Atypical/malignant solitary fibrous tumor of the pancreas with spleen vein invasion: Case report and literature review

INTRODUCTION

Solitary fibrous tumor (SFT) is an uncommon mesenchymal tumor that is most common in the pleura. However, according to previous studies, the SFT of the pancreas is extremely rare; only 20 cases have been reported so far. Here, we conduct a literature review and report the first case of atypical/malignant SFT of the pancreas with spleen vein invasion.

PATIENT CONCERNS

The patient is a 61-year-old Chinese male who presented with 1 week of upper abdominal pain. Abdominal magnetic resonance imaging showed a huge mass (>10 cm) at the distal end of the pancreas, and the mass obstructing the splenic vein.

DIAGNOSIS

Atypical/malignant SFT of the pancreas with splenic vein tumor thrombus.

INTERVENTIONS

The patient underwent laparoscopic distal pancreatectomy with splenectomy procedure to achieve a radical resection, and did not undergo chemotherapy or radiotherapy.

OUTCOMES

Abdominal computed tomography scans were performed at 1 and 4 months after resection, and no signs of recurrence or metastasis were found (. B).(Figure is included in full-text article.) CONCLUSION:: The clinical symptoms of atypical/malignant SFT of the pancreas with spleen vein invasion are not atypical, and imaging feature is lack of specificity. Preoperative diagnosis is difficult, and there is a potential for malignancy. However, due to the paucity of randomized control trials, there is no established, globally accepted treatment strategy, radiation therapy and chemotherapy regimens have not demonstrated global effectiveness, and no standardized treatments have been identified. Therefore, we recommend complete surgical resection and close clinical follow-up.

Wall shear stress in portal vein of cirrhotic patients with portal hypertension

AIM

To investigate wall shear stress (WSS) magnitude and distribution in cirrhotic patients with portal hypertension using computational fluid dynamics.

METHODS

Idealized portal vein (PV) system models were reconstructed with different angles of the PV-splenic vein (SV) and superior mesenteric vein (SMV)-SV. Patient-specific models were created according to enhanced computed tomography images. WSS was simulated by using a finite-element analyzer, regarding the blood as a Newtonian fluid and the vessel as a rigid wall. Analysis was carried out to compare the WSS in the portal hypertension group with that in healthy controls.

RESULTS

For the idealized models, WSS in the portal hypertension group (0-10 dyn/cm²) was significantly lower than that in the healthy controls (10-20 dyn/cm²), and low WSS area (0-1 dyn/cm²) only occurred in the left wall of the PV in the portal hypertension group. Different angles of PV-SV and SMV-SV had different effects on the magnitude and distribution of WSS, and low WSS area often occurred in smaller PV-SV angle and larger SMV-SV angle. In the patient-specific models, WSS in the cirrhotic patients with portal hypertension (10.13 ± 1.34 dyn/cm²) was also significantly lower than that in the healthy controls (P < 0.05). Low WSS area often occurred in the junction area of SV and SMV into the PV, in the area of the division of PV into left and right PV, and in the outer wall of the curving SV in the control group. In the cirrhotic patients with portal hypertension, the low WSS area extended to wider levels and the magnitude of WSS reached lower levels, thereby being more prone to disturbed flow occurrence.

CONCLUSION

Cirrhotic patients with portal hypertension show dramatic hemodynamic changes with lower WSS and greater potential for disturbed flow, representing a possible causative factor of PV thrombosis.

Pattern of Venous Collateral Development after Splenic Vein Occlusion in an Extended Whipple Procedure (Whipple at the Splenic Artery) and Long-Term Results

BACKGROUND

Extended Whipple procedures may require division of the splenic vein (SV). Controversy exists regarding the risk of sequelae of sinistral portal hypertension when the SV is ligated without reimplantation. The aim of this study was to identify postoperative venous collateral patterns and sequelae of SV ligation, as well as long-term results in an extended Whipple procedure.

STUDY DESIGN

Patients who had an extended Whipple procedure (Whipple at the Splenic Artery or WATSA) were entered in an institutional database. Evaluation of the venous collaterals was performed at least 5 months postoperatively by imaging. Spleen size and platelet counts were measured before and after operation.

RESULTS

Fifteen patients were entered from 2009 to 2014. SV was not reconstructed and the IMV-SV junction was always resected. Two collateral routes developed. An inferior route was present 14/15 patients. It connected the residual SV to the SMV via intermediate collateral veins in the omentum and along the colon. A superior route, present in 10/15 patients connected the residual SV to the portal vein via gastric, perigastric, and coronary veins. Gastrointestinal bleeding did not occur. Mean platelet count and spleen size were not affected significantly. Procedures were long, but few severe complications developed. In 12 patients with adenocarcinoma, the median survival has not been reached.

CONCLUSIONS

Patients who have SV ligation in an extended Whipple are protected against sequelae of sinestral portal hypertension by inferior collateral routes. The omentum and marginal veins of the colon are key links in this pathway.

High patency of proximal splenorenal shunt: A myth or reality ? - A prospective cohort study

BACKGROUND

Proximal splenorenal shunt (PSRS) is a well-accepted surgical procedure for non-cirrhotic portal hypertension (NCPH). Though a patent shunt is important for good long term outcome, there are very few studies on patency of these shunts. We analysed shunt patency using dynamic computed tomographic (CT) portography and compared it with other modalities.

METHODS

From 2004 to 2014, 50 patients with PSRS were evaluated prospectively for shunt patency using dynamic CT portography, clinical parameters and ultrasound Doppler.

RESULTS

The causes of NCPH were extrahepatic portal vein obstruction (EHPVO) in 38 patients and non-cirrhotic portal fibrosis (NCPF) in 12 patients. The shunt patency rate using clinical parameters, ultrasound Doppler and dynamic CT portography were 70%, 40% and 60% respectively. Clinical parameters overestimated while ultrasound Doppler underestimated the shunt patency rate. Dynamic portography had 100% correlation with conventional angiography in the five patients when this was done. The site of shunt could be demonstrated convincingly by dynamic CT portography. The shunt patency rate decreased over time. It was 64%, 60% and 43% in <1 year, 1-5 years and >5 years respectively. Our NCPF patients had a greater shunt patency rate compared to EHPVO patients (9/12 vs. 21/38) though the difference was not significant. Only size of the splenic vein had a significant impact on the shunt patency rate on statistical analysis.

CONCLUSIONS

Dynamic CT portography is useful for evaluation of shunt patency. Proximal splenorenal shunts have a high blockage rate which has hitherto not been reported.

Endovascular Embolization of a Large High-Flow Splenic Arteriovenous Fistula and Aneurysm Using the Amplatzer Vascular Plug II

We describe the use of an Amplatzer Vascular Plug (AVP) II for embolizing a large high-flow splenic arteriovenous fistula and an aneurysm in a young patient. This patient presented to our center with persistent mild abdominal discomfort, 5 years after open splenectomy. Contrast-enhanced computed tomography angiography showed the presence of a fistula between the splenic arterial and splenic venous remnants and a resultant fusiform aneurysmal dilatation of the residual splenic vein. We decide to embolize the splenic artery with a 12-mm diameter AVP II with an oversizing by 70% of the vessel diameter. Celiac angiography performed 5 min postembolization revealed complete obliteration of the splenic artery and closure of the arteriovenous fistula. The overall procedure time was 40 min, and overall radiation exposure was 32 Gy cm(2) (dose-area product).

Reversed portal flow: Clinical influence on the long-term outcomes in cirrhosis

AIM: To elucidate the natural history and the longitudinal outcomes in cirrhotic patients with non-forward portal flow (NFPF).

