Ultraschall Med 2012; 33(1): 8-32
DOI: 10.1055/s-0031-1299145
Continuing Education
© Georg Thieme Verlag KG Stuttgart · New York

Ultraschall bei Pfortaderhochdruck – Teil 2 – und EFSUMB-Empfehlungen zur Durchführung und Dokumentation von Ultraschalluntersuchungen bei Pfortaderhochdruck

Ultrasound in Portal Hypertension – Part 2 – and EFSUMB Recommendations for the Performance and Reporting of Ultrasound Examinations in Portal Hypertension
A. Berzigotti
1   Hepatic Hemodynamic Laboratory, Liver Unit, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd)
2   Abdominal Imaging Section, Centre Diagnostic per la Imatge (CDIC), Hospital Clinic i Provincial, Barcelona, Spain
,
F. Piscaglia
3   Division of Internal Medicine, Department of Digestive Disease and Internal Medicine, General and University Hospital S. Orsola-Malpighi, Bologna, Italy
,
and the EFSUMB Education and Professional Standards Committee › Author Affiliations
Further Information

Publication History

Publication Date:
09 February 2012 (online)

Empfehlung 

Bei Patienten mit eindeutigen klinischen Befunden eines Pfortaderhochdrucks ist die Duplex-Doppler-Sonografie eine sehr treffsichere Methode zur Klärung der Ätiologie.

Insbesondere kann sowohl eine Pfortaderthrombose als auch eine Lebervenenthrombose mittels Duplex/Doppler-US diagnostiziert oder ausgeschlossen werden.

Wie in [Tab. 1], [2] genau beschrieben, können die zu untersuchenden und dokumentierenden Parameter, je nach Qualifikation der Einrichtung, zu der der Patient zur Erstuntersuchung überwiesen wurde, variieren. Wenn keine Diagnose gestellt werden kann oder der untersuchende Arzt keine ausreichenden Informationen für eine adäquate klinische Betreuung gewinnen kann, sollte der Patient in einer höher spezialisierten Ultraschall-Einrichtung oder mit anderen diagnostischen Techniken untersucht werden.

Empfehlungen 

Bei allen Patienten mit chronischen Lebererkrankungen sollte bei Erstdiagnose eine dopplersonografische Untersuchung durchgeführt werden, um das Vorliegen einer Zirrhose und eines Pfortaderhochdrucks zu erkennen, da die US-Befunde bei der Diagnose dieser Erkrankungen eine zufriedenstellende Sensitivität und hohe Spezifität besitzen.

Die unverzichtbaren Befunde, nach denen gesucht werden muss ([Tab. 2]), sind: Zeichen einer Zirrhose, Durchgängigkeit der Pfortader, deren Durchmesser und Richtung des Blutflusses, Durchmesser der Milz- und Mesenterialvenen mit Darstellung deren respiratorischen Differenzen und Flussrichtung, Milzgröße, Nachweis/Fehlen von portosystemischen abdominalen Kollateralen und Nachweis/Fehlen von Aszites.

Die meisten dopplersonografischen Befunde besitzen eine hohe Spezifität für die Diagnose eines klinisch signifikanten Pfortaderhochdrucks. Da die Doppler-Sonografie nicht invasiv und wiederholbar ist, wird, wie in [Tab. 1], [2] (Tab. 2 finden Sie online unter www.thieme-connect.de/ejournals). gezeigt, wird die Erhebung dieser speziellen Befunde in jeder Einrichtung unabhängig von deren Zentrumsstufe empfohlen.

Die dopplersonografische Untersuchung sollte bei Patienten mit Zirrhose jedes Mal bei Auftreten einer neuen klinischen Symptomatik wiederholt werden, um eine Pfortaderthrombose oder ein hepatozelluläres Karzinom auszuschließen, welche die häufigsten Ursachen für eine plötzliche Verschlechterung des Pfortaderhochdrucks und der klinischen Dekompensation sind.

Empfehlungen 

Bei Patienten mit Zirrhose und Pfortaderhochdruck bietet die Doppler-Sonografie keine exakten Informationen über das hämodynamische Ansprechen auf Betablocker, die zur Vermeidung von Varizenblutungen eingesetzt werden. Daher kann sie nicht eingesetzt werden, um zwischen Respondern und Non-Respondern der medikamentösen Therapie zu unterscheiden.

