Doppler ultrasound assessment of hepatic hemodynamics in hepatic steatosis: a case–control study

Non-Alcoholic Fatty Liver Disease (NAFLD) has various spectrums of liver diseases like isolated fatty liver, steatohepatitis and cirrhosis usually progressing in a linear fashion. In this process they are known to cause certain haemodynamic changes in the portal flow and hepatic artery flow. The aim of the study was to study these haemodynamic changes in patients with NAFLD and to correlate it with the disease severity. Ninety patients diagnosed to have NAFLD based on ultrasound abdomen (30 each in grade1, grade2 and grade3 NAFLD) and 30 controls (Normal liver on ultrasound abdomen) were subjected to portal vein and hepatic artery Doppler study. Peak maximum velocity (Vmax), Peak minimum velocity (Vmin), Mean flow velocity (MFV), and Vein pulsality index (VPI) of the portal vein and hepatic artery resistivity index (HARI) of the hepatic artery were the doppler parameters which were assessed. Liver span was also assessed both for the fatty liver and controls. The mean Vmax, Vmin, MFV and VPI of the portal vein in patients with NAFLD was 12.23±1.74cm/sec, 9.31±1.45cm/sec, 10.76±1.48cm/sec, and 0.24±0.04 as compared to 14.05±2.43cm/sec, 10.01±2.27cm/sec, 12.23±2.47cm/sec, 0.3±0.08 in controls respectively. All these differences were statistically significant except for Vmin. The Mean HARI in patients with fatty liver was 0.65±0.06 when compared to controls of 0.75±0.06 (p=0.001). HARI (r-value of -0.517) had a better negative correlation followed by VPI (r-value of -0.44) and Vmax (r-value of -0.293) with the severity of NAFLD. MFV had a very weak negative correlation (r-value of -0.182) with the severity of NAFLD. The Vmax, MFV, VPI and HARI were significantly less when compared to controls suggesting a reduced portal flow and an increased hepatic arterial flow in patients with NAFLD. Among the parameters, HARI correlated better with the severity of NAFLD followed by VPI.

Objective. To study the possibilities of comprehensive ultrasound imaging with pulsed wave mode and Doppler color flow mapping in evaluation of hepatic blood flow and its compensatory capabilities in pre-eclampsia (PE) of different severity. Patients and methods. Complex liver ultrasonography combined with Doppler assessment of arterial and venous blood flow was performed in 87 pregnant women at 28–40 weeks’ gestation. The study group comprised 59 women with PE of varying severity and 12 women with HELLP syndrome. The control group included 30 women with normal pregnancy. Results. Doppler assessment of blood flow in the hepatic artery and in the maternal-placental-fetal system arteries in patients with moderate and severe PE revealed similar changes, which were manifested by elevated vascular resistance in these vessels and correlated with the severity of PE. The maximum values of pulsatility index and resistance index in the hepatic artery were observed in patients with HELLP syndrome – 1.6 ± 0.11 and 0.74 ± 0.08, respectively. Qualitative and quantitative characteristics of blood flow in the portal vein in patients with moderate PE did not statistically differ from those in the control group, while patients with severe PE and HELLP syndrome showed statistically significant disturbances of portal vein blood flow manifested by an increase in portal vein diameter and a decrease in maximum linear velocity of blood flow in the portal vein. Changes in hepatic arterial blood flow were found in patients with moderate PE in the absence of clinical and laboratory manifestations of liver dysfunction. Already in the early stages of PE, a shift of hemodynamic indices toward an increase in peripheral vascular resistance was determined. The increase in hepatic artery vascular resistance was observed in parallel with the increase of similar indices in the uterine-placental-fetal blood flow. Disturbance of blood flow in the portal vein was determined only in patients with severe PE and HELLP syndrome. Conclusion. Vascular disorders of the liver can serve as an additional diagnostic method for early diagnosis of liver involvement in the pathological process, while the signs of portal vein blood flow disorders are a criterion of extremely severe PE course, prognostically unfavorable regarding HELLP syndrome development. Key words: resistance index, liver dysfunction, hepatic artery, pre-eclampsia, hepatic blood flow, pulsatility index, HELLP syndrome

No. 205: The Preliminary Study of CT Perfusion for the Graft Hemodynamic Changes after Liver Transplantation

