CC BY 4.0 · Journal of Gastrointestinal and Abdominal Radiology 2023; 06(02): 123-137
DOI: 10.1055/s-0043-1764311
Original Article

Imaging Approach to Portal Hypertension

1   Department of Radiodiagnosis, Christian Medical College, Vellore, India
,
Reetu John
1   Department of Radiodiagnosis, Christian Medical College, Vellore, India
,
Betty Simon
1   Department of Radiodiagnosis, Christian Medical College, Vellore, India
,
1   Department of Radiodiagnosis, Christian Medical College, Vellore, India
,
Shyamkumar N. Keshava
1   Department of Radiodiagnosis, Christian Medical College, Vellore, India
,
Anu Eapen
1   Department of Radiodiagnosis, Christian Medical College, Vellore, India
› Author Affiliations

Abstract

Increase in portal venous pressure (termed portal hypertension) is seen in a variety of liver diseases. Imaging tests are useful to detect portal hypertension and identify its cause. Noninvasive tests like abdominal ultrasound and Doppler studies are routinely done in clinical practice for this indication. Cross-sectional studies like computed tomography and magnetic resonance imaging are especially useful to delineate morphological abnormalities in the liver. Invasive tests like assessment of hepatic venous pressure gradient are done less frequently for specific indications. Distinctive imaging findings help differentiate the different causes of portal hypertension like cirrhosis and vascular liver disorders like noncirrhotic portal hypertension, extrahepatic portal venous obstruction, and Budd–Chiari syndrome. Radiological interventions are increasingly used to treat complications of portal hypertension like refractory ascites or refractory bleeding from gastroesophageal varices.