Die Doppler-Sonografie ist sinnvoll und wird daher zur nicht invasiven Nachuntersuchung von Patienten mit TIPS, postosystemischen chirurgischen Anastomosen und Meso-Rex-Bypass empfohlen.

Recommendation 

In patients with clear clinical signs of portal hypertension, duplex Doppler US is an accurate method to establish the cause.

Specifically, portal vein thrombosis and hepatic vein thrombosis can be identified or ruled out by duplex Doppler US.

The parameters to be investigated and reported may vary according to the level of expertise of the center to which the patient is referred for first examination, as detailed in [ Tables 1], [2] (Tab. 2, see online: www.thieme-connect.de/ejournals). If a diagnosis is not reached or the clinician in charge has not obtained enough information for adequate clinical management, the patient is to be assessed by US at a higher level of care or by other diagnostic techniques.

Recommendation 

All patients with chronic liver diseases should undergo a US Doppler examination at the time of first diagnosis to assess the presence of signs of cirrhosis and portal hypertension, since US signs provide satisfactory sensitivity and a high specificity for the diagnosis of these conditions.

The essential parameters to be described ([Table 2]) (Tab. 2, see online: www.thieme-connect.de/ejournals) are: signs of cirrhosis, portal vein patency, diameter and direction of flow, splenic vein and mesenteric vein diameters with respiratory variation and direction of flow, spleen size, presence/absence of porto-systemic abdominal collaterals and presence/absence of ascites.

Most US Doppler signs show high specificity for the diagnosis of clinically significant portal hypertension. Since US Doppler is noninvasive and repeatable, the search for these specific findings according to the level of care reported in [ Tables 1], [2] (Tab. 2, see online: www.thieme-connect.de/ejournals) is recommended.

US Doppler examination should be repeated in patients with cirrhosis every time a new clinical event occurs, to rule out portal vein thrombosis and hepatocellular carcinoma, which are frequent causes of rapid worsening of portal hypertension and clinical decompensation.

Recommendation 

Doppler US does not provide accurate information on the hemodynamic response to beta-blockers, utilized for the prevention of variceal bleeding, in patients with cirrhosis and portal hypertension. Thus, it cannot be utilized to discriminate responders from non-responders to drug treatment.

Doppler US is useful and recommended for the noninvasive follow-up of patients with TIPS, porto-systemic surgical shunts and meso-Rex bypass.

* EFSUMB Education and Professional Standards Committee members: Jan Tuma (chairman); Radu Badea, Vito Cantisani, Christoph F. Dietrich, Hilde Berner Hammer, Gebhard Mathis, Dieter Nürnberg, Frantisek Zatura.


Addendum (PDF)