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

The aim of this study was to search for morphological and hemodynamic changes in hepatic and splanchnic vasculature in alcoholic patients without the signs of hepatic damage and subtyped by Cloninger classification by means of sonography, and compare the subtypes among themselves and with nonalcoholic healthy subjects. Thirty alcohol dependent patients and 30 healthy subjects with no alcohol problem or hepatic impairment were included in the study. Patients were subtyped by Cloninger classification and all patients were evaluated by gray-scale and spectral Doppler ultrasound. The diameter of the portal vein, portal venous velocity, peak systolic and end diastolic velocities of hepatic and superior mesenteric arteries were assessed. RI, PI and systolic/diastolic velocity ratios were also calculated. Portal vein diameter (PV diameter), portal vein cross sectional area (PV area), portal vein velocity (PV PSV), hepatic artery peak systolic velocity (HA PSV), hepatic artery end diastolic velocity (HA EDV), hepatic artery resistive index (HA RI), hepatic artery pulsatility index (HA PI), and systolic/diastolic velocity ratios (HA S/D), superior mesenteric artery peak systolic velocity (SMA PSV), superior mesenteric artery end diastolic velocity (SMA EDV), superior mesenteric artery resistive indices (SMA RI), pulsatility index (SMA PI), and systolic/diastolic velocity rates (SMA S/D) showed no significant difference among the groups (P > 0.01). Although there is no significant difference in PV PSV, HA PSV, SMA PSV, SMA EDV values between the groups, mean values of Type II alcoholics is greater than other groups. Portal vein cross-sectional area was greater in alcoholic patients (Type I, II and III) compared to the control group (P = 0.000). Portal vein velocity, hepatic artery peak systolic and end diastolic velocity, superior mesenteric artery peak systolic and end diastolic velocity were significantly greater in alcoholic patients than in the control group (P < 0.001). No statistical difference was detected between other parameters evaluated. In alcohol dependent patients, some hemodynamic and morphologic changes occur in hepatic and splanchnic circulation, even before the signs of hepatic damage develop, which can be detected by means of Doppler and gray-scale sonography. But as there is no significant difference between the Doppler ultrasonographic findings among alcoholics subtyped by a Cloninger classification, which is a clinical classification, it suggests that psychiatric classification doesn't show any correlation with biological parameters, and because of this Cloninger classification a psychiatric classification cannot be considered as a characteristic determinative factor in the prognosis of hepatic disorder due to alcohol use. However, higher values of Type II alcoholics can be attributed to the longer alcohol intake of this subtype.

Covering the Cover

The value of color Doppler flow imaging (CDFI) and intravenous contrast-enhanced ultrasound (CEUS) for assessing the transplanted liver and early diagnosing complications by examining hemodynamic changes was discussed. Seventy-five patients with orthotopic liver transplantation (OLT) underwent CDFI. The following parameters were measured: peak systolic velocity (PS), resistance index (RI) and Doppler perfusion index (DPI) of the hepatic artery (HA), time average velocity (TAV) of portal vein (PV) and velocity of hepatic vein (HV) in different stages postoperation. And 11 patients of them received CEUS. Thirty healthy subjects were enrolled as controls. The results showed that: (1) In 23 patients without obvious complications, TAV of PV within 15 days post-operation was significantly higher than in controls (P<0.05), PS and DPI of HA within 7 days postoperation were lower, but RI was higher than in controls (P<0.05); (2) When the hepatic artery thrombosis (HAT) occurred, PS and DPI of HA were obviously decreased, but TAV of PV significantly increased like a high saw-tooth wave; (3) While rejection occurred, both TAV of PV and PS of HA were decreased with the increase in RI of HA, and the triphasic wave of HV disappeared and displayed as saw-tooth wave; (4) The incidence of biliary complications in liver transplantation was increased when DPI was reduced; (5) Seven cases of hepatic carcinoma relapse after OLT demonstrated hyperecho in the arterial phase and hypoecho in the portal and later phase on CEUS; (6) In 2 cases of HA thrombus, there was no visualized enhancement in arterial phase of CEUS, but enhancement during the portal vein and parenchymal phase. It was concluded that the hemodynamic changes of PV, HA and HV in the transplanted liver are valuable for assessing the transplanted liver and early diagnosing complications on CDFI and CEUS.

