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УДК 616.149-008.341.1.
Мардиева Гульшод Маматмуродовна
к.м.н., доцент, заведующая кафедрой лучевой диагностики
и терапии Самаркандского государственного медицинского института,
Самарканд, Узбекистан.
Облобердиева Парвина Облоберди кизи
студентка магистратуры по специальности
«Медицинская радиология» кафедры лучевой диагностики и
терапии Самаркандского государственного медицинского института,
Самарканд, Узбекистан
УЛЬТРАЗВУКОВАЯ ВЕРИФИКАЦИЯ ПОРТАЛЬНОЙ ГИПЕРТЕНЗИИ ПРИ ЦИРРОЗЕ ПЕЧЕНИ
For citation:
Mardieva Gulshod Mamatmurodovna, Obloberdieva Parvina Obloberdi qizi. Ultrasonic verification of portal
hypertension in liver cirrhosis. Journal of hepato-gastroenterology research. 2020, vol. 3, issue 1, pp. 36-39
http://dx.doi.org/10.26739/
2181-1008-2020-3-9
АННОТАЦИЯ
В основу работы положены результаты обследования больных с диффузными заболеваниями печени методом
ультразвуковой допплерографии. Были выделены безусловные и условные типы ультразвуковых признаков,
позволяющих обнаружить цирроз печени и сопровождающую его портальную гипертензию. У больных всех групп
были проанализированы
значения основных
ультразвуковых параметров,
отражающих структурные
и
гемодинамические изменения при циррозе печени. Ультразвуковой метод с допплерографией сосудов позволил
проследить динамику нарастания проявлений портальной гипертензии у больных циррозом печени на разных стадиях
развития патологического процесса. Ультразвуковая диагностика цирроза печени затруднена у больных при наличии
начальных проявлений портальной гипертензии и имеет исключительно высокую информативность при исследовании
больных со сформировавшимся синдромом портальной гипертензии.
Ключевые слова:
ультразвуковая допплерография, портальная гипертензия, цирроз печени.
Mardieva Gulshod Mamatmurodovna
t.f.n., Samarqand davlat tibbiyot instituti,
Nurli diagnostika va terapiya kafedrasi mudiri dotsent,
Samarqand, O’zbekiston
Obloberdieva Parvina Obloberdi qizi
Nurli diagnostika va terapiya kafedrasi,
«Tibbiy radiologiya» yo’nalishi bo’yicha magistratura talabasi,
Samarqand, O’zbekiston
JIGAR SIRROZIDA PORTAL GIPERTENZIYANING ULTRATOVUSH TEKSHIRUVI
ANNOTATSIYA
Bizning tadqiqotimiz diffuz jigar kasalligi bilan og'rigan bemorlarni ultratovushli doppler tekshiruvi natijalariga
asoslangan. Jigar sirrozi va unga hamroh bo'lgan portal gipertenziyasini aniqlashga imkon beradigan ultratovush belgilarining
shartsiz va shartli turlari aniqlandi. Barcha guruhdagi bemorlarda ultratovush tekshiruvining asosiy parametrlarining qiymatlari
tahlil qilindi, bu jigar sirrozidagi strukturaviy va gemodinamik o'zgarishlarni aks ettiradi. Tomirlarni ultratovush tekshiruvi
patologik jarayonlarning rivojlanishining turli bosqichlarida jigar sirrozi bilan og'rigan bemorlarda portal gipertenziya rivojlanish
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dinamikasini kuzatishga imkon beradi. Portal gipertenziyasi erta boshlangan bemorlarda jigar sirrozi diagnostikasi qiyin bo'lgan
va portal gipertenziya va gipertoniya sindromi rivojlangan bemorlarda o'ta tashxis qo'yadi.
Kalit so'zlar:
Doppler ultratovush tekshiruvi, portal gipertenziya, jigar sirrozi.
Mardieva Gulshod Mamatmurodovna
Candidate of Medical Sciences, Associate Professor,
Head of the Department of Radiation Diagnostics and Therapy,
Samarkand State Medical Institute,
Samarkand, Uzbekistan
Obloberdieva Parvina Obloberdi qizi
Master's student in the specialty "Medical Radiology"
Department of Radiation Diagnostics and Therapy,
Samarkand State Medical Institute,
Samarkand, Uzbekistan
ULTRASONIC VERIFICATION OF PORTAL HYPERTENSION IN LIVER CIRROSIS
ANNOTATION
The work is based on the results of examination of patients with diffuse liver diseases by ultrasound Doppler.
Unconditional and conditional types of ultrasound signs were identified, allowing to detect cirrhosis of the liver and the
accompanying portal hypertension. The values of the main ultrasound parameters reflecting structural and hemodynamic changes
in liver cirrhosis were analyzed in patients of all groups. The ultrasound method with vascular Doppler imaging made it possible
to trace the dynamics of the increase in the manifestations of portal hypertension in patients with liver cirrhosis at different stages
of the development of the pathological process. Ultrasound diagnostics of liver cirrhosis is difficult in patients with initial
manifestations of portal hypertension and is extremely informative in the study of patients with developed portal hypertension
syndrome.
