Ultrasound Doppler of the Liver & Portal Hypertension

Ultrasound Doppler 

of the Liver & Portal Hypertension 

Myron A. Pozniak, MD 

Professor of fRadiology 

University of Wisconsin 

Madison, Wisconsin 

Objectives: 

Review the normal hepatic Doppler flow profiles 

Recognize e the hemodynamic changes of portal 

hypertension 

Recognize the common and unusual pathways of 

porto-systemic shunting 

Hepatic artery 

• Normal waveform 

• Brisk upstroke in 

systole 

• RI 60-70% 

• Diastolic velocity 

Portal vein normal flow 

• Relatively uniform velocity. 

Some periodicity OK. 

• But not too much 

• Velocity just under 

20 cm/sec 

in a fasting patient 

The liver vascular index 

• Relationship of portal vein velocity to hepatic artery velocity 

The liver vascular index 

• Relationship of portal vein velocity to hepatic artery velocity 

2

Hepatic Vein Anatomy 

Hepatic Vein Anatomy 

Hepatic vein laminar flow dynamics 

3

Venous waveform terminology 

• Pulsatility 

• Periodicity 

• Phasicity 

Hepatic Vein Flow Dynamics 

Hep Vein 

Velocity 

Tracing 

A 

C 

S 

V 

D 

ECG 

Tricuspid 

M-Mode 

Back to the Porta Hepatis 

Altered flow profiles 

4

Altered porta-hepatis hemodynamics 

Increased Periodicity of Portal vein flow 



• May be due to 

hyperdynamic 

arterial ilifl inflow 

• May be secondary 

to increased 

retropulsation with 

cardiac disease 



•Liver disease 

•AV fistula 

•Cardiac issues 

•Tricuspid regurgitation 

•Right ventricular dysfunction 

5

Normal hepatic blood flow 

• 25% of cardiac output 

• 1.5 Liters per minute 

• Portal inflow 2/3; arterial inflow 1/3 

• 90% of Oxygen via Hepatic Artery 

• The Artery supplies the disease process. 

The altered liver vascular index 

} 

Increased hepatic arterial flow / Decreased portal vein flow 


• Verifies the “starry sky” liver as abnormal 

6

The altered liver vascular index 

• Initially reported to be highly sensitive and specific for 

diagnosis of Hepatocellular Carcinoma (HCC) 

• Many other causes 

Iwao T, et al. Value of Doppler ultrasound parameters of portal vein and hepatic artery in 

the diagnosis of cirrhosis and portal hypertension. Am J Gastroenterol 1997;92:1012-1017. 


• Diffuse hepatocellular disorder 

• Hepatitis – viral, chemical, alcoholic 

• Focal lesions 

• Lymphoma 

• Metastatic disease 

• Hepatitis 

• Etc. 

• Non-specific 

• It’s not really compensatory 

Nomenclature 

• Normal portal flow is hepatopetal 

• Not –pedal 

• Reversed portal flow is hepatofugal 

• As in: centrifugal force / centripetal force 

7

The degree of PV flow reversal correlates 

with the severity of the liver disease. 

Except in the presence of a paraumbilical vein 

Resistance to inflow may result in relative 

Portal Vein stasis. 

PV flow reversible with Valsalva 

8

Portal hypertension 

• Increased pressure gradient between the portal vein 

and the IVC above 6 mmHg 

• >6 mmHg 12 mmHg (clinically evident) 

18 

12 

6 

0 

Hepatic Vascular Anatomy 

Portal Triad 

9

Hepatic Vascular Anatomy 

Portal Triad 

Classifications of portal hypertension 

• Pre-sinusoidal 

• Sinusoidal 

• Post-sinusoidalsinusoidal 

X 

X 

X 

Pre-sinusoidal 

• Extrahepatic 

• Portal vein obstruction 

• compression 

• occlusion 

• Arterio-portal fistula 

• Intrahepatic 

• Fibrosis 

• Wilson disease 

• Sarcoid 

• Parasites 

X 

X 

X 

10

Sinusoidal 

• Cirrhosis 

• Laennec 

• Hepatitis 

• Sclerosing cholangitis 

X X X X 

X X X 

Post-sinusoidal - Budd Chiari Syndrome 

• Hepatic vein 

thrombosis 

• Hepatic venous 

outflow 

obstruction 

• Cardiac 

• Pulmonary 

X 

X 

X 

Clinical Presentation Depends on Severity of Disease 

• Elevated Liver Enzymes 

• Ultrasound is usually the 1 st imaging test 

• You must perform (request) Doppler 

11

With Hepatocellular disease… 

• Portal flow decreases 

• Arterial flow increases 

(early in the disease 

process) 

Reversed PV flow 

Where is this blood coming from? 

