AJR 2001; 177:1109-1112
© American Roentgen Ray Society
Intrahepatic Spontaneous Retrograde Portal Flow in Patients with Cirrhosis of the Liver
Reversal by Food Intake
Hitoshi Tochio1,
Masatoshi Kudo2,
Shin-ichi Nishiuma3 and
Yoshihiro Okabe3
1
Division of Clinical Pathology, Kobe City General Hospital, 4-6,
Minatojima-Nakamachi, Chuo-ku Kobe, 650-0046, Japan.
2
Department of Gastroenterology and Hepatology, Kinki University School of
Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
3
Department of Gastroenterology, Kobe City General Hospital, Chuo-ku Kobe,
650-0046, Japan.
Received March 13, 2001;
accepted after revision May 15, 2001.
Address correspondence to M. Kudo.
Abstract
OBJECTIVE. The purpose of our study was to assess whether
intrahepatic spontaneous retrograde portal flow in patients with cirrhosis of
the liver can be reversed to a normal portal venous flow by food intake.
CONCLUSION. Of the 18 cirrhotic patients with intrahepatic
spontaneous retrograde portal flow, 16 (89%) showed a marked change in portal
flow direction after food intake. This evidence strongly suggests that
intrahepatic spontaneous retrograde portal flow may be reversible.
Furthermore, this finding implies that regular food intake may be important in
the maintenance of effective hepatic blood flow in cirrhotic patients.
Introduction
Localized intrahepatic spontaneous retrograde portal flow is occasionally
encountered in patients with cirrhosis of the liver
[1] and has been observed by
invasive radiologic examinations such as percutaneous transhepatic portography
[2]. However, Doppler
sonography provides a noninvasive assessment of this phenomenon under
physiologic conditions and without the use of contrast media
[3]. The increase in portal
flow is associated with intestinal flow after meals in healthy patients and in
patients with liver cirrhosis
[4,
5]. Similar observations have
been reported with Doppler sonography
[1,
6,7,8].
However, to our knowledge, accurate comparisons of the hemodynamic changes
before and after meals in localized intrahepatic spontaneous retrograde portal
flow have never been reported. In our study, with the use of color and pulsed
Doppler sonography, we observed a marked hemodynamic change immediately after
meals in localized intrahepatic spontaneous retrograde portal flow in patients
with cirrhosis of the liver.
Materials and Methods
In 18 patients (eight men and 10 women; age range, 37-72 years; mean, 53
years) with cirrhosis of the liver, localized intrahepatic spontaneous
retrograde portal flow was confirmed by color and pulsed Doppler sonography
(LOGIQ 700 EXPERT series; General Electric Medical Systems, Milwaukee, WI).
Informed consent was obtained from each patient, and institutional review
board approval was also obtained.
The causes for liver cirrhosis in our patient group included hepatitis B
virus (two patients), hepatitis C virus (nine patients), alcohol (five
patients), and unknown (two patients). All patients had signs of portal
hypertension due to liver cirrhosis, including esophageal varices (n
= 18), splenomegaly (n = 18), dilated portal vein (n = 10),
dilated splenic vein (n = 6), or ascites (n = 3). When this
study was performed, all patients were eating regular hospital food during
their hospitalization. Portal reversal flows were observed in the different
Couinaud [9] liver segments.
Portal branching of localized intrahepatic spontaneous retrograde portal flow
detected on color Doppler imaging was located at the second branch in two
patients, at the third branch in 11 patients, and at the fourth branch in five
patients.
Doppler sonography was performed in patients resting in a supine position
after fasting for more than 12 hr. Pulsed Doppler waveform analysis was
performed with the patient breath-holding after exhalation. For a period of
10-30 min after food intake, hemodynamic changes were observed in the portal
branch, in which localized intrahepatic spontaneous retrograde portal flow had
been detected before food intake. After the Doppler study before food intake,
all patients ate the regular meal provided by our hospital, which contained
1255.2 J with 15 g of protein, 6 g of fat, and 60 g of carbohydrate. The long
observation period for the return to normal flow after food intake was
assessed in six of 18 patients.
The data of the reversed flow and the reversal of the reversed flow were
recorded on videotape for later review. By reviewing the videotape, two
observers and a sonographic examiner evaluated the reversed portal flow and
the reversal of the reversed flow.
The 16 patients in whom the reversal phenomenon of the reversed portal flow
was observed were followed up by sonography at an outpatient clinic to assess
whether the phenomenon of reversed portal flow was observed without food
intake.
Results
Of the 18 patients with localized intrahepatic spontaneous retrograde
portal flow before meals, a normal portal flow direction returned in 16 (89%).
Hepatopetal portal flow took at least 10 min after meals in the affected
portal branches studied and lasted for at least 30 min. (Fig.
1A,1B).
In six patients in whom long-period observation was performed, the duration of
the return to normal flow after food intake varied. Normograde portal flow
lasted 2 hr in one patient (Fig.
2A,2B,2C,2D),
3 hr in four patients, and 5 hr in one patient (Fig.