A change in hepatic blood flow caused by the hepatic arterial buffer response (HABR) occurs as fatty liver disease progress. The aim of this longitudinal cohort study was to investigate whether fatty liver with the HABR induces metabolic disorders. In 2009 and 2010, 494 (89.5%) participants were enrolled. The median follow‐up duration was 5.0 (interquartile range, 3.9‐6.0) years. The hazard ratios of fatty liver with the HABR for incident metabolic disorders were assessed by Cox proportional hazard models. A non–fatty liver group (non‐FL group, hepatorenal echo intensity ratio <1.12), a fatty liver without portal hypertension (FL group, hepatorenal echo intensity ratio ≥1.12 and ratio of the maximal blood velocity in the right hepatic artery to maximal blood velocity in the right portal vein <3.1) group, and a fatty liver with portal hypertension (FL‐HABR group, hepatorenal echo intensity ratio ≥1.12 and ratio of the maximal blood velocity in the right hepatic artery to maximal blood velocity in the right portal vein ≥3.1) group were defined based on echo intensity and Doppler ultrasonography. Fatty liver with and without the HABR was significantly associated with the incidence of diabetes on multivariate analysis (non‐FL versus FL group, hazard ratio, 3.36; 95% confidence interval, 1.05‐12.85; FL versus FL with the HABR group, HR, 2.68; 95% confidence interval, 1.28‐6.04). With respect to the incidence of hypertension and dyslipidemia, only FL with the HABR was a significant factor (hypertension, non‐FL versus FL, P = 0.874, FL versus FL‐HABR, P = 0.016, non‐FL versus FL‐HABR, P = 0.023; dyslipidemia, non‐FL versus FL, P = 0.311, FL versus FL‐HABR, P = 0.194, non‐FL versus FL‐HABR, P = 0.038). Conclusion: Fatty liver with the HABR is a high‐risk condition for metabolic diseases. (Hepatology Communications 2017;1:623–633)

To study the function of the endothelium in conducting vascular pharmacological samples in normal and blocking the synthesis of nitric oxide by ultrasound examination of the velocity of central blood flow in the femoral artery in comparison with the changes in systemic hemodynamics and the linear velocity of microcirculatory flow using laser flowmetry. It was studied the parameters of the blood flow velocity (the maximum systolic and diastolic velocity, average systolic and diastolic velocity, Gosling index of pulsatility and resistance index by the Doppler ultrasound Minimax-Doppler-K), the parameters of central circulation (Biopac-systems AcqKnowledge 4.2, USA), and linear velocity of the microcirculatory flow of the musculus vastus medialis (Biopac MP-150, USA) in intact animals and rats with N-Nitro-L-argininemethyl ester (L-NAME) induced deficiency of nitric oxide. Quantitative evaluation of endothelial dysfunction in the conduct of pharmacological tests with endothelium-dependent (acetylcholine) and endothelium-independent (sodium nitroprusside) vasodilatation is most indicative in calculating the coefficient reflecting the ratio of vascular responses areas in intact rats with L-NAME induced deficiency of nitric oxide. Blood flow parameters (the maximum systolic velocity, the calculated difference between systolic and diastolic velocities) showed a high correlation, both with mean arterial pressure and a linear velocity of the microcirculatory flow. We conclude, that ultrasound Doppler were reflected in the systemic and local vascular response to the administration of vasodilators. It allows an assessment of endothelial function by using the Minimax-Doppler-K device.

15 infants (gestational age 47 +/- 11 weeks; weight 3180 +/- 1082 g) with angiocardiographically proven coarctation of the aorta and 53 healthy infants (gestational age 39 +/- 8 weeks; weight 2830 +/- 1418 g) were investigated by echocardiography and pulsed doppler sonography. In all children pulsed doppler recordings were obtained in the anterior cerebral artery (prestenotic reference vessel) and the truncus coeliacus (poststenotic reference vessel). Nine variables were measured from each doppler signal: The maximal systolic velocity, the endsystolic and enddiastolic velocity, the pulsatility-index, the acceleration slope (peak rate of acceleration), the deceleration slope (peak rate of deceleration), the antegrade flow time and the acceleration and deceleration time. The healthy infants showed a pulsatile flow profile in the anterior cerebral artery and the truncus coeliacus. In normal subjects the maximal systolic velocity and the acceleration slope in the truncus coeliacus were always higher than in the anterior cerebral artery. There was no difference in the endsystolic and enddiastolic velocity, the pulsatility-index, the flow times and the deceleration slope. In children with coarctation of the aorta a decreased and nonpulsatile flow in the truncus coeliacus could be shown. The following variables were significantly lower than in the healthy control group: The maximal systolic velocity, the pulsatility-index, the acceleration and deceleration slope and the antegrade flow time and acceleration time. In the anterior cerebral arteries of children with coarctation the maximal systolic and enddiastolic velocity were significantly higher than in the healthy control group. Pulsed doppler recordings were obtained in 9 patients after surgical correction: The maximal systolic and endsystolic velocity, the pulsatility-index, the acceleration and deceleration slope in the truncus coeliacus increased significantly although these values were lower than in the healthy control group. The flow parameters in the anterior cerebral arteries postoperatively showed no significant difference from the preoperative values. Pulsed dopplersonography of the flow in the anterior cerebral artery and the truncus coeliacus is a good method for diagnosis of coarctation of the aorta and postoperative controls.

