Checklist
a. Liver echotexture
b. Portal vein
c. Spleen size
d. Splenic and Superior mesenteric veins
e. Portosystemic collaterals
f. Hepatic artery
g. Hepatic veins
1. Liver echotexture: Coarsened echotexture (doesn’t mean increased echogenicity) with irregular nodular surface is characteristic of cirrhosis. Portal and hepatic veins are less visualized. Right lobe may shrink in size, with enlarged caudate and left lobe. “Caudate:Right lobe ratio exceeds 0.65.” (measured by comparing maximum transverse dimensions at axial image just below portal bifurcation).
2. Portal vein diameter: It should be less than 13 mm, measured where portal vein crosses the IVC, during quiet respiration, in supine position. “Diameter more than 13 mm indicates portal hypertension with high specificity.”
3. Response of the portal, splenic and superior mesenteric vein to respiration: Diameter of these veins should increase by more than 70% from quite to deep respiration. “Less than 70% increase in diameter indicates portal hypertension.”
4. Portal flow direction, velocity and waveforms: Normal flow is hepatopedal, with mean flow velocity (TAM) of 15-18 cm/s and shows respiratory variation. “Loss of respiratory variation, to-and-fro biphasic flow or reversal/hepatofugal flow signifies portal hypertension.” *
5. Spleen size: Spleen size more than 13 cm, measured in cephalocaudad direction in coronal plane.
6. Presence of portosystemic collaterals: These can be identified by following these simple steps:
• Start from left side, see if flow reversal is there in splenic vein, look for splenorenal and splenogastric collaterals (adjacent to upper and lower poles of spleen respectively).
• Evaluate blood flow direction in main portal vein. Flow reversal indicates collateralization
• Return to left portal vein and follow it till falciform ligament, where umbilical vein collateral may be visible.
• Look for a cephalad directed vessel arising from portal vein just at superior mesenteric vein-portal vein junction.
• Look for GB wall collaterals.
• Gastric and gastro-epiploic collaterals may be seen adjacent to posterior surface of liver towards left lobe.
• Look for collaterals at GE junction.
7. Hepatic artery: Due to decrease in portal flow, flow in hepatic artery is increased to maintain hepatic blood supply,
* Flow reversal in portal and splenic vein is a variable finding depending on collateral development. If splenorenal collaterals are predominant, flow may reverse in portal vein. However, if large umbilical vein collateral is predominant, flow may be hepatopedal in portal and splenic veins because diverting collateral (umbilical vein) arises in left portal system.
a. Liver echotexture
b. Portal vein
c. Spleen size
d. Splenic and Superior mesenteric veins
e. Portosystemic collaterals
f. Hepatic artery
g. Hepatic veins
1. Liver echotexture: Coarsened echotexture (doesn’t mean increased echogenicity) with irregular nodular surface is characteristic of cirrhosis. Portal and hepatic veins are less visualized. Right lobe may shrink in size, with enlarged caudate and left lobe. “Caudate:Right lobe ratio exceeds 0.65.” (measured by comparing maximum transverse dimensions at axial image just below portal bifurcation).
2. Portal vein diameter: It should be less than 13 mm, measured where portal vein crosses the IVC, during quiet respiration, in supine position. “Diameter more than 13 mm indicates portal hypertension with high specificity.”
3. Response of the portal, splenic and superior mesenteric vein to respiration: Diameter of these veins should increase by more than 70% from quite to deep respiration. “Less than 70% increase in diameter indicates portal hypertension.”
4. Portal flow direction, velocity and waveforms: Normal flow is hepatopedal, with mean flow velocity (TAM) of 15-18 cm/s and shows respiratory variation. “Loss of respiratory variation, to-and-fro biphasic flow or reversal/hepatofugal flow signifies portal hypertension.” *
5. Spleen size: Spleen size more than 13 cm, measured in cephalocaudad direction in coronal plane.
6. Presence of portosystemic collaterals: These can be identified by following these simple steps:
• Start from left side, see if flow reversal is there in splenic vein, look for splenorenal and splenogastric collaterals (adjacent to upper and lower poles of spleen respectively).
• Evaluate blood flow direction in main portal vein. Flow reversal indicates collateralization
• Return to left portal vein and follow it till falciform ligament, where umbilical vein collateral may be visible.
• Look for a cephalad directed vessel arising from portal vein just at superior mesenteric vein-portal vein junction.
• Look for GB wall collaterals.
• Gastric and gastro-epiploic collaterals may be seen adjacent to posterior surface of liver towards left lobe.
• Look for collaterals at GE junction.
7. Hepatic artery: Due to decrease in portal flow, flow in hepatic artery is increased to maintain hepatic blood supply,
* Flow reversal in portal and splenic vein is a variable finding depending on collateral development. If splenorenal collaterals are predominant, flow may reverse in portal vein. However, if large umbilical vein collateral is predominant, flow may be hepatopedal in portal and splenic veins because diverting collateral (umbilical vein) arises in left portal system.
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