Publication History

Article published online:
17 April 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Bloom S, Kemp W, Lubel J. Portal hypertension: pathophysiology, diagnosis and management. Intern Med J 2015; 45 (01) 16-26
  • 2 Martí-Bonmatí L, Delgado F. MR imaging in liver cirrhosis: classical and new approaches. Insights Imaging 2010; 1 (04) 233-244
  • 3 Sangster GP, Previgliano CH, Nader M, Chwoschtschinsky E, Heldmann MG. MDCT imaging findings of liver cirrhosis: spectrum of hepatic and extrahepatic abdominal complications. HPB Surg 2013; 2013: 129396
  • 4 Gupta AA, Kim DC, Krinsky GA, Lee VSCT. CT and MRI of cirrhosis and its mimics. AJR Am J Roentgenol 2004; 183 (06) 1595-1601
  • 5 Iranpour P, Lall C, Houshyar R. et al. Altered Doppler flow patterns in cirrhosis patients: an overview. Ultrasonography 2016; 35 (01) 3-12
  • 6 Kinjo N, Kawanaka H, Akahoshi T. et al. Portal vein thrombosis in liver cirrhosis. World J Hepatol 2014; 6 (02) 64-71
  • 7 Gherlan GS. Liver ultrasound elastography: more than staging the disease. World J Hepatol 2015; 7 (12) 1595-1600
  • 8 Barr RG, Ferraioli G, Palmeri ML. et al. Elastography assessment of liver fibrosis: society of radiologists in ultrasound consensus conference statement. Radiology 2015; 276 (03) 845-861
  • 9 Xu XY, Wang WS, Zhang QM. et al. Performance of common imaging techniques vs serum biomarkers in assessing fibrosis in patients with chronic hepatitis B: a systematic review and meta-analysis. World J Clin Cases 2019; 7 (15) 2022-2037
  • 10 Dietrich CF, Bamber J, Berzigotti A. et al. EFSUMB guidelines and recommendations on the clinical use of liver ultrasound elastography, update 2017 (long version). Ultraschall Med 2017; 38 (04) e16-e47
  • 11 European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; Clinical Practice Guideline Panel; Chair; EASL Governing Board representative; Panel members. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol 2021; 75 (03) 659-689
  • 12 Ferraioli G, Wong VW, Castera L. et al. Liver ultrasound elastography: an update to the world federation for ultrasound in medicine and biology guidelines and recommendations. Ultrasound Med Biol 2018; 44 (12) 2419-2440
  • 13 Su TH, Liao CH, Liu CH. et al. Acoustic radiation force impulse US imaging: liver stiffness in patients with chronic hepatitis b with and without antiviral therapy. Radiology 2018; 288 (01) 293-299
  • 14 Harbin WP, Robert NJ, Ferrucci Jr JT. Diagnosis of cirrhosis based on regional changes in hepatic morphology: a radiological and pathological analysis. Radiology 1980; 135 (02) 273-283
  • 15 Awaya H, Mitchell DG, Kamishima T, Holland G, Ito K, Matsumoto T. Cirrhosis: modified caudate-right lobe ratio. Radiology 2002; 224 (03) 769-774
  • 16 Ito K, Mitchell DG, Kim MJ, Awaya H, Koike S, Matsunaga N. Right posterior hepatic notch sign: a simple diagnostic MR finding of cirrhosis. J Magn Reson Imaging 2003; 18 (05) 561-566
  • 17 Ito K, Mitchell DG, Gabata T, Hussain SM. Expanded gallbladder fossa: simple MR imaging sign of cirrhosis. Radiology 1999; 211 (03) 723-726
  • 18 Watanabe A, Ramalho M, AlObaidy M, Kim HJ, Velloni FG, Semelka RC. Magnetic resonance imaging of the cirrhotic liver: an update. World J Hepatol 2015; 7 (03) 468-487
  • 19 Aubé C, Bazeries P, Lebigot J, Cartier V, Boursier J. Liver fibrosis, cirrhosis, and cirrhosis-related nodules: imaging diagnosis and surveillance. Diagn Interv Imaging 2017; 98 (06) 455-468 NCPF
  • 20 Toros AB, Gokcay S, Cetin G, Ar MC, Karagoz Y, Kesici B. Portal hypertension and myeloproliferative neoplasms: a relationship revealed. ISRN Hematol 2013; 2013: 673781
  • 21 Sarin SK, Kumar A, Chawla YK. et al; Members of the APASL Working Party on Portal Hypertension. Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment. Hepatol Int 2007; 1 (03) 398-413
  • 22 Nakanuma Y, Tsuneyama K, Ohbu M, Katayanagi K. Pathology and pathogenesis of idiopathic portal hypertension with an emphasis on the liver. Pathol Res Pract 2001; 197 (02) 65-76
  • 23 Arora A, Sarin SK. Multimodality imaging of obliterative portal venopathy: what every radiologist should know. Br J Radiol 2015; 88 (1046): 20140653
  • 24 Furuichi Y, Moriyasu F, Taira J. et al. Noninvasive diagnostic method for idiopathic portal hypertension based on measurements of liver and spleen stiffness by ARFI elastography. J Gastroenterol 2013; 48 (09) 1061-1068
  • 25 Glatard AS, Hillaire S, d'Assignies G. et al. Obliterative portal venopathy: findings at CT imaging. Radiology 2012; 263 (03) 741-750
  • 26 Krishnan P, Fiel MI, Rosenkrantz AB. et al. Hepatoportal sclerosis: CT and MRI appearance with histopathologic correlation. AJR Am J Roentgenol 2012; 198 (02) 370-376
  • 27 Waguri N, Suda T, Kamura T, Aoyagi Y. Heterogeneous hepatic enhancement on CT angiography in idiopathic portal hypertension. Liver 2002; 22 (03) 276-280
  • 28 Sarin SK, Khanna R. Non-cirrhotic portal hypertension. Clin Liver Dis 2014; 18 (02) 451-476
  • 29 Duseja A. Portal cavernoma cholangiopathy: clinical characteristics. J Clin Exp Hepatol 2014; 4 (Suppl (Suppl. 01) S34-S36
  • 30 Dhiman RK, Saraswat VA, Valla DC. et al. Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver. J Clin Exp Hepatol 2014; 4 (Suppl (Suppl. 01) S2-S14
