Pediatr Radiol (1990) 21:71-72
Pediatric Radiology 9 Springer-Verlag 1990
Color-coded Doppler evaluation of cholecystic varices in portal hypertension F. M. K a i n b e r g e r 1, K. A. Vergesslich 2, M. E i l e n b e r g e r 3, S. P o e l t n e r 4 a n d W. P o n h o l d 2 1 Department of Diagnostic Radiology, 2nd Medical Clinic, 2 Pediatric Clinics, 3 Central Institute of Diagnostic Radiology, University of Vienna, and 4 St. Anna Kinderspital, Vienna, Austria Received: 26 February 1990; accepted: 29 March 1990
Abstract. A l 1-year-old white girl presented with a diagnosis of thrombosis of the portal vein after newborn septicemia. Duplex sonography revealed significant narrowing of the portal vein and its right and left branches. A Doppler signal could only be obtained in certain short segments of the portal vein and indicated hepatopetal flow. Color-coded Doppler sonography showed extensive varicose veins in the gallbladder with a bigger draining vessel running to the porta hepatis. Documentation of varices like those in the gallbladder wall confirms the diagnosis of portal hypertension and may increase the sensitivity of Doppler sonography. Color mapping has the potential to detect unexpected flow and to analyze blood flow to better advantage.
Dilated cholecystic and pericholecystic veins are a rarely recognized phenomenon and have been observed in patients with portal hypertension and in patients with gallbladder carcinoma [1]. With pulsed-wave duplex sonography (PWDoppler US), portal venous blood flow velocity and flow direction can be evaluated with high sensitivity [2]. Color coded Doppler sonography (CCDS), with its capability to display blood flow throughout the entire scan plane, offers direct visualisation of both flow disturbances and abnormal vessel morphology. Case report A 11-year-old white girl presented with diagnosis of thrombosis of the portal vein after newborn septicemia complicated by one episode of upper gastrointestinal bleeding. A duplex US study (UM 4, Advanced Technology Laboratories; Bothell, Wash)
and a CCDS (Acuson 128; Mountain View, CA) were performed on the fasting patient. Duplex-sonography revealed significant narrowing of the portal vein and its right and left branches. A Doppler signal could only be gained in some short segments of the vessels and indicated hepatopetal flow. The wall of the normal-sized gallbladder was markedly thickened with dilated tortuous vessels their size varying from 1 to 5 mm (Fig. 1). Interrogation of the veins with the Doppler beam was markedly impaired because of tissue movements due to respiratory and cardiac motion. Continuity of one vessel with the portal vein was demonstrated. No other forms of portosystemic or portoportal collaterals could be detected. CCDS showed extensive varicose veins in the gallbladder wall protruding into the lumen (Fig. 2) with a bigger venous draining vessel running to the porta hepatis. Four segments of the portal circulation with different blood flow patterns could be described: (1) hepatopetal flow in the portal vein during its course in the thickened hepatoduodenal ligament, (2) no flow and an echogeniccollection in the lumen of the vein in the porta hepatis indicating circumscribed thrombosis, (3)tiny collaterals in the porta hepatis and the gallbladder bed with a venous signal detectable with PW-duplex US, (4) and flow reversal in the right main stem toward the porta hepatis. Anastomoses surrounding the cardia indicated esophageal varices which were proved at esophagoscopy.
curs with ascites and hypoalbuminemia as well as various other nonbiliary conditions [4]. However, enlarged veins without wall-thickening may also occur [1]. With CCDS, they can be demonstrated easily. Color Doppler provides direct visualisation of blood-flow that cannot be gained with duplex Doppler sonography. Mirror-image and flip artifacts which commonly occur when scanning tortuous varicosities may be excluded to better advantage. In our patient, circumscribed preportal thrombosis was missed with PW-Doppler because of a Doppler angle not small enough. It could be demonstrated with CCDS. Esophageal varices also became visible. They were not detected with PW Doppler because of respiratory tissue motion and a very small acoustic window due to obscuring bowel gas. Several pathogenetic mechanisms concerning the development of gallbladder varices have been described [1, 5].
