Ultraschall bei Pfortaderhochdruck – Teil 1

Hauptaussagen

• Ultraschall ist die Untersuchungsmethode der Wahl bei Patienten mit Verdacht auf Pfortaderhochdruck.

• Die Farbdoppler-Sonografie ermöglicht bei Patienten mit den klinischen Symptomen eines Pfortaderhochdrucks in den meisten Fällen eine nicht invasive Diagnose von dessen Ursachen.

• In ausgewählten Fällen mit Verdacht auf Thrombose des Pfortader- oder Lebervenensystems verbessert die Verwendung von US-Kontrastmitteln die diagnostische Darstellung in der Sonografie.

• Bei Patienten mit kompensierten chronischen Lebererkrankungen spricht das Vorliegen von portosystemischen Kollateralen und ein Umkehrfluss in der Pfortader mit 100 % Spezifität für einen klinisch signifikanten Pfortaderhochdruck und identifiziert diejenigen Patienten, bei denen ein erhöhtes Risiko für Zirrhose, hepatozelluläre Karzinome und Mortalität besteht.

• Eine zunehmende Milzgröße ist das sensitivste US-Merkmal für eine Verdachtsdiagnose auf Pfortaderhochdruck bei Zirrhosepatienten, die Spezifität dieses Merkmals ist jedoch begrenzt, sogar im Falle einer chronischen Lebererkrankung.

• Die Kombination der mehrerer Zeichen eines Pfortaderhochdrucks erhöht die diagnostische Treffsicherheit der dopplersonografischen Untersuchung.

• Die erniedrigte Flussgeschwindigkeit in der Pfortader ist der alleinige und wichtigste quantitative Doppler-Parameter und ergab in einer Vielzahl von Studien wichtige prognostische Aussagen.

• Arterielle Doppler-Parameter werden in den nicht routinemäßig in Zentren der Stufe 1 und 2 durchgeführt. Ihre Bewertung sollte unter standardisieren Bedingungen zur Vermeidung von Fehlinterpretationen durch erfahrene Untersucher in Stufe-3-Zentren erfolgen. Die am einfachsten zu bestimmenden und treffsichersten arteriellen Parameter für die Diagnose des PH sind die Doppler-Impedanz-Indizes der Milzarterie, während der wichtigste arterielle Einzel-Parameter mit prognostischer Bedeutung der Doppler-Widerstandsindex der intraparenchymalen Nierenarterie ist.

Main statements

• Ultrasonography is the first-line imaging technique to be used in patients with suspected portal hypertension

• In patients with clinical signs of portal hypertension, color Doppler ultrasound examination permits noninvasive classification of its cause in most cases

• In selected cases with suspected thrombosis of the portal venous system or of the hepatic venous system, the use of US contrast agents improves the diagnostic performance of ultrasound

• In patients with compensated chronic liver disease, porto-systemic collaterals and the reversal of portal blood flow are 100 % specific signs of clinically significant portal hypertension and identify patients who are at higher risk of all complications of cirrhosis, hepatocellular carcinoma and death

• Increased spleen size is the most sensitive ultrasound sign suggesting portal hypertension in cirrhosis, but its specificity is limited even in the setting of chronic liver diseases

• The combination of multiple signs of portal hypertension improves the diagnostic accuracy of US Doppler examination in this field

• Reduced portal vein velocity is the single most important quantitative Doppler parameter, and provided relevant prognostic information in a large number of studies

• Arterial Doppler parameters are not routinely used in first and secondary level settings for diagnostic purposes. They should be evaluated by experienced operators in tertiary level centers, under standardized conditions to avoid misinterpretation. The easiest to measure and most accurate arterial parameters for the diagnosis of PH are the splenic artery Doppler impedance indexes, while the single most important arterial parameter with prognostic meaning is the intra-parenchymal renal artery Doppler resistance index.

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