METHODS: The present retrospective study consisted of 222 cirrhotic patients (120 males and 102 females; age, 61.7 ± 11.1 years). The portal hemodynamics were evaluated at baseline and during the observation period using both pulsed and color Doppler ultrasonography. The diameter (mm), flow direction, mean flow velocity (cm/s), and mean flow volume (mL/min) were assessed at the portal trunk, the splenic vein, the superior mesenteric vein, and the collateral vessels. The average values from 2 to 4 measurements were used for the data analysis. The portal flow direction was defined as follows: forward portal flow (FPF) for continuous hepatopetal flow; bidirectional flow for to-and-fro flow; and reversed flow for continuous hepatofugal flow. The bidirectional flow and the reversed flow were classified as NFPF in this study. The clinical findings and prognosis were compared between the patients with FPF and those with NFPF. The median follow-up period was 40.9 mo (range, 0.3-156.5 mo).

RESULTS: Twenty-four patients (10.8%) demonstrated NFPF, accompanied by lower albumin level, worse Child-Pugh scores, and model for end-stage liver disease scores. The portal hemodynamic features in the patients with NFPF were smaller diameter of the portal trunk; presence of short gastric vein, splenorenal shunt, or inferior mesenteric vein; and advanced collateral vessels (diameter > 8.7 mm, flow velocity > 10.2 cm/s, and flow volume > 310 mL/min). The cumulative incidence rates of NFPF were 6.5% at 1 year, 14.5% at 3 years, and 23.1% at 5 years. The collateral vessels characterized by flow velocity > 9.5 cm/s and those located at the splenic hilum were significant predictive factors for developing NFPF. The cumulative survival rate was significantly lower in the patients with NFPF (72.2% at 1 year, 38.5% at 3 years, 38.5% at 5 years) than in those with forward portal flow (84.0% at 1 year, 67.8% at 3 years, 54.3% at 5 years, P = 0.0123) using the Child-Pugh B and C classifications.

CONCLUSION: NFPF has a significant negative effect on the prognosis of patients with worse liver function reserve, suggesting the need for careful management.

Splanchnic vein thrombosis in necrotizing acute pancreatitis: Detection by computed tomographic venography

AIM: To assess the diagnostic accuracy of computed tomographic venography (CTV) for splanchnic vein thrombosis (SVT) detection in necrotizing acute pancreatitis (AP) patients.

METHODS: Forty-three patients with necrotizing AP who underwent both CTV and digital subtraction angiography (DSA) within 3 d were analyzed in this retrospective comparative study. All CTV procedures were performed with a dual-source CT scanner. The presence and location of SVT were determined via blinded imaging data analyses.

RESULTS: According to the DSA results, 17 (39.5%) of the total 43 patients had SVT. The sensitivity, specificity, positive and negative predictive values of CTV for SVT detection were 100% (95%CI: 77.1%-100%), 92.3% (95%CI: 73.4%-98.7%), 89.5% (95%CI: 65.5%-98.2%) and 100% (95%CI: 82.8%-100%), respectively.

CONCLUSION: CTV is an effective examination for SVT detection in patients with necrotizing AP with high positive and negative predictive values.

Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy

Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts. The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration. Therefore, the embolization of these shunts has been performed to control HE manifestations, but the presence of portal vein thrombosis is considered a contraindication. In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt. Case report: a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma, even without precipitant factors. She had a wide portosystemic shunt and also portal vein thrombosis. The abdominal angiography confirmed the splenorenal shunt and showed other shunts. The larger shunt was embolized through placement of microcoils, and the patient had no recurrence of overt HE. There was a little increase of esophageal and gastric varices, but no endoscopic treatment was needed. Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients, portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization. However, in particular cases with many shunts and severe HE, we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery. In conclusion, we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis. As the patient had other shunts, she was successfully treated by embolization of the larger shunt.

Novel therapy for non-cirrhotic hyperammonemia due to a spontaneous splenorenal shunt

Spontaneous splenorenal shunts in the absence of cirrhosis have rarely been reported as a cause hyperammonemia with encephalopathy. Several closure techniques of such lesions have been described. Here we report a case of a patient with no history of liver disease who developed significant confusion. After an extensive workup, he was found to have hyperammonemia and encephalopathy due to formation of a spontaneous splenorenal shunt. There was no evidence of cirrhosis on biopsy or imaging and no portal hypertension when directly measured. The shunt was 18 mm and too large for embolization so the segment of the splenic vein between the portal vein and the shunt was occluded using an Amplatzer plug. Thus, the superior mesenteric flow was directed entirely to the liver. After interventional radiology closure of the shunt using this technique there was complete resolution of symptoms. The case represents the first report of a successful closure of splenorenal shunt via percutaneous embolization of the splenic vein with an amplatzer plug using a common femoral vein approach.

Effects of high hemodynamics upon the morphology of the walls of the great saphenous vein and splenic vein

AIM

Studies have shown that the incidence and development of pathological changes in the walls of the great saphenous vein and splenic vein are closely related to high venous pressure. Such changes are referred to as "vascular adaptive remodeling responses under high venous pressure". The proposition of the concept of vascular remodeling contributes to our knowledge of pathological changes in the venous wall (dilation of the venous lumen and thickening of the venous wall). In the present study, we compared the histomorphology and cytomorphology of the walls of varicose great saphenous veins (GSVs) and diseased splenic veins (SVs) to investigate the remodeling of the venous wall under high hemodynamic pressure.

METHODS

We collected 34 samples of varicose great saphenous veins and diseased splenic veins. Thirty-four samples of normal great saphenous veins and splenic veins were also collected (control group). Samples were made into slices and observed under light microscopy and electron microscopy. The thickness of the tunica intima and tunica media as well as the inner diameter of the venous lumen were measured.

RESULTS

Under light microscopy, the walls of varicose veins stained with H&E were unevenly thickened, and those of diseased splenic veins were evenly thickened; mucoid degeneration of the tunica intima of varicose veins was not obvious by Masson staining (2/20 cases). The boundary between the tunica intima and tunica media was clearly defined. Uneven hyperplasia of muscular connective tissues was observed. For the diseased splenic-vein group, mucoid degeneration of the tunica intima was obvious (8/14 cases), with an unclearly defined boundary between the tunica intima and tunica extima. Uneven hyperplasia of muscular connective tissues was also observed. Differences in the thickness and inner diameter of the tunica intima and tunica media between the great saphenous vein and the splenic vein were significantly different. Under electron microscopy, mitochondrial degeneration in endothelial cells was observed in both groups. Increased numbers of rough endoplasmic reticula in the cytoplasm of smooth muscle cells, ribosomes and mitochondria and decreased numbers of myofilaments were also observed.

CONCLUSION

High hemodynamics affected the remodeling of varicose great saphenous veins and diseased splenic veins. The histomorphology of visceral veins showed more significant pathological changes than that of peripheral veins. Similar cytomorphological changes were observed in both groups.

Porto-spleno-mesenteric venous thrombosis

Porto-spleno-mesenteric (PSM) venous thrombosis is a rare clinical condition that, while being mostly unrecognized, is nonetheless often severe with a high morbidity and mortality. PSM venous thrombosis is the cause of as many as 5-10% of all abdominal ischemic events, and it presents with a highly variable and non-specific pattern of abdominal symptoms. Such complex and non-specific presentation can delay diagnosis, determining the poor clinical outcome of this condition. This review article discusses the information available on the pathogenesis, clinical presentation, diagnosis and general management of PSM venous thrombosis, with a focus on a number of some clinical issues that remain unaddressed. In particular, the current understanding of the predisposing factors and the heterogeneous clinical manifestations of this condition are described in detail. The recent advances in imaging techniques, which are leading to an improved diagnostic accuracy and facilitate an early diagnosis are also presented. Further, the indications and limits of both pharmacological and surgical treatment options are discussed.

[Splenoportal blood flow with nonalcoholic fatty liver disease]

The aim of this study was to characterise by duplex Doppler sonography the splenoportal venous and arterial blood flow in patients with nonalcoholic fatty liver disease (NAFLD) depending on the grade of biopsy proven steatosis.