Discussion Demonstration of collateral vessels with US is essential to diagnose portal hypertension. Subramanyam et al. described 60 different pathways of collateralisation from which many of them can be identified with US [3]. Varices in the adventitial layer of the gallbladder wall are an u n c o m m o n finding. Mostly, they produce the US-sign of a thickened gallbladder wall as it often oc-
Fig.1. The real-time image shows marked thickening of the gallbladder wall with tiny lucencies within the wall. The intraligamentous segment of the portal vein is visible (arrows) with a narrowed lumen and irregular borders not sharplydemarkated from the surrounding tissue
72
Fig.2a. Color image discloses multiple varicosities protruding into the lumen of the gallbladder. No hue in the lumen of the portal vein can be detected. Tiny paravenous color markings indicate periportal collaterals not visible with real-time mode Cystic veins draining the gallbladder vary. Those from the vesical fossa usually enter the liver to join the hepatic veins. The remainder may form one or two cystic veins which enter the liver, too, or drain into the right portal branch. Varices may result when collateral hepatopedal flow via pyloric and cystic veins occurs draining into a low-pressure segment of the portal system [1]. According to Edwards, these vessels should be regarded as accessory portal veins and not necessarily as portosystemic communications [5]. Therefore, they represent a special form of "cavernomatous" transformation of the portal vein. In our patient, this would explain the findings of a bigger draining vessel from the gallbladder to the porta hepatis and of blood flow reversal in the commencement of the right branch of the portal vein. Varicosities of the gallbladder are an uncommon finding [1, 5]. It is not yet clear whether this is due to a wide range of anatomic variations of the gallbladder draining system or due to minor sensitivities of current imaging systems and techniques as assumed previously [1, 6]. CCDS, with its capability to analyze
E M. Kainberger et al.: Color Doppler US of cholecystic varices
Fig.2b. Detailed image of the portal vein asit runs in the thickened hepatoduodenal ligament. The vein is partly perfused partly occluded because of a hypoechoic thrombus with no flow in that segment as demonstrated with PW-Duplex Doppler blood flow velocity and direction noninvasively, may aid in the interpretation of the hemodynamics of gallbladder varices in vivo. Although prehepatic obstruction is the most common cause of portal hypertension in children, varices of the gallbladder wall are a rare sonographic finding in the pediatric patient. A thickened gallbladder wall is common in patients with hepatic disease. There is high correlation between a significant decrease in serum albumin levels and wall thickening [4]. Portal venous or lymphatic congestion may be additional factors influencing wall thickening although varicose veins are not always visible [5]. The concomitant occurrence of gastroesophageal and gallbladder varices may be due to their connection via pyloric and gastric veins. We could not find a report describing how commonly both of them exist together. However, as gastresophageal collaterals are present in 80-90% of patients with portal hypertension a coincidence like in our patient can be assumed. Duplex Doppler sonography is an excellent noninvasive imaging tool for
evaluating the hemodynamics of the portal venous system but has certain limitations because of artifacts and small acoustic windows. Documentation of varices like those in the gallbladder wall confirms the diagnosis of portal hypertension and may increase the sensitivity of the method. Color Doppler mapping offers optimized motion discrimination and a high spatial and temporal resolution. It has the potential to detect unexpected flow, to differentiate real flow from B-mode and Doppler artefacts, and to analyze blood flow in numerous collateral vessels to better advantage.
References 1. Marchal GJF, Van Hotsbeeck M, Tshibwabwa-Ntumba E, Goddeeris PG, Fevery J, Oyen RH, Adisoejoso B, Baert AL, Van Steenbergen W (1985) Dilatation of the cystic veins in portal hypertension: sonographic demonstration. Radiology 154:187 2. Vergesslich KA, Goetz M, Mostbeck GH, Sommer G, Ponhold W (1989) Portal venous blood flow in cystic fibrosis: assessment by duplex Doppler sonography. Pediatr Radio119: 371 3. Subramanyam BR, Balthasar EV, Raghavendra N, Lefheur RS (1983) Sonographic evaluation of patients with portal hypertension. Am J Gastroentero178:369 4. Wegener M, BOrsch G, Schneider J, Wedmann B, Winter R, Zacharias J (1987) Gallbladder wallthickening: frequent findingin various nonbiliary disorders - prospective ultrasonographic study. JCU 15:307 5. Edwards EA (1951) Functional anatomy of the porta-systemic communications. Arch Intern Med 88:137 6. Ralls PW, Mayekawa DS, Lee KP, Colletti PM, Johnson MB, Halls JM (1988) Gallbladder wall varices: diagnosis with color flow Doppler sonography. JCU 16:595 Dr. E M. Kainberger II. Medizinische UniversitSts Klinik Abteilung far diagnostische Radiologie Garnisongasse 13 A-1090 Vienna Austria
Pediatric Radiology 9 Springer-Verlag 1990
Color-coded Doppler evaluation of cholecystic varices in portal hypertension F. M. K a i n b e r g e r 1, K. A. Vergesslich 2, M. E i l e n b e r g e r 3, S. P o e l t n e r 4 a n d W. P o n h o l d 2 1 Department of Diagnostic Radiology, 2nd Medical Clinic, 2 Pediatric Clinics, 3 Central Institute of Diagnostic Radiology, University of Vienna, and 4 St. Anna Kinderspital, Vienna, Austria Received: 26 February 1990; accepted: 29 March 1990
Abstract. A l 1-year-old white girl presented with a diagnosis of thrombosis of the portal vein after newborn septicemia. Duplex sonography revealed significant narrowing of the portal vein and its right and left branches. A Doppler signal could only be obtained in certain short segments of the portal vein and indicated hepatopetal flow. Color-coded Doppler sonography showed extensive varicose veins in the gallbladder with a bigger draining vessel running to the porta hepatis. Documentation of varices like those in the gallbladder wall confirms the diagnosis of portal hypertension and may increase the sensitivity of Doppler sonography. Color mapping has the potential to detect unexpected flow and to analyze blood flow to better advantage.