Eventually the disease worsens to the point that 

even Hepatic Artery flow encounters resistance. 

• It finds a path with less resistance … 

• The portal vein 

The portal vein 

• The end result is… 

• Hepatofugal flow 

12

Imaging findings of portal hypertension 

• Portal vein 

enlargement 

• Decreased or 

reversed flow 

• Varices 

Portosystemic pathways 

• Gastrosplenic (short gastric) 

• Left gastric 

• Recanalized umbilical vein 

• Splenorenal 

l 

• Mesenteric 

• Retroperitoneal 

• Hemorrhoidal 

Identification and mapping of varicees … 

• helps avoid surgical complications 

• helps in planning transplant surgery 

• Helps in planning TIPS 

13

3D CT angiography of portal hypertension 

• Augment perception of the entire collateral 

pathway 

• 150 cc of contrast at 5 cc/sec 

150 cc of contrast at 5 cc/sec 

• Imaging during arterial and portal venous phases 

• 3D reformatting with subtraction 

14

42 y/o liver transplant candidate 

Short Gastric Varix 

Both Short and Left Gastric Varicees 

15

55 y/o liver transplant candidate 

Both Short and Left Gastric Varices 

Short Gastric Varix 

Left Gastric Varix 

16

Esophageal varix 

Left Gastric Varix 

The Doppler window to the…. 

Left gastric varix 

Short gastric varix 

17

Paraumbilical vein 

Recanalized umbilical vein 

When it arrives at the umbilicus, it is still not back to the systemic circulation 

Recanalized umbilical vein 

Drainage pathways 

• Caput medusae 

• Inferior epigastric to external iliac 

• Superficial circumflex iliac vein 

• Substernal veins 

• Anywhere it can 

IVC 

Paraumbilical 

Inferior epigastric 

External iliac 

18

Funny things can happen at the umbilicus. 

32 y/o prisoner with an umbilical hernia 

19

DO NOT biopsy this! 

Varices may complicate the surgical 

approach to underlying pathology 

52 y/o female with LLQ pain, fever, elevated white 

count 

• Clinical diagnosis - diverticulitis 

Clinical diagnosis diverticulitis 

• Past medical history 

• Liver disease 

• Portal hypertension - Apparently resolved 

20

Pericholecystic varices 

• Rare 

• Commonly associated with portal vein thrombosis 

21

Spleno-renal Collateral 

S 

K 

Spleno-renal Collateral 

22

Spleno-renal varices are rarely direct 

They often involve the gonadal vein. 

… or a mesenteric vein 

Spleno-renal-mesenteric collateral 

pathways can be very convoluted 

Spleno-external-iliac collateral (via the panus) 

23

39 y/o female with pelvic 

mass on physical exam 

Portal Hypertension 

• Variceal pathways can be just about anywhere 

Not all portal system varices are due to 

portal hypertension. 

24

Isolated gastric varix due to 

splenic vein thrombosis. 

Not all portal system varices are due to portal 

hypertension. 

Conclusions 

Portal Hypertension 

• Variceal pathways can be just about anywhere. 

• Pre-transplant shunt identification is critical to 

transplant survival. 

• An unsuspected varix can ruin a good surgeon’s 

day 

25

Conclusions 

Portal hypertension (cont.) 

• They can be anywhere 

• When you think you have a cystic mass - don’t 

forget to turn on the Doppler 

Conclusions 

• When the request says: 

“ELEVATED LIVER ENZYMES” 

• Don’t just think anatomy … 

• Think physiology … Hemodynamics 

Conclusions 

• Spectral and color Doppler add 

hemodynamic information to the imaging 

findings. 

26

Ultrasound Doppler of the Liver & Portal Hypertension

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