 
  • Literatur

  • 1 Berzigotti A, Piscaglia F. Ultrasound in Portal Hypertension. Part 1. Ultraschall in Med 2011; 32: 548-571
  • 2 Colli A, Fraquelli M, Andreoletti M et al. Severe liver fibrosis or cirrhosis: accuracy of US for detection analysis of 300 cases. Radiology 2003; 227: 89-94
  • 3 Moriyasu F, Nishida O, Ban N et al. „Congestion index“ of the portal vein. Am J Roentgenol 1986; 146: 735-739
  • 4 Bolondi L, Li BS, Gaiani S et al. Liver cirrhosis: changes of Doppler waveform of hepatic veins. Radiology 1991; 178: 513-516
  • 5 Kim MY, Baik SK, Park DH et al. Damping index of Doppler hepatic vein waveform to assess the severity of portal hypertension and response to propranolol in liver cirrhosis: a prospective nonrandomized study. Liver Int 2007; 27: 1103-1110
  • 6 Piscaglia F, Gaiani S, Gramantieri L et al. Superior mesenteric artery impedance in chronic liver diseases: relationship with disease severity and portal circulation. Am J Gastroenterol 1998; 93: 1925-1930
  • 7 Taourel P, Blanc P, Dauzat M et al. Doppler study of mesenteric, hepatic, and portal circulation in alcoholic cirrhosis: relationship between quantitative Doppler measurements and the severity of portal hypertension and hepatic failure. Hepatology 1998; 28: 932-936
  • 8 Schneider AW, Kalk JF, Klein CP. Hepatic arterial pulsatility index in cirrhosis: correlation with portal pressure. J Hepatol 1999; 30: 876-881
  • 9 Merkel C, Sacerdoti D, Bolognesi M et al. Doppler sonography and hepatic vein catheterization in portal hypertension: assessment of agreement in evaluating severity and response to treatment. J Hepatol 1998; 28: 622-630
  • 10 Zhang L, Duan YY, Li JM et al. Hemodynamic features of Doppler ultrasonography in patients with portal hypertension: intraoperative direct measurement of portal pressure in the portal venous system. J Ultrasound Med 2007; 26: 1689-1696
  • 11 Bolognesi M, Sacerdoti D, Merkel C et al. Splenic Doppler impedance indices: influence of different portal hemodynamic conditions (see comments). Hepatology 1996; 23: 1035-1040
  • 12 Vizzutti F, Arena U, Rega L et al. Performance of Doppler ultrasound in the prediction of severe portal hypertension in hepatitis C virus-related chronic liver disease. Liver Int 2007; 27: 1379-1388
  • 13 Berzigotti A, Casadei A, Magalotti D et al. Renovascular impedance correlates with portal pressure in patients with liver cirrhosis. Radiology 2006; 240: 581-586
  • 14 Bolognesi M, Sacerdoti D, Merkel C et al. Noninvasive grading of the severity of portal hypertension in cirrhotic patients by echo-color-Doppler. Ultrasound Med Biol 2001; 27: 901-907
  • 15 Cottone M, D’Amico G, Maringhini A et al. Predictive value of ultrasonography in the screening of non-ascitic cirrhotic patients with large varices. J Ultrasound Med 1986; 5: 189-192
  • 16 Giannini EG, Zaman A, Kreil A et al. Platelet count/spleen diameter ratio for the noninvasive diagnosis of esophageal varices: results of a multicenter, prospective, validation study. Am J Gastroenterol 2006; 101: 2511-2519
  • 17 Schepis F, Camma C, Niceforo D et al. Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection?. Hepatology 2001; 33: 333-338
  • 18 von Herbay A, Frieling T, Haussinger D. Color Doppler sonographic evaluation of spontaneous portosystemic shunts and inversion of portal venous flow in patients with cirrhosis. J Clin Ultrasound 2000; 28: 332-339
  • 19 Berzigotti A, Merkel C, Magalotti D et al. New abdominal collaterals at ultrasound: a clue of progression of portal hypertension. Dig Liver Dis 2008; 40: 62-67
  • 20 Berzigotti A, Zappoli P, Magalotti D et al. Spleen enlargement on follow-up evaluation: a noninvasive predictor of complications of portal hypertension in cirrhosis. Clin Gastroenterol Hepatol 2008; 6: 1129-1134
  • 21 Siringo S, Bolondi L, Gaiani S et al. Timing of the first variceal hemorrhage in cirrhotic patients: prospective evaluation of Doppler flowmetry, endoscopy and clinical parameters. Hepatology 1994; 20: 66-73