Dilated cholecystic and pericholecystic veins are a rarely recognized phenomenon and have been observed in patients with portal hypertension and in patients with gallbladder carcinoma [1]. With pulsed-wave duplex sonography (PWDoppler US), portal venous blood flow velocity and flow direction can be evaluated with high sensitivity [2]. Color coded Doppler sonography (CCDS), with its capability to display blood flow throughout the entire scan plane, offers direct visualisation of both flow disturbances and abnormal vessel morphology. Case report A 11-year-old white girl presented with diagnosis of thrombosis of the portal vein after newborn septicemia complicated by one episode of upper gastrointestinal bleeding. A duplex US study (UM 4, Advanced Technology Laboratories; Bothell, Wash)
and a CCDS (Acuson 128; Mountain View, CA) were performed on the fasting patient. Duplex-sonography revealed significant narrowing of the portal vein and its right and left branches. A Doppler signal could only be gained in some short segments of the vessels and indicated hepatopetal flow. The wall of the normal-sized gallbladder was markedly thickened with dilated tortuous vessels their size varying from 1 to 5 mm (Fig. 1). Interrogation of the veins with the Doppler beam was markedly impaired because of tissue movements due to respiratory and cardiac motion. Continuity of one vessel with the portal vein was demonstrated. No other forms of portosystemic or portoportal collaterals could be detected. CCDS showed extensive varicose veins in the gallbladder wall protruding into the lumen (Fig. 2) with a bigger venous draining vessel running to the porta hepatis. Four segments of the portal circulation with different blood flow patterns could be described: (1) hepatopetal flow in the portal vein during its course in the thickened hepatoduodenal ligament, (2) no flow and an echogeniccollection in the lumen of the vein in the porta hepatis indicating circumscribed thrombosis, (3)tiny collaterals in the porta hepatis and the gallbladder bed with a venous signal detectable with PW-duplex US, (4) and flow reversal in the right main stem toward the porta hepatis. Anastomoses surrounding the cardia indicated esophageal varices which were proved at esophagoscopy.
curs with ascites and hypoalbuminemia as well as various other nonbiliary conditions [4]. However, enlarged veins without wall-thickening may also occur [1]. With CCDS, they can be demonstrated easily. Color Doppler provides direct visualisation of blood-flow that cannot be gained with duplex Doppler sonography. Mirror-image and flip artifacts which commonly occur when scanning tortuous varicosities may be excluded to better advantage. In our patient, circumscribed preportal thrombosis was missed with PW-Doppler because of a Doppler angle not small enough. It could be demonstrated with CCDS. Esophageal varices also became visible. They were not detected with PW Doppler because of respiratory tissue motion and a very small acoustic window due to obscuring bowel gas. Several pathogenetic mechanisms concerning the development of gallbladder varices have been described [1, 5].