MATERIALS AND METHODS

37 patients with NAFLD were examined: 22 female and 15 male average age 46,8 +/- 10,2 (29-62), with IBM 33,5 +/- 4,8 (28-42). The grade of steatosis was estimated by morphological investigation according to Brunt classification (1999). Colour Doppler sonography was performed by the same researcher using Doppler system Vivid-pro-7, USA with a 3,5 MHz convex probe.

RESULTS

Alterations were detected in the following parameters: increase of portal and splenic vein diameters, slow-down of blood flow velocity in the portal and splenic veins, increase of the congestion index, decrease of systolic and diastolic blood flow velocity in the common hepatic and splenic artery, increase of pulsatility and resistance indexes of these arteries, increase of portal hypertensive index and decrease of liver vascular index according to the progression of steatosis with maximal negative dynamics of all characteristics in patients with III grade of steatosis. The closest correlative connections were revealed between the grade of steatosis and congestion index (r = 0.81), portal hypertensive index (r = 0.79), and negative connection--with liver vascular index (r = -0.69).

CONCLUSION

Using Doppler sonography we have detected a deterioration of venous and arterial splenoportal hemodynamics in patients with nonalcoholic fatty liver disease in connection with the progression of steatosis, therefore this method may be used as a noninvasive way to estimation the grade of steatosis, establish the diagnosis of portal hypertension and detect the formation of liver cirrhosis.

Portal flow and hepatic function after splenectomy and esophagogastric devascularization

We studied 27 patients who had mansonic schistosomiasis and portal hypertension with previous episodes of digestive bleeding from esophageal varices. According to the routine of the Liver and Portal Hypertension Unit of the Faculty of Medical Sciences-Santa Casa de São Paulo, these patients underwent surgical treatment that consisted of azygoportal disconnection and splenectomy. The goal of this study was to analyze the developmental profile of portal flow and hepatic function using Doppler ultrasound and the Child-Turcotte-Pugh criteria, respectively, in the pre- and postoperatory stages, in a 3-year period. The results showed a significant 27% reduction of the portal blood flow in the recent postoperatory period and up to 37% in the first to the second year after surgery, remaining stable after this period. We observed that all patients presented with good hepatic functional reserve in the preoperatory period, with no hepatic alteration in the postoperatory period. We conclude that, despite the reduction of portal flow in response to surgery, there was no deterioration of hepatic function.

[Effect of umbilical sticking therapy with qitou xiaogu plaster in treating liver cirrhosis patients with portal hypertension]

OBJECTIVE

To observe the effect of umbilical sticking therapy (UST) with Qitou Xiaugu Plaster (QXP) on hemodynamics of portal system in patients with liver cirrhosis.

METHODS

One hundred and twenty patients of liver cirrhosis with portal hypertension were assigned to two groups. On the basis of conventional therapy, UST was applied in the 66 patients in treated group, which was exchanged once every 3 days with an interval of 1-day rest. The 54 patients in the control group were orally administered with propanolol. The therapeutic course for both groups was 1 month. Before and after treatment, the hemodynamic changes in portal or splenic veins were observed by color Doppler ultrasonograph, and the changes of liver function, blood coagulation and patients' subjective symptoms were observed as well.

RESULTS

After treatment, portal vein diameter and splenic vein diameter significantly decreased (P < 0.05, portal venous flow velocity and splenic venous flow velocity apparently increased (P < 0.05), and portal venous flow apparently decreased in both groups (P < 0.05), while no significant change was found in the splenic venous flow (P > 0.05). The liver function and blood coagulation indexes in both groups were improved. The improvement of clinical symptoms in the treated group was superior to that in the control group.

CONCLUSION

UST with QXP could decrease the portal vein pressure in a short time, with the therapeutic effect comparable to propanolol, and with no adverse reaction.

[Imaging of collaterals and their impact on portal venous flow in patients with liver cirrhosis]

When the portal hypertension syndrome occurs, patients with liver cirrhosis develop three major collateral blood flow pathways. These are gastroesophageal, splenorenal, and paraumbilical ones along the recanalized umbilical veins. Only both the splenorenal pathway of blood return from the portal venous system, which considerably reduces portal blood flow volume and the paraumbilical one that increases portal blood flow are of hemodynamic significance.

[Role of pancreatic hilar vascular occlusion in sophisticated pancreaticoduodenectomy]

OBJECTIVE

To discuss the value of a simple occlusive technique of the triple vessels, ie, portal vein, superior mesenteric vessels and splenic vein, in complicated pancreaticoduodenectomy.

METHODS

The technique was fulfilled with a No.8 urethral catheter to encycle the portal vein, superior mesenteric vessels and its near tissue plus pancreatic tail and splenic vein than the neck of pancreas was transected and well exposure superior mesenteric vein and complete transaction of uncinate. From November 2005 to November 2006 the technique was applied to 12 cases of pancreatic malignancy which presented very infiltrated and adhesive to the hilar vascular structure.

RESULTS

The 12 cases were accomplished according with this technique. The operating time was (292.4 +/- 36.3) min (270 - 390 min) and the intraoperative blood loss was (833.3 +/- 618.4) ml (300 - 2500 ml). The postoperative complication included one case of lymphatic leakage, two cases of pneumonia, one case of abdominal infection and two cases of wound infection. There was no perioperative mortality. The postoperative hospital stay was 17 d (11 - 29 d).

CONCLUSIONS

Use this triple vessels occlusive technique can improve the safety and feasibility in complicated cases of pancreaticoduodenectomy.

Left-sided portal hypertension

Left-sided portal hypertension is a rare clinical syndrome which may lead to bleeding from isolated gastric varices. Pancreatic disease is the most common etiology. Left-sided portal hypertension should be considered in the presence of gastrointestinal bleeding with normal liver function and unexplained splenomegaly. It may be difficult to diagnose this entity both endoscopically and radiologically. While splenectomy is the treatment of choice for cases complicated by variceal bleeding, there is no consensus on the treatment of asymptomatic patients. The prognosis of left-sided portal hypertension mainly depends on the underlying etiology.

Different hemodynamic patterns of alcoholic and viral endstage cirrhosis: analysis of explanted liver weight, degree of fibrosis and splanchnic Doppler parameters

OBJECTIVE

In cirrhosis, portal hemodynamics is usually considered independently of the disease etiology. The objective of this study was to investigate the role of the etiology of liver disease on the relationship between liver blood flow and liver pathology in endstage cirrhosis.

MATERIAL AND METHODS

Portal blood velocity and volume, congestion index of the portal vein, and hepatic and splenic pulsatility indices were evaluated with echo-Doppler in cirrhotic patients immediately before liver transplantation. When a patent paraumbilical vein was present, its blood flow was measured and effective portal liver perfusion was calculated as portal blood flow minus paraumbilical blood flow. The hemodynamic parameters were correlated with liver weight and the pattern of the liver fibrosis morphometrically assessed in explanted livers. A total of 131 patients with alcoholic or viral cirrhosis were included in the study.

RESULTS

In alcoholic cirrhosis, liver weight was higher than that in viral disease (1246+/-295 g versus 1070+/-254 g, p=0.001), portal liver perfusion per gram of liver tissue was lower (0.49+/-0.36 ml g(-1) min(-1) versus 0.85+/-0.56 ml g(-1) min(-1), p=0.004) and hepatic pulsatility indices were higher (1.45+/-0.31 versus 1.26+/-0.30, p=0.018). The degree of liver fibrosis was similar in alcoholic and viral cirrhosis (11.7+/-5.5% versus 11.0+/-4.4%, p=NS). An inverse relationship between liver weight and Child-Pugh score was disclosed in viral (p<0.001) but not in alcoholic disease.