  • 22 Gaiani S, Bolondi L, Li BS et al. Prevalence of spontaneous hepatofugal portal flow in liver cirrhosis. Clinical and endoscopic correlation in 228 patients. Gastroenterology 1991; 100: 160-167
  • 23 Berzigotti A, Rossi V, Tiani C et al. Prognostic value of a single HVPG measurement and Doppler-ultrasound evaluation in patients with cirrhosis and portal hypertension. J Gastroenterol 2011; 46: 687-695
  • 24 Zocco MA, Di SE, XXX De CR. et al. Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol 2009; 51: 682-689
  • 25 Tarantino G, Citro V, Conca P et al. What are the implications of the spontaneous spleno-renal shunts in liver cirrhosis?. BMC Gastroenterol 2009; 9: 89
  • 26 Ripoll C, Groszmann RJ, Garcia-Tsao G et al. Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis. J Hepatol 2009; 50: 923-928
  • 27 Berzigotti A, Gilabert R, Abraldes JG et al. Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J Gastroenterol 2008; 103: 1159-1167
  • 28 D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44: 217-231
  • 29 Goldberg BB, Goodman GA, Clearfield HR. Evaluation of ascites by ultrasound. Radiology 1970; 96: 15-22
  • 30 Foschi FG, Piscaglia F, Pompili M et al. Real-time contrast-enhanced ultrasound – a new simple tool for detection of peritoneal-pleural communications in hepatic hydrothorax. Ultraschall in Med 2008; 29: 538-542
  • 31 Schrier RW, Arroyo V, Bernardi M et al. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988; 8: 1151-1157
  • 32 Platt JF, Ellis JH, Rubin JM et al. Renal duplex Doppler ultrasonography: a noninvasive predictor of kidney dysfunction and hepatorenal failure in liver disease. Hepatology 1994; 20: 362-369
  • 33 Sacerdoti D, Bolognesi M, Merkel C et al. Renal vasoconstriction in cirrhosis evaluated by duplex Doppler ultrasonography. Hepatology 1993; 17: 219-224
  • 34 Maroto A, Gines A, Salo J et al. Diagnosis of functional kidney failure of cirrhosis with Doppler sonography: prognostic value of resistive index. Hepatology 1994; 20: 839-844
  • 35 Narahara Y, Kanazawa H, Taki Y et al. Effects of terlipressin on systemic, hepatic and renal hemodynamics in patients with cirrhosis. J Gastroenterol Hepatol 2009; 24: 1791-1797
  • 36 Umgelter A, Reindl W, Wagner KS et al. Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial. Crit Care 2008; 12: R4
  • 37 Zoli M, Cordiani MR, Marchesini G et al. Ultrasonographic follow-up of liver cirrhosis. J Clin Ultrasound 1990; 18: 91-96
  • 38 Zoli M, Cordiani MR, Marchesini G et al. Prognostic indicators in compensated cirrhosis. Am J Gastroenterol 1991; 86: 1508-1513
  • 39 Macias-Rodriguez MA, Rendon-Unceta P, Martinez-Sierra MC et al. Prognostic usefulness of ultrasonographic signs of portal hypertension in patients with child-pugh stage A liver cirrhosis. Am J Gastroenterol 1999; 94: 3595-3600
  • 40 Zoli M, Iervese T, Merkel C et al. Prognostic significance of portal hemodynamics in patients with compensated cirrhosis. J Hepatol 1993; 17: 56-61
  • 41 Haag K, Rossle M, Ochs A et al. Correlation of duplex sonography findings and portal pressure in 375 patients with portal hypertension. Am J Roentgenol 1999; 172: 631-635
  • 42 Ohta M, Hashizume M, Kawanaka H et al. Prognostic significance of hepatic vein waveform by Doppler ultrasonography in cirrhotic patients with portal hypertension. Am J Gastroenterol 1995; 90: 1853-1857
  • 43 Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010; 362: 823-832
  • 44 D’Amico G, Garcia-Pagan JC, Luca A et al. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology 2006; 131: 1611-1624
  • 45 Schepke M, Raab P, Hoppe A et al. Comparison of portal vein velocity and the hepatic venous pressure gradient in assessing the acute portal hemodynamic response to propranolol in patients with cirrhosis. Am J Gastroenterol 2000; 95: 2905-2909
  • 46 Iwao T, Oho K, Sakai T et al. Noninvasive hemodynamic measurements of superior mesenteric artery in the prediction of portal pressure response to propranolol. J Hepatol 1998; 28: 847-855
