diffuse fatty infiltration of the liver

OBJECTIVE

To determine the incidence of abnormal hepatic vein Doppler waveform in patients with diffuse fatty infiltration of the liver (FIL).

MATERIALS AND METHODS

In this prospective study, 40 patients with diffuse FIL and 50 normal healthy adults who served as control group underwent hepatic vein (HV) Doppler ultrasonography. The patients with the diagnosis of FIL were 23 men (57.5%) and 17 women aged 30-62 years (mean age +/- S.D., 42 +/- 12 years). Subjects in the control group were 27 men (54%) and 23 women aged 34-65 years (mean age +/- S.D., 45 +/- 14 years). The diagnosis of FIL was confirmed with computed tomography density measurements. The waveforms of HV were classified into three groups: regular triphasic waveform, biphasic waveform without a reverse flow, and monophasic or flat waveform. Etiological factors for FIL were diabetes mellitus (DM), hyperlipidemia and obesity (body mass index > 25). Serum lipid profile was obtained from all the patients with FIL.

RESULTS

Seventeen of the 40 patients (43%) with FIL had an abnormal HV Doppler waveform, whereas only one of the 50 (2%) healthy subjects had an abnormal waveform. The difference in the distribution of normal Doppler waveform pattern between the patients and the control group was significant (P < 0.001). No differences were found in the behaviour of the hepatic vein Doppler waveform in relation to the different etiologic factors for FIL (P > 0.05). There was not any correlation between the degree of fat infiltration and the hepatic vein waveform pattern (P = 0.60).

CONCLUSION

Patients with fatty liver has a high rate of an abnormal hepatic vein Doppler waveform pattern which can be biphasic or monophasic. We could not find a relation between the etiological factors for FIL and the occurrence of an abnormal HV Doppler waveform.

Abnormal hepatic vein Doppler waveform in patients without liver disease

In patients with liver cirrhosis Doppler ultrasound often detects absence of the retrograde (hepatopetal) flow phase in the hepatic vein, suggestive of an increased stiffness of the liver parenchyma around the vein. This is rarely or never reported in healthy control persons. We examined the frequency of absent retrograde flow in a consecutive series of 139 patients referred for abdominal ultrasound. We used state-of-the-art ultrasound scanners, and placed the Doppler gate so that in non-forced end-expiration it would sample the right hepatic vein 4-6 cm from the vena cava. There was no association between the hepatic vein flow pattern and age, sex or body mass index. 43 of 139 studied patients showed absent retrograde flow. Review of the case records revealed liver disease in 26 patients and no sign of liver disease in 17 patients. We suggest that absent retrograde flow in the hepatic veins may be seen not only in patients with overt liver disease but also in apparently liver-healthy patients.

Value of Doppler sonography in assessing the progression of chronic viral hepatitis and in the diagnosis and grading of cirrhosis

OBJECTIVE

The purpose of this study was to evaluate the value of Doppler sonography in assessing the progression of chronic viral hepatitis and in the diagnosis and grading of cirrhosis.

METHODS

Abdominal sonographic and liver Doppler studies were performed in 3 groups: 36 patients with chronic viral hepatitis, 63 patients with cirrhosis, and 30 control subjects with no evidence of liver disease. A series of Doppler indices of hepatic vascularity, including portal vein velocity, portal vein pulsatility score, flow volume of the portal vein, resistive and pulsatility indices of the hepatic artery, modified hepatic index, hepatic vascular index, waveform of the hepatic vein, and focal acceleration of flow, were measured and correlated with liver and spleen size, portal and splenic vein diameter, and presence of ascites and collateral vessels. These indices were compared across the 3 study groups and within the patient groups with respect to presence of inflammation, fibrosis, and steatosis, as determined by histologic evaluation.

RESULTS

The most useful indices were portal vein velocity, the modified hepatic index, and nontriphasic flow in the hepatic vein, which were helpful in distinguishing patients from control subjects. Hepatic vascular and modified hepatic indices were useful for differential diagnosis of cirrhosis and chronic viral hepatitis. However, all measurements were limited in their ability to determine the severity of chronic hepatitis.

CONCLUSIONS

Doppler sonography is sensitive to hemodynamic alterations resulting from inflammation and fibrosis, and if sonography is the study of choice to follow the progression of hepatitis, it will not be adequate without Doppler imaging. Doppler sonography has high diagnostic accuracy in cirrhosis despite some false-positive conditions. However, it has a limited role in clinical grading.

Value of portal hemodynamics and hypersplenism in cirrhosis staging

AIM: To determine the correlation between portal hemodynamics and spleen function among different grades of cirrhosis and verify its significance in cirrhosis staging.