CONCLUSIONS

A different hemodynamic pattern characterizes the advanced stage of cirrhosis of alcoholic and viral origin. A more severe alteration of intrahepatic portal perfusion, probably coexisting with a more severe hepatocyte dysfunction, and a higher liver weight can be detected in alcoholic cirrhosis.

Clinical research on navel application of Shehuang Paste combined with Chinese herbal colon dialysis in treatment of refractory cirrhotic ascites complicated with azotemia

AIM: To explore the efficacy and mechanism of a novel therapeutic method of traditional Chinese medicine in patients with refractory cirrhotic ascites complicated with azotemia.

METHODS: Seventy-five cases of refractory cirrhotic ascites complicated with azotemia were randomly divided into 3 groups: comprehensive treatment (n = 29), simple treatment (n = 24), and control (n = 22). The basic treatment methods were the same in all groups, including liver protecting medicines, diuretics and supportive drugs. The control group underwent only the basic treatment. Shehuang Paste (SHP) was applied to the navels of the two treatment groups once a day for 30 d. Colon dialysis with Chinese herbs was administered to the comprehensive treatment group once every two days. Before and after treatment, we measured abdominal circumference, BUN, Cr, serum Na⁺, urine Na⁺/K⁺, liver function, endotoxin content, NO, and ET-1. Color Doppler ultrasonography was conducted to measure the portal vein blood flow.

RESULTS: The total effective rate for ascites was 72.4% in the comprehensive treatment group, 45.8% in the simple treatment, contrasting with 18.2% in the controls. Between the two treatment groups and the controls, there were significant differences in the effective rates (P < 0.01, and P < 0.05). There was also a significant difference (P < 0.05) between the two treatment groups. Measurements of Cr and BUN showed higher values for the treatment groups, with the comprehensive better than the simple group (P < 0.05). Sera Na, urine Na/K were different, P < 0.01 between pre- and post-treatment in the comprehensive group, and P < 0.05 in the simple group. The treatment groups’ endotoxin content was also significantly reduced (P < 0.01, and P < 0.05), with the comprehensive group better than the simple group (P < 0.05). Portal vein blood flow and NO content significantly reduced (P < 0.05), as did ET-1 content (P < 0.01). There were no significant changes in the control group (P > 0.05). The comprehensive treatment group’s pre- and post-treatment portal vein and splenic vein blood flows showed a positive correlation to NO, ET-1 and endotoxin contents.

CONCLUSION: When treating refractory cirrhotic ascites complicated with azotemia, Shehuang Paste combined with Chinese herbal dialysis is better than Shehuang Paste alone for ascites resolution, azotemia, and endotoxin elimination. However, both methods on their own were also effective for reducing portal and splenic vein blood flow, and lowering the contents of NO, ET-1 in the two treatment groups.

[Hemodynamic study of the patient with hemorrhagic portal hypertension: importance of the left renal vein in patients with a distal splenorenal shunt (Warren)]

INTRODUCTION

There is no information in the literature about surgical outcome of the distal splenorenal shunt (Warren shunt) in those patients with anomalous flow in the left renal vein to the inferior vena cava.

OBJECTIVE

The purpose of this manuscript was to evaluate the incidence of thrombosis in the Warren shunt in those patients with anomalous flow in the left renal vein to the inferior vena cava.

METHODS

We performed a prospective, descriptive and longitudinal study in those patients who performed a surgical procedure to the treatment of hemorrhagic portal hypertension in a tertiary referral center in Mexico City during a one year period (2002-2003). Before the surgical procedure an arterial and venous angiographic study was done including celiac axis, superior mesenteric artery and splenic artery. The patients were scheduled in the outpatient office the first, third, sixth month and the year after the surgical procedure. We looked in them for gastrointestinal bleeding secondary to portal hypertension. In those patients with Warren shunt an angiographic study was done during the first month after the surgical procedure.

RESULTS

Twenty eight patients were included, 17 of them women (60.7%). Median patient age was 48 years old. In 20 patients a Warren shunt were done and in eigth patients a devascularization operation were done. The anomalous flow of the left renal vein was identified in nine patients (28.7%). In seven of them a Warren shunt were done and in two of them a devascularization operation were done. We didn't find gastrointestinal bleeding or thrombosis of the Warren shunt in any of these patients.

CONCLUSION

In those cases of patients with anomalous flow in the left renal vein a Warren shunt can be performed. In this study we didn't find thrombosis of the shunt or gastrointestinal bleeding. In this way a surgical decompression of the portal system can be done preventing bleeding episodes.

Splenic vasculopathy in portal hypertension patients

AIM: To investigate the interaction between portal hypertension, splanchnic hyperdynamic circulation and splanchnic vasculopathy by observing splenic arterial and venous pathological changes and the ro1e of extra-cellular matrix in the pathogenesis of portal hypertensive vasculopathy by measuring the expression of type Ι and type III procollagen mRNA in splenic venous walls of portal hypertensive patients.

METHODS: Morphological changes of splenic arteries and veins taken from portal hypertensive patients (n = 20) and normal controls (n = 10) were observed under optical and electron microscope. Total RNA was extracted and the expression of type Ι and type III procollagen mRNA in splenic venous walls of portal hypertensive patients (n = 20) was semi-quantitatively detected using reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS: Under optical microscope, splenic arterial intima was destroyed and internal elastic membrane and medial elastic fibers of the splenic arterial walls were degenerated and broken. Splenic venous intima became remarkably thick. Endothelia1 cells were not intact with formation of mural thrombus. The tunica media became thickened significantly due to hypertrophy of smooth muscles. Fibers and connective tissues were increased obviously. Under electron microscope, smooth muscle cells of the splenic arteries were degenerated and necrotized. Phenotypes of smooth muscle cells changed from constrictive into synthetic type. Red blood cells and platelets accumulated around the damaged endothelial cells. Synthetic smooth muscle cells were predominant in splenic veins and their cytoplasma had plentiful rough endoplasmic reticulum ribosomes and Golgi bodies. Along the vascular wall, a lot of collagen fibers were deposited, the intima was damaged and blood components accumulated. There was no significant difference in the expression of type I procollagen mRNA in splenic venous wall between the patients with portal hypertension and those without portal hypertension (P > 0.05), but the expression of type III procoagen mRNA was significantly stronger in the patients with portal hypertension than in those without portal hypertension (P < 0.01).

CONCLUSION: Type III procollagen and collagen might be important extra-cellular matrix resulting in neointimal formation and vascular remodeling in the pathogenesis of portal hypertensive vasculopathy. The pathological changes in splenic arteries and veins exist in portal hypertension patients. There might be an interaction between portal hypertension, splanchnic hyperdynamic circulation and splanchnic vasculopathy.

Nonfunctioning pancreatic endocrine tumor presenting with hemorrhage from isolated gastric varices

Hemorrhage from gastric varices due to left-sided portal hypertension is an unusual presentation for pancreatic endocrine tumor. A case of pancreatic endocrine tumor presenting with gastric variceal hemorrhage secondary to left-sided portal hypertension associated with splenic vein occlusion is presented. A 53-year-old man with hemorrhage from isolated gastric varices was referred to our hospital. Laboratory studies revealed normal liver function. Surveys to identify the cause of gastric varices by an abdominal CT, MRCP, and abdominal angiography revealed splenic vein occlusion secondarily attributed to the pancreatic tail tumor and splenomegaly. The pancreatic tumor was suspected to be a resectable endocrine tumor. A distal pancreatectomy, splenectomy, partial resection of the gastric fundus, and limited lymph node dissection were performed. By the histological examination, the diagnosis of nonfunctioning pancreatic endocrine tumor with malignant potential was determined. Three years after the surgery, the patient is doing well and reveals no sign of recurrence. In this case, the unusual presentation for pancreatic endocrine tumors such as a gastric variceal hemorrhage had an advantage that led to early presentation prior to the development of metastases with possible curative surgery.