Key words:
ultrasound Doppler sonography, portal hypertension, liver cirrhosis.
The urgency of the problem.
The widespread occurrence of
portal hypertension, the anatomical features of the portal vein
system, variability of the clinical course, the significant
frequency and multiplicity of complications (including fatal
ones) put this disease on a par with the most severe pathologies
of the human div. That is why knowledge of portal
hypertension (its etiology, pathogenesis, clinical picture,
diagnosis, differential diagnosis and complex treatment), as
well as the complications of this disease, is an important factor
in the preparation of a future doctor. Recently, there has been
an increase in the incidence of liver cirrhosis, which is the
main cause of the development of portal hypertension. It
should be considered as an important link in the pathogenesis
of hemodynamic disorders, leading to significant changes in
blood circulation in the portal vein system and the
development of portosystemic anastomoses [2,8].
Diffuse liver diseases occupy a significant place in
the structure of diseases of the digestive system, being an
extremely urgent clinical, epidemiological and socio-
economic health problem. The number of patients with liver
cirrhosis in Uzbekistan, European countries and the USА is
constantly increasing [1,3].
Diagnosis of diseases of the hepatobiliary system
has always been of great clinical and scientific interest, due to
the rapid progress that methods of radiological diagnostics are
undergoing today. The complexity of diagnosis and
differential diagnosis of diffuse liver lesions lies in the almost
complete absence of specific signs, mainly in the early stages
of the disease [2,4].
Purpose of the study:
determination of the
possibilities of ultrasound dopplerography of the liver in the
diagnosis of portal hypertension and various diseases
accompanied by a similar clinical picture due to this syndrome
[5,6].
Material and research methods.
The work is
based on the results of a comprehensive clinical examination
of 42 patients with diffuse liver diseases (Table 1). Thirty
patients were diagnosed with liver cirrhosis, 12 - chronic
hepatitis without signs of portal hypertension. The control
group consisted of 20 healthy people [7,8].
Sonographic examination was carried out on a
«SonoScape»-S-50 ultrasound scanner with a linear format
transducer in real time, with an operating frequency of 7.5
MHz. Complex Doppler ultrasound was used as a highly
informative method for diagnosing portal hypertension and
associated diseases. A comparative assessment of the
informativeness of the gray scale mode was carried out using
ultrasound Doppler techniques: color Doppler and energy
mapping, pulse-wave Doppler.
Table 1.
Distribution of patients by the nature of pathology
The nature of the pathology
Number
of
patients
Gender male / female
human
Age, years
Chronic hepatitis
12
7 / 5
38,4 ± 15,3
Cirrhosis of the liver
30
18 / 12
59,1 ± 17,7
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Control group
20
9 / 11
28,1 ± 16,6
Research results.
Were identified: unconditional and
conditional types of ultrasound signs, allowing to detect
cirrhosis of the liver and the accompanying portal
hypertension. Unconditional signs included: unevenness of the
liver contour, tortuous course of intrahepatic vessels, blood
flow in the paraumbilical vein, and reverse direction of portal
blood flow. In addition, they reflected direct signs of liver
cirrhosis and portal hypertension - the processes of fibrosis and
regeneration of the liver parenchyma, shunting of the portal
blood flow.
The conditional signs included: splenomegaly, ascites,
dilatation of the veins of the portal system, a decrease in the
portal blood flow velocity (Vpv <15 cm / sec), an increase in
the hepatic artery resistance index (RIha≥0.74), altered blood
flow in the hepatic veins. A set of at least three conditional
ultrasound signs was taken as the criterion for the formation of
liver cirrhosis.
Table 2.
Frequency of occurrence of unconditional and conditional signs of liver cirrhosis and portal hypertension
Sign
Cirrhosis of the
liver
Chronic hepatitis Control
1. Unconditional signs
Uneven liver contour
57%
0 %
0 %
Recanalization of PUV
40%
0 %
0 %
The twisted course of the liver vessels
43%
0 %
0 %
Hepatofugal portal blood flow
3%
0 %
0 %
2. Conditional signs
Splenomegaly
73%
17%
0 %
Expansion of the veins of the portal system
63%
8%
0 %
Changes in blood flow in the hepatic veins
60%
33%
0 %
Decreased portal blood flow velocity
40%
8%
0 %
High Riha
33%
33%
5 %
Ascites
30%
0 %
0 %
In patients of all groups, the values of the main
ultrasound parameters, reflecting structural and hemodynamic
changes in liver cirrhosis, were analyzed. Thus, the speed of
portal blood flow was reduced in patients with liver cirrhosis
in comparison with the control group. Altered blood flow in
the hepatic veins was found in 50% of patients with liver
cirrhosis. The hepatic artery resistance index was increased in
patients with liver cirrhosis as a result of chronic hepatitis
(0.75 ± 0.07). Recanalization of the paraumblical vein was
observed in 30% of patients with liver cirrhosis.
The anterior - posterior size of the right lobe of the liver
was increased in all groups of patients with liver cirrhosis (17.5
± 2.0 cm). The spleen length did not differ significantly among
patients with different etiological forms. Accurate differential
diagnosis of the etiology of liver cirrhosis by ultrasound was
not possible.