3A,3B,3C,3D).
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Fig. 1A. —42-year-old man with alcoholic cirrhosis of liver. Color
Doppler sonogram obtained before food intake reveals blue color
(arrow) in portal branch (Couinaud
[9] segment VI), suggesting
spontaneous flow reversal. Pulsed Doppler analysis confirms that portal flow
has been reversed in relation to hepatopetal arterial pulsatile flow (hepatic
arterial flow) (open arrows).
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Fig. 1B. —42-year-old man with alcoholic cirrhosis of liver. Color
Doppler sonogram obtained after food intake shows portal branch in segment VI
in red (arrow), suggesting normalization of flow direction. Pulsed
Doppler analysis confirms that portal flow direction changed markedly after
food intake; flow has reversed to hepatopetal from hepatofugal direction
(open arrows).
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Fig. 2A. —68-year-old woman with hepatitis C cirrhosis of liver.
Ascites is evident. Color Doppler sonogram obtained before food intake reveals
blue color (arrow) in portal branch (Couinaud
[9] segment V), suggesting
spontaneous flow reversal.
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Fig. 2B. —68-year-old woman with hepatitis C cirrhosis of liver.
Ascites is evident. Pulsed Doppler analysis confirms that portal flow has been
reversed in relation to hepatopetal arterial pulsatile flow (hepatic arterial
flow) (arrowheads).
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Fig. 2C. —68-year-old woman with hepatitis C cirrhosis of liver.
Ascites is evident. Color Doppler sonogram obtained after food intake shows
portal branch in segment V in red (arrow), suggesting normalization
of flow direction.
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Fig. 2D. —68-year-old woman with hepatitis C cirrhosis of liver.
Ascites is evident. Pulsed Doppler analysis confirms that portal flow
direction changed markedly after food intake; flow has been directed to
hepatopetal from hepatofgal direction (arrowheads).
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Fig. 3A. —37-year-old woman with alcoholic cirrhosis of liver. Color
Doppler sonogram obtained before food intake reveals blue color
(arrow) in portal branch (Couniaud
[9] segment IV), next to
hepatic arterial branch, suggesting spontaneous flow reversal.
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Fig. 3B. —37-year-old woman with alcoholic cirrhosis of liver. Pulsed
Doppler analysis confirms that portal flow has been reversed
(arrowheads) in relation to hepatopetal arterial pulsatile flow
(hepatic arterial flow).
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Fig. 3C. —37-year-old woman with alcoholic cirrhosis of liver. Color
Doppler sonogram obtained after food intake shows portal branch in segment IV
in red (arrow), suggesting normalization of flow direction.
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Fig. 3D. —37-year-old woman with alcoholic cirrhosis of liver. Pulsed
Doppler analysis confirms that portal flow direction changed markedly after
food intake; flow has been directed to hepatopetal from hepatofugal direction
(arrowheads). Arterial flow is blue because of low pulse repetition
frequency, causing aliasing phenomenon.
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All 16 patients did not show the phenomenon of the reversed portal flow
without food intake. This was proved many times during follow-up sonography at
the outpatient clinic after the patients were discharged from the
hospital.
Discussion
The results of this study indicate that localized intrahepatic spontaneous
retrograde portal flow in patients with cirrhosis of the liver can be reversed
by food intake. This finding is important because intrahepatic hepatopetal
portal flow increases hepatic blood flow. To our knowledge, this report is the
first that documents restoration of portal flow by food intake in patients
with preingestive localized intrahepatic spontaneous retrograde portal flow.
Previous reports assessing the hemodynamic change of the hepatic artery
[10] and the portal vein
[11,
12] before and after food
intake show that portal hemodynamic change after a meal is related to the
severity of portal hypertension, including esophageal varices, spontaneous
portal systemic shunts, and liver cirrhosis. However, no reports have observed
a reversal phenomenon after food intake in localized intrahepatic portal
reversed flow. Furthermore, a localized intrahepatic spontaneous retrograde
portal flow reversal can be obtained noninvasively under a complete
physiologic condition, namely, by the use of color and pulsed Doppler
sonographic techniques, without affecting the flow hemodynamics induced by
injecting contrast media or exerting pressure on injection for discriminative
visualization. Therefore, color and pulsed Doppler sonography are noninvasive
approaches that provide in vivo pathophysiologic visualization of the portal
venous hemodynamics.
This finding also provides information useful for the clinical treatment of
patients with liver cirrhosis and advocates the importance of regular food
intake by patients with liver cirrhosis. Moreover, a well-regulated
food-intake regimen not only provides nutritional sustenance but also ensures
improvement in effective hepatic blood flow, even in patients with regional
intrahepatic spontaneous retrograde portal flow.
In conclusion, using the color and pulsed Doppler songographic approaches
under completely physiologic conditions, we revealed evidence of localized
intrahepatic spontaneous retrograde portal flow reversal by food intake in
patients with cirrhosis of the liver, thus raising an important issue for the
treatment of patients with cirrhosis of the liver.
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Abstract
Introduction