METHODS: The portal and splenic vein hemodynamics and spleen size were investigated by ultrasonography in consecutive 38 cirrhotic patients with cirrhosis (Child’s grades A to C) and 20 normal controls. The differences were compared in portal vein diameter and flow velocity between patients with and without ascites and between patients with mild and severe esophageal varices. The correlation between peripheral blood cell counts and Child’s grades was also determined.

RESULTS: The portal flow velocity and volume were significantly lower in patients with Child’s C (12.25±1.67 cm/s vs 788.59±234 mm/min, respectively) cirrhosis compared to controls (19.55±3.28 cm/s vs 1254.03±410 mm/min, respectively) and those with Child’s A (18.5±3.02 cm/s vs 1358.48±384 mm/min, respectively) and Child’s B (16.0±3.89 cm/s vs 1142.23±390 mm/min, respectively) cirrhosis. Patients with ascites had much lower portal flow velocity and volume (13.0±1.72 cm/s vs 1078±533 mm/min) than those without ascites (18.6±2.60 cm/s vs 1394±354 mm/min). There was no statistical difference between patients with mild and severe esophageal varices. The portal vein diameter was not significantly different among the above groups. There were significant differences in splenic vein diameter, flow velocity and white blood cell count, but not in spleen size, red blood cell and platelet counts among the various grades of cirrhosis. The spleen size was negatively correlated with red blood cell and platelet counts (r = -0.620 and r = -0.8.34, respectively).

CONCLUSION: An optimal system that includes parameters representing the portal hemodynamics and spleen function should be proposed for cirrhosis staging.

[Diagnosis and quantification of hepatic fibrosis with diffusion weighted MR imaging: preliminary results]

PURPOSE

Diagnosis and quantification of hepatic fibrosis are especially important in patients with chronic liver disease. Liver biopsy remains the gold standard for diagnosis of cirrhosis but has several limitations. The purpose of this study was to determine the usefulness of diffusion-weighted MR imaging, for the diagnosis of cirrhosis and quantification of hepatic fibrosis, and to define the best sequence parameters for this evaluation.

METHODS AND MATERIALS

Diffusion-weighted imaging using a 1.5 T MR unit was performed in 14 healthy volunteers and 13 cirrhotic patients. Sets of 8 images with different b values (200, 400, 600, and 800 sec/mm2) and different TR (3500 and 5000 ms) were acquired with breath-holding. Apparent diffusion coefficients (ADCs) were calculated. Correlation between Child-Pugh scores, serum hyaluronate concentrations and ADCs were performed.

RESULTS

ADCs were significantly lower in cirrhotic patients (2,055 10-3) compared to controls (2,915 10-3) (p<0.05) when the b value was 200 s/mm2 and the TR was 5000 ms. Significant correlations were observed between Child-Pugh scores and ADCs (p<0.05), and between serum hyaluronate concentrations and ADCs (p<0.05), when the b value was 400 sec/mm2 and the TR was 5000 ms.

CONCLUSION

Our preliminary study showed that the measurement of ADCs has good potential for diagnosis and quantification of hepatic fibrosis, especially when using b values of 200 sec/mm2 and 400 sec/mm2.

New Doppler ultrasound signs improve the non-invasive diagnosis of cirrhosis or severe liver fibrosis

OBJECTIVES

To determine whether ultrasound and, particularly, new Doppler signs increased the diagnostic accuracy of the most accurate, currently available markers for the diagnosis of cirrhosis or severe fibrosis.

METHODS

Thirty-two clinical (n = 4), biochemical (n = 11) and Doppler ultrasound (n = 17) variables were recorded in 106 patients with compensated chronic liver disease. Diagnostic accuracy was evaluated by discriminant analysis; first, globally, using all variables then by stepwise analysis.

RESULTS

(A) Diagnosis of cirrhosis. Using Doppler ultrasound, diagnostic accuracy was 92% (95% confidence interval 81-98) globally, and 89% (76-95) with three variables (spleen length, hepatic vein spectrum and maximum portal vein velocity). Based upon clinical signs, diagnostic accuracy was 86% (77-92) globally, and 85% (76-91) with one variable (firm liver). Based upon biochemical parameters, diagnostic accuracy was 80% (70-88) globally, and 81% (72-88) with two variables (hyaluronate and platelet count). Based upon all parameters, diagnostic accuracy was 91% (79-96.5) globally, and 91% (79-96.5) with four variables (firm liver, hyaluronate, platelet and hepatic vein spectrum). On an intention to diagnose basis, Doppler ultrasound provided a lower independent contribution due to missing data. (B) In the diagnosis of severe fibrosis, diagnostic accuracy was 83% (69-92) globally, and 77% (62-87) with one variable.