Discussion Demonstration of collateral vessels with US is essential to diagnose portal hypertension. Subramanyam et al. described 60 different pathways of collateralisation from which many of them can be identified with US [3]. Varices in the adventitial layer of the gallbladder wall are an u n c o m m o n finding. Mostly, they produce the US-sign of a thickened gallbladder wall as it often oc-
Fig.1. The real-time image shows marked thickening of the gallbladder wall with tiny lucencies within the wall. The intraligamentous segment of the portal vein is visible (arrows) with a narrowed lumen and irregular borders not sharplydemarkated from the surrounding tissue
72
Fig.2a. Color image discloses multiple varicosities protruding into the lumen of the gallbladder. No hue in the lumen of the portal vein can be detected. Tiny paravenous color markings indicate periportal collaterals not visible with real-time mode Cystic veins draining the gallbladder vary. Those from the vesical fossa usually enter the liver to join the hepatic veins. The remainder may form one or two cystic veins which enter the liver, too, or drain into the right portal branch. Varices may result when collateral hepatopedal flow via pyloric and cystic veins occurs draining into a low-pressure segment of the portal system [1]. According to Edwards, these vessels should be regarded as accessory portal veins and not necessarily as portosystemic communications [5]. Therefore, they represent a special form of "cavernomatous" transformation of the portal vein. In our patient, this would explain the findings of a bigger draining vessel from the gallbladder to the porta hepatis and of blood flow reversal in the commencement of the right branch of the portal vein. Varicosities of the gallbladder are an uncommon finding [1, 5]. It is not yet clear whether this is due to a wide range of anatomic variations of the gallbladder draining system or due to minor sensitivities of current imaging systems and techniques as assumed previously [1, 6]. CCDS, with its capability to analyze
E M. Kainberger et al.: Color Doppler US of cholecystic varices
Fig.2b. Detailed image of the portal vein asit runs in the thickened hepatoduodenal ligament. The vein is partly perfused partly occluded because of a hypoechoic thrombus with no flow in that segment as demonstrated with PW-Duplex Doppler blood flow velocity and direction noninvasively, may aid in the interpretation of the hemodynamics of gallbladder varices in vivo. Although prehepatic obstruction is the most common cause of portal hypertension in children, varices of the gallbladder wall are a rare sonographic finding in the pediatric patient. A thickened gallbladder wall is common in patients with hepatic disease. There is high correlation between a significant decrease in serum albumin levels and wall thickening [4]. Portal venous or lymphatic congestion may be additional factors influencing wall thickening although varicose veins are not always visible [5]. The concomitant occurrence of gastroesophageal and gallbladder varices may be due to their connection via pyloric and gastric veins. We could not find a report describing how commonly both of them exist together. However, as gastresophageal collaterals are present in 80-90% of patients with portal hypertension a coincidence like in our patient can be assumed. Duplex Doppler sonography is an excellent noninvasive imaging tool for
evaluating the hemodynamics of the portal venous system but has certain limitations because of artifacts and small acoustic windows. Documentation of varices like those in the gallbladder wall confirms the diagnosis of portal hypertension and may increase the sensitivity of the method. Color Doppler mapping offers optimized motion discrimination and a high spatial and temporal resolution. It has the potential to detect unexpected flow, to differentiate real flow from B-mode and Doppler artefacts, and to analyze blood flow in numerous collateral vessels to better advantage.
References 1. Marchal GJF, Van Hotsbeeck M, Tshibwabwa-Ntumba E, Goddeeris PG, Fevery J, Oyen RH, Adisoejoso B, Baert AL, Van Steenbergen W (1985) Dilatation of the cystic veins in portal hypertension: sonographic demonstration. Radiology 154:187 2. Vergesslich KA, Goetz M, Mostbeck GH, Sommer G, Ponhold W (1989) Portal venous blood flow in cystic fibrosis: assessment by duplex Doppler sonography. Pediatr Radio119: 371 3. Subramanyam BR, Balthasar EV, Raghavendra N, Lefheur RS (1983) Sonographic evaluation of patients with portal hypertension. Am J Gastroentero178:369 4. Wegener M, BOrsch G, Schneider J, Wedmann B, Winter R, Zacharias J (1987) Gallbladder wallthickening: frequent findingin various nonbiliary disorders - prospective ultrasonographic study. JCU 15:307 5. Edwards EA (1951) Functional anatomy of the porta-systemic communications. Arch Intern Med 88:137 6. Ralls PW, Mayekawa DS, Lee KP, Colletti PM, Johnson MB, Halls JM (1988) Gallbladder wall varices: diagnosis with color flow Doppler sonography. JCU 16:595 Dr. E M. Kainberger II. Medizinische UniversitSts Klinik Abteilung far diagnostische Radiologie Garnisongasse 13 A-1090 Vienna Austria