Portal systemic shunt through the renal vein

BACKGROUND

Despite the semi-routine use of color Doppler sonography for evaluating portal circulation abnormalities, there is a relative paucity of detailed color Doppler findings of portal systemic (P-S) shunt through the renal vein (P-SR shunt).

METHODS

We reviewed the color Doppler findings of 18 patients with P-SR shunt to determine its clinical significance and appropriate scanning techniques for diagnosing accurately P-SR shunt.

RESULTS

The splenorenal shunt was imaged as a highly tortuous vessel at the splenic hilum, which then coursed backward behind the spleen. Splenic vein flow was reversed or very slow. The gastrorenal shunt originated from the splenic vein, coursed backward, and joined the left renal vein. Flow direction in the splenic vein was always hepatopetal. The P-S shunt through the right renal vein originated from duodenal or jejunal varices, coursed posterolaterally, and joined the right renal vein at the renal hilum.

CONCLUSION

Familiarity with these color Doppler findings will help increase the diagnostic confidence of P-SR shunt by color Doppler sonography.

Hepatocavopathy and isolated splenic vein thrombosis due to hypercoagulability state

We report a patient with protein C and protein S deficiency and factor V Leiden mutation presenting with splenic vein thrombosis and with a web between the hepatic venous confluence and vena cava inferior. These two findings were thought to be due to the hypercoagulable state of the patient. Interestingly, there was no need for invasive procedures as the inferior accessory hepatic vein was patent. Hepatic venous flow was being maintained by the inferior accessory hepatic vein or a dominant collateral vein.

Regional portal hypertension diagnosed by ultrasonography: imaging findings and diagnostic values

BACKGROUND/AIMS

To investigate the diagnostic accuracy of ultrasonography for regional portal hypertension (RPH) and ascertain the best diagnosis method for RPH.

METHODOLOGY

Eleven cases of regional portal hypertension diagnosed by ultrasonography were retrospectively studied. Their etiological features, clinical findings, and ultrasonographic diagnosis criteria were analyzed. Other diagnostic approaches were also compared and related literature was reviewed.

RESULTS

Eleven patients were all verified by operation. The diagnostic accuracy of color Doppler ultrasonography was 100%. The etiological diagnostic accuracy was 91% (10/11).

CONCLUSIONS

Color Doppler ultrasonography should be considered as the first choice to diagnose RPH due to its safety, accuracy, and simplicity. RPH can be classified etiologically into 3 types: pancreatic RPH, splenic RPH, retroperitoneal RPH.

Three-dimensional linear endoscopic ultrasound-feasibility of a novel technique applied for the detection of vessel involvement of pancreatic masses

BACKGROUND

Endoscopic ultrasound (EUS) can reliably diagnose and stage pancreatic cancer but is less competent for the differentiation between vascular compression (VC) and invasion (VI).

AIM

Prospective comparison of linear EUS with/without three-dimensional (3D) EUS for vessel involvement in pancreatic cancer to evaluate the feasibility of linear 3D ultrasound.

MATERIAL AND METHODS

Linear echoendoscopy was used to identify the pancreatic tumor, the tumor-vessel relation and for EUS-FNA to obtain tissue diagnosis. Immediately afterwards, 3D image acquisition was performed using a magnetic tracked 3D sensor. The acquisition time was 10-20 s.

RESULTS

EUS results of 22 patients with solid pancreatic lesions were compared to surgical histology. This proved adenocarcinoma in 17 patients and chronic pancreatitis in 5. EUS showed VI in 10 patients, VC in 6, and no vascular involvement (NVI) in 6. Additional 3D evaluation showed VI in 6 patients, VC in 10, and NVI in 6. Surgery proved VI in 7 patients, VC in 9, and NVI in 6. EUS showed VI in 3/5 patients with chronic pancreatitis, 3D showed VC only, while surgery found two patients to have VC and with NVI. In two patients with pancreatic cancer, VI was diagnosed on two dimensional (2D), but VC on 3D evaluation. Surgery showed VC and VI in one each. In the 2D, one patient with NVI had VI on surgery; and on 3D one VC proved to have NVI at surgery. In 1/22 patients the result of 3D was false negative, while 4/22 were false positives and one false negative in conventional EUS.

CONCLUSION

Linear 3D EUS seems feasible for pancreatic evaluation. In addition, linear EUS enhanced the evaluation of vascular involvement of pancreatic lesions, especially in chronic pancreatitis.

[Successful balloon-occluded retrograde transvenous obliteration (B-RTO) in a case of symptomatic epilepsy with hepatic encephalopathy due to non-cirrhotic porto-systemic shunt]

We report a 66-year-old man with hepatic encephalopathy due to a non-cirrhotic porto-systemic shunt during the course of treatment for epilepsy with sodium valproate. The patient developed symptomatic epilepsy after an operation for intracranial arterio-venous malformation at the age of 41, and had been treated with sodium valproate and phenytoin since. At the age of 66, he developed convulsions that were thought to be symptomatic epilepsy with hyperammonemia. Despite sodium valproate having been tapered rapidly and then discontinued, hyperammonemia continued. Abdominal contrast enhanced CT demonstrated a large spleno-renal shunt. Although he was treated with lactulose, he developed encephalopathy with hyperammonemia several times. At the age of 67, we occluded the spleno-renal shunt by balloon-occluded retrograde transvenous obliteration (B-RTO), after which, his clinical symptoms improved, together with normalizing of the ammonia level and EEGs.

A simplified technique of performing splenorenal shunt (Omar's technique)

The splenorenal shunt procedure introduced by Robert Linton in 1947 is still used today in those regions of the world where portal hypertension is a common problem. However, because most surgeons find Linton's shunt procedure technically difficult, we felt that a simpler technique was needed. We present the surgical details and results of 20 splenorenal anastomosis procedures performed within a period of 30 months. Half of the patients (Group I) underwent Linton's conventional technique of splenorenal shunt; the other half (Group II) underwent a newly devised, simplified shunt technique. This new technique involves dissection of the fusion fascia of Toldt. The outcome of the 2 techniques was identical with respect to the reduction of preshunt portal pressure. However, our simplified technique was advantageous in that it significantly reduced the duration of surgery (P <0.001) and the amount of intraoperative blood loss (P <0.003). No patient died after either operation. Although Linton's splenorenal shunt is difficult and technically demanding, it is still routinely performed. The new technique described here, in addition to being simpler, helps achieve good vascular control, permits easier dissection of the splenic vein, enables an ideal anastomosis, decreases intraoperative blood loss, and reduces the duration of surgery. Therefore, we recommend the routine use of this simplified technique (Omar's technique) for the surgical treatment of portal hypertension.

Patterns of collateral pathways in extrahepatic portal hypertension as demonstrated by multidetector row computed tomography and advanced image processing

Pancreatic neoplasm can compromise the portal vein or its tributaries, resulting in extrahepatic portal hypertension. Collateral channels may develop, usually in a hepatopetal direction. These include gastroepiploic veins, short gastric veins, left gastric vein, left colic veins, and spontaneous splenorenal shunts. We present the spectrum of these collaterals as delineated by multidetector row computed tomography with advanced image processing. Delineation of these collaterals is important before surgery so as to avoid possible uncontrollable bleeding if they are inadvertently disrupted.