CONCLUSIONS

Cirrhosis can be correctly diagnosed in approximately 90% of patients with compensated chronic liver disease using a few Doppler ultrasound signs including a new sign, the hepatic vein spectrum. Doppler ultrasound could be used for the first line diagnosis and biochemical markers, such as hyaluronate, in patients with missing Doppler ultrasound data.

Diagnostic value of Doppler assessment of the hepatic and portal vessels and ultrasound of the spleen in liver disease

OBJECTIVES

To investigate the clinical utility and the intra-observer and inter-observer variability of Doppler ultrasound assessment of the hepatic and portal vessels along with measurement of spleen size in the diagnosis of chronic liver disease and cirrhosis.

METHODS AND MATERIALS

Ultrasound measurements of portal vein diameter (PVD), portal vein velocity (PVV), hepatic arterial resistance index (HARI), hepatic vein profile (HVP), and spleen size were obtained in 49 controls and 45 patients with liver disease (23 with primary biliary cirrhosis, 22 with hepatitis C) by two experienced observers, who each performed three blinded measurements of each variable. Control values were derived from normal hospital workers. Percutaneous liver biopsies in 41 of the patients showed cirrhosis (14 patients), moderate/severe fibrosis (13 patients), and early disease (14 patients).

RESULTS

Seventy-one percent of cirrhotic patients had splenomegaly (> 13.6 cm). The spleen size was significantly larger in cirrhotics (16.0 cm) than in non-cirrhotics (13.0 cm, P < 0.009) and healthy controls (10.7 cm, P < 0.00005), and was the only independent predictor of cirrhosis, with a threshold of 15 cm predicting cirrhosis with a specificity of 98%, positive predictive value of 93%, sensitivity of 57% and negative predictive value of 80%. HVP was abnormal in 76.9% of cirrhotics, 57.7% of non-cirrhotics and 2.1% of controls (P < 0.04). However, the mean PVV, PVD and HARI were no different between controls and patients or between cirrhotic and non-cirrhotic liver disease. There was significant inter-observer variability for PVV, but intra-observer and inter-observer variability was acceptable for the other measurements.

CONCLUSIONS

Splenomegaly size and abnormal HVP are useful predictors of chronic liver disease and cirrhosis, and both can be measured reliably and reproducibly. However, Doppler measurements of PVV, PVD and HARI are not useful in distinguishing patients with chronic liver disease from normal controls.

Liver fibrosis in chronic viral hepatitis: An ultrasonographic study

AIM: To select valuable ultrasonographic predictors for the evaluation of hepatic inflammation and fibrosis degree in chronic hepatitis, and to study the value of ultrasonography in the evaluation of liver fibrosis and compensated liver cirrhosis in comparison with serology and histology.

METHODS: Forty-four ultrasonographic variables were analyzed and screened using color Doppler ultrasound system in 225 patients with chronic viral hepatitis and compensated liver cirrhosis. The valuable ultrasonographic predictors were selected on the basis of a comparison with histopathological findings. The value of ultrasonography and serology in the evaluation of liver fibrosis degree and the diagnosis of compensated liver cirrhosis was also studied and compared. Meanwhile, the influencing factors on ultrasonographic diagnosis of compensated liver cirrhosis were also analyzed.

RESULTS: By statistical analysis, the maximum velocity of portal vein and the degree of gall-bladder wall smoothness were selected as the valuable predictors for the inflammation grade (G), while liver surface, hepatic parenchymal echo pattern, and the wall thickness of gall-bladder were selected as the valuable predictors for the fibrosis stage (S). Three S-related independent ultrasonographyic predictors and three routine serum fibrosis markers (HA, HPCIII and CIV) were used to discriminate variables for the comparison of ultrasonography with serology. The diagnostic accuracy of ultrasonography in moderate fibrosis was higher than that of serology (P < 0.01), while there were no significant differences in the general diagnostic accuracy of fibrosis as well as between mild and severe fibrosis (P < 0.05). There were no significant differences between ultrasonography and serology in the diagnosis of compensated liver cirrhosis. However, the diagnostic accuracy of ultrasonography was higher in inactive liver cirrhosis and lower in active cirrhosis than that of serology (both P < 0.05). False positive and false negative results where found when the diagnosis of compensated liver cirrhosis was made by ultrasonography.

CONCLUSION: There are different ultrasonographic predictors for the evaluation of hepatic inflammation grade and fibrosis stage of chronic hepatitis. Both ultrasonography and serology have their own advantages and disadvantages in the evaluation of liver fibrosis and compensated liver cirrhosis. Combined application of the two methods is hopeful to improve the diagnostic accuracy.

