Silvia Li Bassi

Diagnosis of Budd-Chiari syndrome by pulsed Doppler ultrasound.

Computed tomography and real-time ultrasonography may not be conclusive for the diagnosis of the Budd-Chiari syndrome; in many cases more information may be needed, especially on vascular alterations. Doppler ultrasonography provides qualitative data on flow direction and pattern, thereby contributing significantly to diagnosis. Eight cases in which hepatic vein patency was unclear and presence of intrahepatic vessels resembling hepatic veins raised problems of interpretation in real-time ultrasonography are described. In some cases, patency or occlusion of the upper portion of the inferior vena cava were difficult to identify with real-time ultrasonography. Doppler ultrasonographic investigation showed flow in the hepatic veins to be completely absent in two cases and reversed in another two. In the remaining four cases, a flat waveform was evident. Flow in the inferior vena cava was reversed in four cases and showed a flat waveform in three other cases. Portal vein thrombosis was detected in only one case, whereas the remaining seven patients showed slow hepatopetal flow. These findings demonstrate that absent or reversed flow in the hepatic veins and/or flat flow in the hepatic veins associated with reversed flow in the inferior vena cava may be considered diagnostic for the Budd-Chiari syndrome. For this series the sensitivity of Doppler ultrasonography was 87.5%.

Doppler flowmetry in portal hypertension

Clinical applications of Doppler flowmetry of hepatic vessels include assessment of the presence, direction, and characteristics of blood flow. Quantitative measurement of the volume of blood flow has also been attempted in some of the major abdominal arteries and veins, and this possibility is awakening increasing interest; however the reliability of these measurements is still questioned. Otherwise, the qualitative information about flow pattern provided by the Doppler investigation is no longer in question, since it not only contributes to clarifying doubtful images in real-time ultrasonography but also provides new insights in many clinical conditions.

Impaired response of main pancreatic duct to secretin stimulation in early chronic pancreatitis

In the present study we compared sonographic measurements of the main pancreatic duct (MPD) following maximal secretin stimulation (75 CU intravenous in 1 min) in 15 chronic pancreatitis patients (CP) with those of 18 normal control subjects. The mean caliber of the main pancreatic duct was 1.2±0.4 mm in controls and 1.8±0.9 in patients with chronic pancreatitis (P<0.025). In the control group a dilatation of the duct with a peak at the third minute was found. In patients with chronic pancreatitis a flatter profile of the response curve with a slower increase and inconstant return to basal values was found. A statistically significant difference was found between absolute variations of MPD caliber over basal values (1.7±1.06 in controls vs 0.8±0.69 in CP, P<0.005) and the dilatation index [(Dmax-D)/D] (1.31±0.6 in controls vs 0.66±0.69 in CP, P<0.005). The mean percent increase at the third minute was 131% in control subjects vs 53% of patients with CP (P<0.0005). In the five cases of CP showing a caliber increase >100%, a persistent dilatation (100–200%) was found 15 min after secretin administration. At this time, the mean percent increase over basal value in controls was 25%. If we accept an abnormal response to secretin as evidence of pancreatic pathology, the absent or decreased (<50%) MPD dilatation after secretin and/or the persistence of a dilatation >100% at the 15 min, the sensitivity of this provocative test in discriminating early chronic pancreatitis from controls reaches the 86.6% (13 of 15 cases). Results of the present study suggest that the ultrasonographic examination of the main pancreatic duct (MPD) after maximal secretin stimulation may reveal morphological changes not visible under basal conditions, thus helping to diagnose early chronic pancreatitis (CP).

Systemic and regional hemodynamics in pre-ascitic cirrhosis: effects of posture

BACKGROUND/AIMS To clarify the hemodynamic pattern of pre-ascitic cirrhosis, we compared the impact of posture on systemic and regional hemodynamics of patients and healthy subjects without and with plasma volume expansion. METHODS Cardiac index (CI), peripheral vascular resistance (PVRi), heart rate, mean arterial pressure, and the mean blood flow velocities of superior mesenteric (SMAV) and common femoral arteries were evaluated by duplex-Doppler techniques in 10 patients and 20 healthy controls after 2 h of standing and 2 h after lying down. Ten healthy controls received saline infusion (15 ml/kg body weight) when they changed their posture, and five were also evaluated after plasma volume expansion in the upright posture. RESULTS Standing systemic and regional hemodynamics did not differ between patients and controls. After saline infusion, standing control subjects showed greater CI and SMAV than patients. Recumbency caused changes of CI, PVRi and SMAV greater in patients and controls with plasma expansion than in controls without expansion, so that supine patients and controls with expansion were indistinguishable, showing higher CI and SMAV and lower PVRi than controls without expansion. CONCLUSIONS Systemic and regional hemodynamics of patients with pre-ascitic cirrhosis are mainly determined by blood volume expansion which is compartmentalized within the splanchnic venous bed during standing and translocates towards the central and arterial circulatory districts during recumbency.

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.

Changes in mesenteric venous flow due to celiac sprue

SummaryVillus atrophy in celiac sprue determines not only a great reduction of the intestinal absorptive surface, but also destroys the underlying microcirculation which depends on the small artery of the villus and the rich network of capillaries. This may result in a significant shortening of the mesenteric vascular bed.We describe three cases of celiac sprue in which duplex Doppler ultrasound flowmetry revealed a high blood flow velocity in the superior mesenteric vein during the acute stage of the disease. A gluten withdrawal diet produced in all cases a restoration of the normal thickness of the mucosa, together with a significant decrease of blood flow velocity in the superior mesenteric vein.