When determining the dynamics of the increase in
manifestations of portal hypertension, the evolution of
ultrasound signs was traced in patients with different
functional classes according to the Child-Pugh classification,
who had different degrees of esophageal varicose veins. In
patients with chronic hepatitis, as well as in patients with liver
cirrhosis with functional class A, who did not have esophageal
varices, ultrasound criteria for liver cirrhosis and portal
hypertension were not revealed. Differential ultrasound
diagnostics of chronic hepatitis and preclinical stage of liver
cirrhosis was not possible. There was a moderate expansion of
the splenic vein - on average up to 0.86 ± 0.21 cm and a
moderate increase in the spleen - on average up to 12.9 ±, 5
cm. The velocity indicators of blood flow in the veins of the
portal system in patients of this group tended to decrease,
however their average values were added up to the limits of
the permissible norm. In 33% of patients, blood flow in the
paraumblical vein was detected, in 42% there was an
unevenness of the liver contour.
In patients with liver cirrhosis with functional class B
and pronounced varicose veins of the esophagus, there was a
further increase in ultrasound signs of portal hypertension:
more pronounced expansion of the splenic vein - 0.98 ± 0.17
cm, splenomegaly (spleen length - 14.8 ± 2.7 cm ). Blood flow
in the paraumblical vein was observed more often in 63% of
patients. Ascites was found in 10% of cases. The contours of
the liver were mostly uneven (73%). The values of the portal
blood flow velocity corresponded to the lower limit of the
norm.
At a late stage of liver cirrhosis, a significant expansion of the
main trunk of the portal vein was noted - on average to 1.42 ±
0.10 cm, a pronounced decrease in the portal blood flow rate
on average to 10.0 ± 2.3 cm / s, a significant increase in the
diameter of the paraumblical vein - on average, up to 0.76 ±
0.31 cm. Persistent ascites and uneven contours of the liver are
characteristic of all patients in this group. The ultrasound
method made it possible to make an accurate diagnosis in all
patients with class C according to the Child-Pugh
classification.
Based on the data presented, splenomegaly (spleen
length more than 12.0 cm) and enlargement of the splenic vein
(> 0.8 cm), which are the initial manifestations of portal
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hypertension syndrome, can be attributed to the early
ultrasound signs of formed liver cirrhosis. In parallel with
progressive splenomegaly and expansion of the splenic vein, a
collateral bed develops (varicose veins of the esophagus and
recanalization of the paraumblical vein. The structural
reorganization of the liver parenchyma gradually increases,
manifested by the unevenness of the contour, heterogeneity of
the structure and deformation of the course of intrahepatic
vessels. Late ultrasound signs of decompensated liver cirrhosis
and severe portal hypertension include ascites, portal vein
dilation, decreased portal blood flow velocity and a significant
diameter of the paraumblical vein, as well as, in some cases,
the appearance of reverse blood flow in the branches of the
portal vein.
Summarizing the above data, it should be noted that
ultrasound diagnostics of liver cirrhosis is difficult in patients
with initial manifestations of portal hypertension and is
extremely informative in the study of patients with developed
portal hypertension syndrome. In patients with extrahepatic
portal hypertension, splenomegaly is more pronounced than in
patients with liver cirrhosis, which, however, cannot be
considered a reliable clinical sign of portal vein thrombosis.
Lack of blood flow, parietal blood flow in the veins of the liver,
and collateral blood flow during cavernous transformation of
the portal vein made it possible to diagnose the extrahepatic
form of portal hypertension caused by venous thrombosis.
Conclusions.
Reverse blood flow in the branches of the
portal vein, deformation of the vascular pattern of the liver and
the presence of blood flow in the paraumblical vein are signs
of hepatic cirrhosis. The absence of unconditional ultrasound
signs does not allow to exclude the presence of liver cirrhosis
and requires a quantitative assessment of the parameters of
hepatic hemodynamics. The combination of a decrease in the
portal blood flow rate with an increase in the hepatic artery
resistance index, as well as monophasic blood flow in the
hepatic veins, is characteristic of the formed liver cirrhosis.
The absence of the changes listed above suggests a low
probability of portal hypertension, which, however, does not
exclude an early stage of its development.
When detecting low-specific diffuse changes in the
liver parenchyma or signs of liver vein pathology in the gray
scale mode, it is recommended to use the color Doppler
mapping mode, which allows to assess the patency of the liver
vessels, to determine the direction of blood flow in the
branches of the portal vein, and to identify functioning port-
system shunts.
The ultrasound method makes it possible to trace the
dynamics of the growth of manifestations of portal
hypertension in patients with liver cirrhosis at different stages
of the development of the pathological process. Doppler
ultrasound of the liver vessels is advisable to be performed in
patients in order to identify signs of portal hypertension and
differential diagnosis of the causes of its development. If it is
necessary to exclude the extrahepatic form of portal
hypertension caused by hepatic vein thrombosis, it is
preferable to use the power Doppler mode.
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