  • 31 Gupta P, Kalra N, Gulati A. et al. Changes in liver morphology in patients with extrahepatic portal venous obstruction: a retrospective magnetic resonance imaging study. Br J Radiol 2019; 92 (1098): 20180890
  • 32 Pargewar SS, Desai SN, Rajesh S, Singh VP, Arora A, Mukund A. Imaging and radiological interventions in extra-hepatic portal vein obstruction. World J Radiol 2016; 8 (06) 556-570
  • 33 Shin SM, Kim S, Lee JW. et al. Biliary abnormalities associated with portal biliopathy: evaluation on MR cholangiography. AJR Am J Roentgenol 2007; 188 (04) W341-7
  • 34 Llop E, de Juan C, Seijo S. et al. Portal cholangiopathy: radiological classification and natural history. Gut 2011; 60 (06) 853-860
  • 35 Cura M, Haskal Z, Lopera J. Diagnostic and interventional radiology for Budd-Chiari syndrome. Radiographics 2009; 29 (03) 669-681
  • 36 Brancatelli G, Vilgrain V, Federle MP. et al. Budd-Chiari syndrome: spectrum of imaging findings. AJR Am J Roentgenol 2007; 188 (02) W168-76
  • 37 Ferral H, Behrens G, Lopera J. Budd-Chiari syndrome. AJR Am J Roentgenol 2012; 199 (04) 737-745
  • 38 Das CJ, Soneja M, Tayal S. et al. Role of radiological imaging and interventions in management of Budd-Chiari syndrome. Clin Radiol 2018; 73 (07) 610-624
  • 39 Bansal V, Gupta P, Sinha S. et al. Budd-Chiari syndrome: imaging review. Br J Radiol 2018; 91 (1092): 20180441
  • 40 Philips CA, Arora A, Shetty R, Kasana V. A comprehensive review of portosystemic collaterals in cirrhosis: historical aspects, anatomy, and classifications. Int J Hepatol 2016; 2016: 6170243
  • 41 Sharma M, Rameshbabu CS. Collateral pathways in portal hypertension. J Clin Exp Hepatol 2012; 2 (04) 338-352
  • 42 Arora A, Rajesh S, Meenakshi YS, Sureka B, Bansal K, Sarin SK. Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review. Insights Imaging 2015; 6 (05) 559-572
  • 43 McIndoe AH. Vascular lesions of portal cirrhosis. Arch Pathol (Chic) 1928; 5: 23-40
  • 44 Bandali MF, Mirakhur A, Lee EW. et al. Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy. World J Gastroenterol 2017; 23 (10) 1735-1746
  • 45 Cho O-K, Koo JH, Kim YS, Rhim HC, Koh BH, Seo HS. Collateral pathways in Budd-Chiari syndrome: CT and venographic correlation. AJR Am J Roentgenol 1996; 167 (05) 1163-1167
  • 46 Berzigotti A, Seijo S, Reverter E, Bosch J. Assessing portal hypertension in liver diseases. Expert Rev Gastroenterol Hepatol 2013; 7 (02) 141-155
  • 47 Zwiebel WJ. Sonographic diagnosis of hepatic vascular disorders. Semin Ultrasound CT MR 1995; 16 (01) 34-48
  • 48 Berzigotti A, Ashkenazi E, Reverter E, Abraldes JG, Bosch J. Non-invasive diagnostic and prognostic evaluation of liver cirrhosis and portal hypertension. Dis Markers 2011; 31 (03) 129-138
  • 49 Indiran V, Vinod Singh N, Ramachandra Prasad T, Maduraimuthu P. Does coronal oblique length of spleen on CT reflect splenic index?. Abdom Radiol (NY) 2017; 42 (05) 1444-1448
  • 50 Wachsberg RH, Bahramipour P, Sofocleous CT, Barone A. Hepatofugal flow in the portal venous system: pathophysiology, imaging findings, and diagnostic pitfalls. Radiographics 2002; 22 (01) 123-140
  • 51 Kang HK, Jeong YY, Choi JH. et al. Three-dimensional multi-detector row CT portal venography in the evaluation of portosystemic collateral vessels in liver cirrhosis. Radiographics 2002; 22 (05) 1053-1061
  • 52 Leyendecker JR, Rivera Jr E, Washburn WK, Johnson SP, Diffin DC, Eason JD. MR angiography of the portal venous system: techniques, interpretation, and clinical applications. Radiographics 1997; 17 (06) 1425-1443
  • 53 Fehrenbach U, Gül-Klein S, de Sousa Mendes M. et al. Portosystemic shunt surgery in the era of TIPS: imaging-based planning of the surgical approach. Abdom Radiol (NY) 2020; 45 (09) 2726-2735
  • 54 Kirby JM, Cho KJ, Midia M. Image-guided intervention in management of complications of portal hypertension: more than TIPS for success. Radiographics 2013; 33 (05) 1473-1496
  • 55 Keshava SN, Kota GK, Mammen T. et al. Direct intrahepatic cavo-portal shunts in Budd-Chiari syndrome: role of simultaneous fluoroscopy and trans-abdominal ultrasonography. Indian J Gastroenterol 2006; 25 (05) 248-250
  • 56 Keshava SN, Moses V, Sharma A. et al. Technical and medium-term clinical outcomes of transjugular intrahepatic portosystemic shunt with fluoroscopy and additional trans-abdominal ultrasound guidance. Indian J Radiol Imaging 2021; 31 (04) 858-866
  • 57 Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003; 4 (02) 109-116
  • 58 Pereira P, Peixoto A. Left-sided portal hypertension: a clinical challenge. GE Port J Gastroenterol 2015; 22 (06) 231-233
  • 59 Sharma A, Keshava SN, Eapen A, Elias E, Eapen CE. An update on the management of Budd-Chiari syndrome. Dig Dis Sci 2021; 66 (06) 1780-1790
  • 60 Keshava SN, Moses V, Surendrababu NR. Cannula-assisted and transabdominal ultrasound-guided hepatic venous recanalization in Budd Chiari syndrome: a novel technique to avoid percutaneous transabdominal access. Cardiovasc Intervent Radiol 2009; 32 (06) 1257-1259
  • 61 Ahmed M, Keshava SN, Moses V. et al. Transjugular intrahepatic portosystemic shunt through the strut of a previously placed stent: technical feasibility and long-term follow-up results. Cardiovasc Intervent Radiol 2018; 41 (11) 1794-1798
  • 62 Won JY, Choi SY, Ko HK. et al. Percutaneous peritoneovenous shunt for treatment of refractory ascites. J Vasc Interv Radiol 2008; 19 (12) 1717-1722