  • 47 Bolognesi M, Sacerdoti D, Merkel C et al. Effects of chronic therapy with nadolol on portal hemodynamics and on splanchnic impedance indices using Doppler sonography: comparison between acute and chronic effects. J Hepatol 1997; 26: 305-311
  • 48 Piscaglia F, Gaiani S, Siringo S et al. Duplex-Doppler evaluation of the effects of propranolol and isosorbide-5-mononitrate on portal flow and splanchnic arterial circulation in cirrhosis. Aliment Pharmacol Ther 1998; 12: 475-481
  • 49 Zoli M, Marchesini G, Marzocchi A et al. Portal pressure changes induced by medical treatment: US detection. Radiology 1985; 155: 763-766
  • 50 Berzigotti A, Rinaldi MF, Magalotti D et al. Primary prophylaxis with nadolol in cirrhotic patients: Doppler patterns of splanchnic hemodynamics in good and poor responders. J Hepatol 2006; 44: 310-316
  • 51 Bureau C, Garcia-Pagan JC, Otal P et al. Improved clinical outcome using polytetrafluoroethylene-coated stents for tips: Results of a randomized study. Gastroenterology 2004; 126: 469-475
  • 52 Casado M, Bosch J, Garcia-Pagan JC et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998; 114: 1296-1303
  • 53 Abraldes JG, Gilabert R, Turnes J et al. Utility of color Doppler ultrasonography predicting tips dysfunction. Am J Gastroenterol 2005; 100: 2696-2701
  • 54 Foshager MC, Ferral H, Nazarian GK et al. Duplex sonography after transjugular intrahepatic portosystemic shunts (TIPS): normal hemodynamic findings and efficacy in predicting shunt patency and stenosis. Am J Roentgenol 1995; 165: 1-7
  • 55 Chong WK, Malisch TA, Mazer MJ et al. Transjugular intrahepatic portosystemic shunt: US assessment with maximum flow velocity. Radiology 1993; 189: 789-793
  • 56 Dodd III GD, Zajko AB, Orons PD et al. Detection of transjugular intrahepatic portosystemic shunt dysfunction: value of duplex Doppler sonography. Am J Roentgenol 1995; 164: 1119-1124
  • 57 Piscaglia F, Nolsoe C, Dietrich CF et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): Update 2011 on non-hepatic applications. Ultraschall in Med 2012; 33: 33-59
  • 58 Superina R, Shneider B, Emre S et al. Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant 2006; 10: 908-913
  • 59 Chen W, Rodriguez-Davalos MI, Facciuto ME et al. Experience with duplex sonographic evaluation of meso-rex bypass in extrahepatic portal vein obstruction. J Ultrasound Med 2011; 30: 403-409
  • 60 Iwao T, Toyonaga A, Oho K et al. Value of Doppler ultrasound parameters of portal vein and hepatic artery in the diagnosis of cirrhosis and portal hypertension (see comments). Am J Gastroenterol 1997; 92: 1012-1017
  • 61 Piscaglia F, Donati G, Serra C et al. Value of splanchnic Doppler ultrasound in the diagnosis of portal hypertension. Ultrasound Med Biol 2001; 27: 893-899
  • 62 Blomley MJ, Lim AK, Harvey CJ et al. Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study. Gut 2003; 52: 1188-1193
  • 63 Berzigotti A, Nicolau C, Bellot P et al. Evaluation of regional hepatic perfusion (RHP) by contrast-enhanced ultrasound in patients with cirrhosis. J Hepatol 2011; 55: 307-314
  • 64 Luca A, Garcia-Pagan JC, Feu F et al. Noninvasive measurement of femoral blood flow and portal pressure response to propranolol in patients with cirrhosis. Hepatology 1995; 21: 83-88
  • 65 Albillos A, Perez-Paramo M, Cacho G et al. Accuracy of portal and forearm blood flow measurements in the assessment of the portal pressure response to propranolol. J Hepatol 1997; 27: 496-504
  • 66 Merkel C, Bolognesi M, Sacerdoti D et al. Disagreement between acute and chronic haemodynamic effects of nadolol in cirrhosis: a pathophysiological interpretation. Aliment Pharmacol Ther 2005; 22: 433-439
  • 67 Choi YJ, Baik SK, Park DH et al. Comparison of Doppler ultrasonography and the hepatic venous pressure gradient in assessing portal hypertension in liver cirrhosis. J Gastroenterol Hepatol 2003; 18: 424-429
  • 68 Baik SK, Kim JW, Kim HS et al. Recent variceal bleeding: Doppler US hepatic vein waveform in assessment of severity of portal hypertension and vasoactive drug response. Radiology 2006; 240: 574-580