Orthotopic liver transplants in children: change in hepatic venous Doppler wave pattern as an indicator of acute rejection

PURPOSE

To determine whether a change in hepatic venous flow pattern can be seen during hepatic graft rejection and if it is reversible with treatment.

MATERIALS AND METHODS

Thirty-nine children received 42 liver allografts during a 10-year span. Doppler ultrasonographic (US) recordings of hepatic venous wave patterns were reviewed. Nine children (ten grafts) with continuously monophasic flow were not included in the study. Changes from triphasic to monophasic flow were recorded and correlated with clinical findings in all 30 patients and biopsy findings in 25. Biopsy results were compared with US data recorded within 24 hours of biopsy. Standard statistical tests were conducted to assess value of Doppler US in diagnosis of graft rejection. Significance was assessed with chi(2) statistics.

RESULTS

Of 113 Doppler US recordings in 30 children, 74 showed an episode of change in flow from triphasic to monophasic in 27 patients; biopsy correlation existed for 39 episodes. Thirty-five episodes were due to acute graft rejection (true-positive results). Thirty-nine episodes were due to a variety of pathologic causes (determined with biopsy results for 12 and by clinical means for 27) (false-positive results). Thirty-six assessments were true-negative (US and biopsy results negative for rejection); three were false-negative. When US results were evaluated against clinical and biopsy data, analysis revealed that change to monophasic flow predicted rejection with sensitivity of 92% (35 of 38) and specificity of 48% (36 of 75). Negative predictive value of evidence of persistent triphasic flow was 92% (36 of 39). In the subgroup of US findings with biopsy correlation, specificity increased from 48% (36 of 75) to 75% (36 of 48). It was zero (0 of 27) for the group with clinical correlation only.

CONCLUSION

Change of hepatic venous flow pattern from triphasic to monophasic is sensitive but nonspecific for detection of graft rejection. Evidence of persistent triphasic flow helps eliminate the possibility of graft rejection with a high negative predictive value.

Association between duplex Doppler sonographic flow pattern in right hepatic vein and various liver diseases

PURPOSE

The aim of this study was to evaluate the association between the Doppler sonographic waveforms in the right hepatic vein and various liver diseases.

METHODS

We performed Doppler sonography of the right hepatic vein in 225 individuals (189 patients with liver disease and 36 control subjects). Patients were categorized on the basis of their histologic diagnosis: cirrhosis (n = 122), fibrosis (n = 23), fatty liver disease (n = 11), metastatic liver disease (n = 8), and noncirrhotic liver disease with neither fatty infiltration nor metastases (n = 25). The waveforms of the hepatic veins were categorized as type 1, triphasic; type 2, biphasic; or type 3, flat.

RESULTS

Type 1 waveforms were found in 100% of the control subjects and in patients with each of the various liver diseases, including 40% of those with cirrhosis. Type 2 waveforms were not found in control subjects or in patients with either fatty infiltration or metastatic liver disease. Type 2 waveforms were, however, found in 16% of patients with cirrhosis, 13% of patients with fibrosis, and 4% of patients with other noncirrhotic liver diseases. Type 3 waveforms were found in 43% of patients with liver cirrhosis, 13% of patients with liver fibrosis, 27% of patients with fatty liver disease, and 50% of patients with metastatic liver disease. In contrast, type 3 waveforms were not found in any control subjects or in patients with other noncirrhotic liver diseases without fatty liver or metastases.

CONCLUSIONS

Type 3 waveforms in the right hepatic vein are suggestive of liver cirrhosis, although they may also occur in patients with fibrosis, fatty liver disease, or metastatic liver disease.

Doppler waveform of hepatic veins in healthy children

OBJECTIVE

This study intends to document the presence or absence of triphasic waveforms in hepatic veins in healthy children. Does absence of triphasic hepatic vein flow indicate hepatic abnormality?

SUBJECTS AND METHODS

One hundred children without a known hepatic or intrathoracic abnormality underwent Doppler sonography of their hepatic veins. Fifty girls and 50 boys were divided into five age groups.

RESULTS

Forty-two children had triphasic flow in all three hepatic veins. Veins approaching an angle of 90 degrees with the inferior vena cava could not be assessed or had the least flow modulations despite angle correction. Neonates had the highest percentage of monophasic flow (seven of 21) in all three hepatic veins and none had triphasic flow in all three veins.

CONCLUSION

Not all healthy children have a triphasic flow pattern in all hepatic veins. Before suspecting hepatic abnormality with abnormal parenchymal compliance (cirrhosis, graft rejection) by virtue of lack of triphasic hepatic vein flow, a normal variant of the flow should be considered. Only the change of a previously documented triphasic flow to monophasic flow in a given vein should be assessed as a sign of possible abnormality.