Hemodynamic assessment of splenomegaly in beta-thalassemia patients undergoing splenectomy

Splenomegaly is a common finding in beta-thalassemia; however, its hemodynamic features and its potential correlations with high output state and hepatic disorders, both also frequent in thalassemia, have not yet been assessed in these patients. Eight beta-thalassemia patients with the indication for splenectomy and no symptoms or signs of heart disease, aged 25.6+/-5.5 years, were studied. Preoperative assessment included hematological profile, liver biology, hepatitis virus serology, and echocardiography. During splenectomy, splenic artery blood flow and splenic vein pressure were directly measured and liver biopsies were taken. Preoperative echocardiographic data were compared with those of 34 healthy controls. The preoperative cardiac index was significantly elevated in patients (4.8+/-1.3 vs 3.4+/-1.1 l/min per m2 in controls, p<0.001). Splenic blood flow, although increased, was not particularly high, being 285+/-56 ml/min or 0.13+/-0.04 ml/min per g of splenic mass, representing 4.1+/-0.9% of total cardiac output (CO). Splenic vein pressure was considerably elevated (29.7+/-5.5 cmH2O). Hepatic fibrosis, iron deposition, and extramedullary foci were found in all eight biopsies. Serology was positive in five of eight cases. beta-thalassemia patients with extensive splenomegaly requiring splenectomy are characterized by high output state, increased splenic blood flow, which probably makes a limited contribution to CO elevation, and portal hypertension, manifest by increased splenic vein pressure and hepatic histopathological abnormalities.

Portosplenic Blood Flow Separation in a Patient with Portosystemic Encephalopathy and a Spontaneous Splenorenal Shunt

A patient with portosystemic encephalopathy, hyperammonemia, and a spontaneous splenorenal shunt was admitted to the authors' institution after a failed attempt at transvenous retrograde shunt obliteration. As an alternative approach, the authors separated splenic and portal flows by embolizing only the proximal splenic vein while leaving the shunt intact. Thus, the splenic flow could escape into the systemic circulation and an extreme increase in portal pressure was avoided. The procedure could provide rapid decreases in blood ammonia levels and a fast resolution of symptoms, but repeated interventions were required.

Portal and splenic hemodynamics in cirrhotic patients: relationship between esophageal variceal bleeding and the severity of hepatic failure

BACKGROUND

The relationship between portal and splenic vein hemodynamics, liver function, and esophageal variceal bleeding in patients with cirrhosis remains unclear. The aim of the present study was to investigate quantitative Doppler parameters of splanchnic hemodynamics in cirrhotic patients and to determine the value of the Doppler parameters in predicting esophageal variceal bleeding.

METHODS

With the help of pulsed Doppler ultrasonography, we investigated portal and splenic hemodynamics in 18 healthy controls and in 45 patients with liver cirrhosis, in whom the relationship of splenic hemodynamics with esophageal variceal bleeding and the grade of cirrhosis was examined.

RESULTS

Portal flow velocity was decreased in cirrhotic patients with Child's C cirrhosis, as compared to those with Child's A cirrhosis ( P < 0.001). The portal blood flow volume in Child's C cirrhosis were also significantly low compared to patients with Child's A and Child's B cirrhosis ( P < 0.001 and P < 0.05, respectively). There was a significant increase in the portal vein congestion index and splenic vein congestion index in patients with Child's C cirrhosis as compared to patients with Child's A cirrhosis ( P < 0.001). Among cirrhotic patients, the group with esophageal variceal bleeding had significantly greater splenic blood flow volume and splenic vein congestion index ( P < 0.001). Patients with ascites had significantly lower portal flow velocity ( P < 0.001) and higher portal vein congestion index and splenic vein congestion index ( P = 0.003 and P = 0.05, respectively) as compared to those without ascites.

CONCLUSIONS

In this report we have shown that the decrease in blood flow and increased congestion indexes in the portal vein and splenic vein are related to the impairment of liver function in cirrhotic patients; these indexes may be valuable factors for predicting esophageal variceal bleeding.

Combined liver vein and spleen pulp pressure measurements in patients with portal or splenic vein thrombosis

BACKGROUND

Patients with thrombosis of the portal or splenic vein may develop portal hypertension with bleeding from oesophageal or gastric varices. The relevant portal pressure cannot be measured by liver vein catheterization or transhepatic puncture of the portal vein because the obstruction is peripheral to the accessible part of the portal system.

METHODS

Liver vein catheterization was combined with percutaneous splenic pressure measurement in 10 patients with portal or splenic vein thrombosis and no cirrhosis, and 10 cirrhotic patients without thrombosis. The splenic pressure was measured by percutaneous puncture below the curvature of the ribs with an angle of the needle to skin of 30 degrees in order to minimize the risk of cutting the spleen if the patient took a deep breath.

RESULTS

None of the patients in whom the described procedure was followed had complications. Pressure measurements in the spleen pulp and splenic vein were concordant. The pressure gradient across the portal venous system (splenic-to-wedged hepatic vein pressure) was -1.3 to 8.5 mmHg (median, 2.8 mmHg) in cirrhosis patients and 0-44 mmHg (median, 18 mmHg) in thrombosis patients, the variation reflecting various degrees of obstruction to flow in the portal venous system. Peripheral portal pressure (splenic-to-free liver vein pressure gradient) was 1.1-28 mmHg (median, 17 mmHg) in cirrhotic patients and 11-52 mmHg (median, 23 mmHg) in thrombosis patients.

CONCLUSIONS

Liver vein catheterization combined with percutaneous splenic pressure measurement is feasible in quantifying pressure gradient across a thrombosis of the portal/splenic vein and in quantifying portal pressure peripheral to this kind of thrombosis.

Portal vein occlusion with aberrant left gastric vein functioning as a hepatopetal collateral pathway

A rare case of an aberrant left gastric vein functioning as a hepatopetal collateral as a result of portal vein occlusion is presented herein. The portal venous phase of multislice computed tomography clearly demonstrated this anatomic variation and provided a reliable vascular "road map" for percutaneous transhepatic portal venous stent placement. Portal hypertension associated with extensive gastrojejunal varices improved dramatically after stent placement.

[The significance of disturbances of draining functions of the azygos vein in pathogenesis of varicose dilatation of the veins of the esophagus and stomach in portal hypertension (experimental-clinical investigation)]

Under analysis were the results of investigations on 30 corpses, 25 dogs and of examinations of 187 patients with portal hypertension. In the experiments the disturbances of blood flow in the portal and azygos veins and the veins of the gastroesophageal basin were modeled. It was found that changes of the veins of the esophago-gastric area in diffuse lesions of the liver were already present even if there were no definitely detectable signs of portal hypertension. The experimental osseo-azygography has revealed dilatation of the azygos vein. The findings of examination of the patients admitted with esophago-gastric bleedings allowed detection of 5 degrees of impairments of blood flow along the azygos vein which increased risk of esophgeal-gastric bleedings.

Viral cirrhosis with chronic right heart failure and cardiac liver sclerosis: a hypothesis on the differentiation between the two diseases through pulsed Doppler sonography examination

Chronic right heart failure determines cardiac liver sclerosis as a consequence of the hepatic venous congestion that is easily detectable with pulsed Doppler sonography measuring hepatic venous pulsatility. These Doppler parameters profoundly change on the basis of the causative agent of the liver sclerosis. In fact, on pulsed Doppler examination, we detected a flat waveform in hepatic veins of subjects with viral liver cirrhosis whereas we only observed biphasic waveforms in subjects with cardiac liver sclerosis. On the contrary, a pulsed Doppler sonography pattern in subjects with viral cirrhosis and associated chronic right heart failure is unknown. We suppose that splanchnic pulsed Doppler sonography has an important role both in differentiating cardiac liver sclerosis from viral cirrhosis with chronic right heart failure and in the follow-up of the seriousness of the right ventricular failure.

[Late morphologic and hemodynamic changes in the splenic territory of patients with mansoni's hepatosplenic schistosomiasis after distal splenorenal shunt. (Ultrasonography-Doppler study)]

BACKGROUND

The distal splenorenal anastomosis (Warren's operation) has been indicated for the treatment of high digestive bleeding caused by esophagic varices because it would ideally reduce the venous pressure in the cardiotuberositary territory without changing the mesenteric-portal venous flow. However, the changes it produce in the splenic territory have not been fully understood.

AIM

To appraise the late morphologic and hemodynamic changes in the splenic territory produced by the distal splenorenal anastomosis in patients with portal hypertension due to mansoni's hepatosplenic schistosomiasis complicated by esophagic bleeding.

METHOD

Ultrasonography-Doppler study of the splenic region of 52 patients with portal hypertension due to mansoni's schistosomiasis and previous bleeding by esophagic varices. They were divided in two groups: 40 non operated upon and 12 with a distal splenorerenal anastomosis. The following parameters and indices were compared between the two groups: a) morphometric parameters (splenic artery and vein's diameter, splenic diameters (longitudinal, transversal and antero-posterior); b) velocimetric parameters of the splenic vessels (systolic peak velocity in the splenic artery, mean flow velocity in the splenic vein; c) biometric index of the spleen (longitudinal x transversal); volumetric index of the spleen (longitudinal x transversal x antero-posterior x 0,523); hemodynamic indices of the splenic artery's impedance: pulsatility and resistivity.

RESULTS

The patients with distal splenorenal anastomosis showed: a) reduction in splenic indices: volumetric (non operated 903,83 +/- 452, 77 cm / distal splenorenal anastomosis 482,32 +/- 208,02 cm (46,64%)) and biometric (non operated 138,14 +/- 51,89 cm /distal splenorenal anastomosis 94,83 +/- 39,83 cm (33,35%)); b) no change: splenic artery's diameter (non operated 0,57 +/- 0,16 cm/distal splenorenal anastomosis 0,57 +/- 0,23 cm); velocity in the splenic artery non operated 107 +/- 42,02 cm/seg/distal splenorenal anastomosis 89,81 +/- 41,20 cm/seg), resistivity (non operated 0,58 +/- 0,008/distal splenorenal anastomosis 0,56 +/- 0,06) and pulsatility (non operated 0,91 +/- 0,19/distal splenorenal anastomosis 0,86 +/- 0,15, splenic vein (non operated 1,10 +/- 0,30 cm/distal splenorenal anastomosis 1,19 +/- 0,29 cm); c) increase: mean flow velocity in the splenic vein (non operated 20,54 +/- 8,45 cm/seg/distal splenorenal anastomosis 27,83 +/- 9,29 cm/seg).

CONCLUSIONS

The comparison of the ultrasonography Doppler results of the two groups of patient (non operated and distal splenorenal anastomosis) showed that in patients with distal splenorenal anastomosis there was a decrease of the volume of spleen; increase in the mean flow velocity in the splenic vein; no changes in the morphologic and hemodinamyc parameters of the splenic artery neither in its velocimetric indices.

[Correlative study between portal vein pressure and portal hemodynamics in patients with portal hypertension]

OBJECTIVE

To explore the characteristics of the portal vein hemodynamics and the correlation with the portal vein pressure.

METHODS

There were 41 cases of hepatic cirrhosis complicating portal hypertension. The liver function was graded Child-Pugh A+B in 31 cases and Child-Pugh C in 10 cases. The inner-diameter and blood stream speed of the portal vein (PV), the spleen vein (SV) and the superior mesentery vein (SMV) were measured by the color Doppler ultrasonography. The vascular acreage and blood flow volume were calculated. The portal vein pressure was directly measured during the operation. Thirty-two healthy people and 26 patients with chronic hepatitis B (CHB) served as controls in this study.

RESULTS

The inner-diameter of the three veins was obviously wider and the blood flow speed was slower in two portal hypertension groups than in CHB and normal groups (P<0.01). In Child C group, the speed was the slowest. The speed of SV and SMV in two hypertension groups did not show any significant difference (P>0.05). In Child A+B group, the blood flow volume of the three veins was larger than that in normal and CHB groups (P<0.01 or P<0.05). The volume of PV was less in Child C group than Child A+B group (P<0.01), but the volume of SV and SMV was not obviously different (P>0.05). In Child A+B group, the portal vein pressure (Ppv) had a close correlation with the portal vein width, blood flow quantitation (Qpv), and blood stream volume (Qsv) of the spleen vein.

CONCLUSIONS

The Qpv in Child A+B grade can be measured by the color Doppler ultrasonography technique, and the portal vein pressure can be monitored easily by the equation of Ppv=1.8951+0.0011Qpv.

Doppler sonographic diagnosis of respiration-dependent reversed flow in the hilar splenic vein

We describe respiration-dependent reversed flow in the splenic vein detected by color Doppler sonography in 2 patients. In case 1, gray-scale sonography in a patient with liver cirrhosis and abdominal pain showed a hyperechoic, thickened colonic segment and diverticula, with increased echogenicity around the diseased colon. The liver was small, with a nodular surface and coarse echotexture. Doppler sonography of the portal and splenic veins showed a constant hepatopetal flow while the patient held her breath in midinspiration and a brief, transient color change restricted to the hilar splenic veins when the patient took a deep breath. In case 2, abdominal sonography in a patient with pneumonia and right-sided abdominal pain showed mural thickening of the appendix and left-sided pneumonic infiltration. The liver size and texture were normal. Color Doppler sonography of the portal and splenic veins showed a constant hepatopetal flow while the patient held his breath in midinspiration and a transient reversal of flow restricted to the splenic veins when the patient took a deep breath. Although the cause of this flow pattern is unclear, increased intra-abdominal pressure is a possible explanation.

Portal hemodynamics in cirrhotics with portal hypertension using color Doppler velocity profile

OBJECTIVE

To investigate portal hemodynamics and its correlation with esophageal variceal bleeding (EVB) in cirrhotics with portal hypertension by using a newly-developed technique, color Doppler velocity profile (CDVP).

METHODS

Hemodynamics of portal trunk (PT), right anterior branch (RAB) and splenic vein (SV) were evaluated in 48 cirrhotics with portal hypertension and 35 normal volunteers by CDVP. The parameters included maximum cross-sectional velocity (CS-Vmax), flow volume, congestion index (CI), profile parameter N and pattern of flow curve. Stepwise logistic regression model was employed to determine EVB-relating factors in cirrhotics.

RESULTS

CS-Vmax in PT and RAB was significantly lower in cirrhotic group than that of normal group, being 14.91 +/- 3.08 cm/s, 9.44 +/- 2.70 cm/s vs 30.52 +/- 6.75 cm/s, 12.82 +/- 2.69 cm/s, respectively (P < 0.01 for both). Flow volume of PT and SV was significantly higher in cirrhotic group compared with that of normal group, being 25.16 +/- 10.48 ml.min-1.kg-1, 15.83 +/- 9.18 ml.min-1.kg-1 vs 20.43 +/- 5.57 ml.min-1.kg-1, 5.81 +/- 2.04 ml.min-1.kg-1, respectively (P < 0.01 for both). CI of PT, RAB and SV was significantly higher in cirrhotic group than in normal group, being 0.142 +/- 0.0654, 0.105 +/- 0.0496, 0.0884 +/- 0.0431 vs 0.0326 +/- 0.0142, 0.0757 +/- 0.0342, 0.0483 +/- 0.0230, respectively (P < 0.01 for all). In dynamic variation of flow volume over time, RAB and SV in cirrhotic group increasingly presented flat pattern and periodically changed pattern, respectively (P < 0.01 for both). Between cirrhotic subgroups without and with EVB history, there were significant differences in flow volume, CI and N value of SV, splenic size, degree of esophageal varices (EV) and portal hypertensive gastropathy (PHG), and stepwise logistic regression revealed that N value of SV, splenic size, degree of EV and PHG were four independent factors in relation to EVB. EVB scores calculated from the regression equation had a close correlation with EVB. In patients with EVB score > 0, 88.9% of them had EVB, and in those with EVB < 0, 76.9% of them had no history of EVB.

CONCLUSION

In cirrhotics with portal hypertension, portal venous system has the features of elevated vascular resistance and hyperdynamics, and the latter mainly results from increased blood flow in SV. EVB score may become a valuable parameter in predicting occurrence of EVB.

Anatomy of spontaneous splenorenal and gastrorenal venous anastomoses. Review of the literature

Portal hypertension is characterised by the development of a collateral portocaval circulation. Among these venous reroutings, some are situated posteriorly in the left subphrenic compartment. These are the spontaneous splenorenal and gastrorenal anastomoses. Their incidence is estimated at around 16%. On the one hand, there are the direct shunts, which anastomose the spelling v. to the left renal v., of an anecdotal nature, and on the other the spontaneous indirect splenorenal shunts, characterised by the presence of a complete neurovascular pedicle traversing the gastrophrenic ligament. This relates to the gastric collateral v., which is connected to the left renal v. via the inferior v. of the left crus of the diaphragm and the middle capsular v., hence the name "gastro-phreno-capsulo-renal shunt". At an advanced stage of portal hypertension these splenorenal shunts may acquire a major caliber and behave like actual surgical shunts.

Use of balloon-occluded retrograde transvenous obliteration with ethanolamine oleate for the treatment of hepatic encephalopathy in a cirrhotic patient with a large spontaneous splenorenal shunt

We describe a technique for the treatment of hepatic encephalopathy in a cirrhotic patient with a large spontaneous splenorenal shunt. This large shunt was successfully occluded without severe complications by retrograde transrenal venous obliteration with ethanolamine oleate after balloon occlusion. This procedure may be an effective method to occlude a large spontaneous splenorenal shunt for the treatment of hepatic encephalopathy.

[Effects of radix Salviae miltiorrhizae on hemodynamics of portal hypertension: clinical and experimental study]

By measuring portal pressure of hepatocirrhotic dogs of bile duct ligation directly, and detecting portal system flow in patients with hepatic cirrhosis by ultrasound doppler, we studied the portal hemodynamic effects of Radix Salviae Miltiorrhizae (RSM). After intravenous administration of RSM in hepatocirrhotic dogs, the portal venous pressure (PPV), wedge hepatic venous pressure (WHVP), and hepatic venous pressure gradient (HVPG) were significantly decreased (P < 0.05-0.01), but the mean arterial pressure (MAP), and heart rate (HR) unchanged (P > 0.05). After long-term administration of RSM (10-12 weeks), the diameter of portal vein (DPV) and splenic vein (DSV), the flow of portal vein (QPV), and splenic vein (QSV) in patients with hepatic cirrhosis were significantly decreased respectively (P < 0.05-0.001). Hypodynamia, abdominal distension, anorexia and liver function (ALT) were improved partially after administration of RSM in patients with hepatic cirrhosis. Side-effects of RSM were not found. The results demonstrated that RSM is an effective drug of depressing portal pressure with few side-effects.

Gradual occlusion of extrahepatic portosystemic shunts in dogs and cats using the ameroid constrictor

Gradual occlusion of the splenic vein, using a specialized device (ameroid constrictor), was evaluated experimentally in three normal beagle dogs. Splenoportograms were used to verify that total occlusion of the splenic vein had occurred in all dogs within 4 to 5 weeks after application of the device. The ameroid constrictor (AC) was also evaluated as a method of gradual vascular occlusion in 12 dogs and two cats with single, extrahepatic, portosystemic shunts (PSS). Serum bile acid (SBA) concentrations were measured and portal scintigraphy (PS) was performed on all 14 animals preoperatively and 10, 20, 30, and 60 days postoperatively. Two dogs (14%) died from portal hypertension in the early postoperative period. One dog and one cat developed multiple acquired PSS, confirmed by mesenteric portography 90 days after the operation. Portal scintigraphy confirmed total occlusion of the primary shunt in the other 10 animals. Shunt fractions (SF), as measured by PS on postoperative days 30 and 60, declined significantly from preoperative values. Significant decreases were noted between preoperative and postoperative values for preprandial SBA on postoperative day 60 and for postprandial SBA on postoperative day 30. SBA concentrations did not correlate with SF. Based on this study, gradual vascular occlusion using the AC is recommended as a method for treatment of single, extrahepatic, PSS.

[Measurement of portal and splenic venous flow volume (PV and SV), congestion index (CI) and SV/PV% in various liver diseases using by Doppler echo-sonography]

We measured the portal and splenic venous flow volume (PV and SV), congestion index (CI) and SV/PV% in various stages of the liver diseases chronic inactive hepatitis (CIH), chronic active hepatitis (CAH), liver cirrhosis without esophageal varices (LCvarix(-)), and liver cirrhosis with esophageal varices (LCvarix(+))¿, and normal volunteers (NC). The results were as follows: PV was 869.4 +/- 184.0 ml/min in NC, 920.4 +/- 242.5ml/min in CIH, 900.0 +/- 216.9ml/min in CAH, 841.8 +/- 253.0 ml/min in LCvarix(-) and 909.7 +/- 430.7ml/min in LCvarix(+). SV was 241.0 +/- 80.0 ml/min in NC, 289.4 +/- 131.6 ml/min CIH, 286.4 +/- 108.8 ml/min CAH, 272.7 +/- 135.7 ml/min in LCvarix(-), 398.0 +/- 280.5 ml/min in LCvarix(+). SV/PV% was 28.1 +/- 10.1 in NC, 31.4 +/- 14.0 CIH, 32.1 +/- 9.6 in CAH, 32.4 +/- 16.0 in LCvarix(-), 43.1 +/- 23.7 in LCvarix(+). CI was 0.06 +/- 0.019 in NC, 0.07 +/- 0.028 in CIH, 0.09 +/- 0.05 in CAH, 0.11 +/- 0.03 in LCvarix(-), 0.145 +/- 0.047 in LCvarix(+). These results suggested that: (1) From the measurement of CI, portal venous pressure is begun to increase at the stage of chronic active hepatitis. (2) Increasing of splenic venous flow volume is begun at the stage of chronic hepatitis and it effects to the portal hypertension of liver cirrhosis. (3) The change of component of intrahepatic portal venous blood flow and decreasing of liver function tests was affected by increasing of splenic venous flow volume. (4) SV/PV% may be useful parameter to evaluate the decreasing of liver function tests and to estimate the complication of esophageal varices at the liver cirrhosis.

[An experimental study of regional spontaneous portasystemic shunt in cirrhotic rats]

CCl4 induced splenic portasystemic shunt (SPSS) was measured in 11 CCl4-induced cirrhotic rats and 10 controls, and mesenteric shunt (MPSS) was measured in 11 controls. 125I labeled albumin microspheres was used as nuclear markers for measurement of shunting rate. It was found that, portal resistance, free portal pressure, wedged hepatic venous pressure, portahepatic venous pressure gradient were all elevated markedly in cirrhotic rats, while the volume of portal flow had no significant difference between the two groups. SPSS and MPSS were higher remarkably those that in the normal controls, and SPSS was greater than MPSS significantly. It suggested that splenogastric venous bed is the main area for compensatory shunt and also the dangerous site of bleeding. Portaazygous disconnection is the operation of choice for control of bleeding. However it could impair the mechanism of spontaneous shunting compensation seriously. Disconnection operation combined with splenorenal shunt seems to be a reseasonable consideration.

[Hemodynamic study of distal splenorenal shunt (DSRS)]

Color-flow Doppler sonography (FDS) was used for assessing the hemodynamic changes in 8 patients undergoing distal splenorenal shunt (DSRS). Results were compared with 14 patients with portal-azygos disconnection (PAD). It was found that 3 weeks after DSRS portal venous flow (PVF) decreased by 50%, and at least in some patients the reduction of the PVF was a continuous process during the period of two years in the DSRS group. The postoperative decrease in PVF in DSRS patients was in sharp contrast to that in PAD patients (P < 0.001), hence PAD is superior to DSRS in remaining satisfactory PVF.