The objective: study the features of porto1hepatic blood flow in patients with alcoholic liver cirrhosis (ALC) in conjunction with chronic bronchitis (CB) according to Doppler ultrasound.&#x0D; Patients and methods. The study involved 60 patients who were hospitalized, 20 ALC patients in stage B according to Child-Pugh without CB (Ist group), 20 ALC patients in stage B according to Child-Pugh combined with CB in the acute phase (IInd group), 20 patients exacerbation of chronic bronchitis, for which there was no evidence of digestive system diseases (IIIrd group). All patients underwent a complex ultrasonic research techniques scanning in B-mode, the VD-mode, color duplex scanning using «Hitachi EUB 7000» ultrasonic scanner connected to the Doppler flourimetr was visualized main arterial and venous vessels of hepatic and splenic pools.&#x0D; Results. Changes porto-hepatic blood flow were most pronounced in patients with ALC in combination with CB when compared with patients of groups I and III (p&lt;0,05) according to the obtained Doppler indices: diameter of the hepatic artery was 5,55±0,19 mm, portal vein – 12,60±0,17 mm, where increased by 159,12% and 53,56%, respectively (p&lt;0,05) higher than those in healthy individuals.&#x0D; The diameter of the splenic artery and splenic vein at the ALC for combination with CB significantly increased compared with control on 31,13% and 35,67%, respectively (p&lt;0,05).&#x0D; Linear and volumetric blood flow rate in portal vein decreased in this group of patients, 60,24% and 22,68%, respectively (p&lt;0,05) compared with healthy individuals, the linear velocity of blood flow in the splenic vein also significantly slowed down compared to the control on 41,06% (p&lt;0,05), and the volumetric blood flow velocity v. lienalis grew by 155,80% (p&lt;0,05).&#x0D; Among the characteristics of the arterial blood flow hepato-splenic system Gosling pulsatility index (PI) and Pursello resistance index (RI) of hepatic artery also Pursello resistance index (RI) of splenic artery significantly grew in ALC patients in combination with CB 147,20%, 65,49% and 32,31%, respectively (p&lt;0,05) compared with the control group.&#x0D; Maximal systolic velocity of blood flow in the hepatic artery of patients – grew by 8,95% (p&lt;0,05). End diastolic blood flow velocity in the hepatic artery tended to decrease on 13,36% (p&lt;0,05) compared with healthy individuals.&#x0D; Conclusion. Violation of porto-hepatic blood flow in patients with ALC is characterized by its redistribution in the veins of the portal system in the direction of the spleen with a decrease in the average linear and the volumetric velocity in the portal and hepatic veins, increasing the resistance index in the interlobar arteries.

The purpose of this study was to investigate hemodynamic changes in the hepatic artery after glucose ingestion. We used color Doppler sonography to measure hemodynamic changes in the right hepatic artery and the right portal vein in response to glucose ingestion (225 ml, 300 kcal) in 25 healthy subjects and 25 patients with cirrhosis. In healthy subjects, the peak systolic and end-diastolic velocities in the right hepatic artery decreased (33 +/- 3% and 53 +/- 3%) from baseline velocities measured in the fasting state. The resistance index of the right hepatic artery and the velocity in the right portal vein in these subjects significantly (p < 0.01) increased (14 +/- 2% and 32 +/- 2%) from baseline values after glucose ingestion. Glucose ingestion produced significantly (p < 0.01) smaller changes in cirrhotic patients. The maximum decrease in the peak systolic and end-diastolic velocities in the right hepatic artery were 13 +/- 2% and 25 +/- 3% from baseline velocities, and the maximum increases in the resistance index of the right hepatic artery and the velocity in the right portal vein were 6 +/- 1% and 10 +/- 3% from baseline values. The decrease in blood flow velocity in the right hepatic artery after glucose ingestion is presumably a homeostatic mechanism to maintain constant hepatic perfusion. This reciprocal response was reduced in cirrhotic patients.

Purpose The purpose of this study was to investigate hemodynamic changes in the hepatic artery after glucose ingestion. Methods We used color Doppler sonography to measure hemodynamic changes in the right hepatic artery and the right portal vein in response to glucose ingestion (225 ml, 300 kcal) in 25 healthy subjects and 25 patients with cirrhosis. Results In healthy subjects, the peak systolic and end-diastolic velocities in the right hepatic artery decreased (33 ± 3% and 53 ± 3%) from baseline velocities measured in the fasting state. The resistance index of the right hepatic artery and the velocity in the right portal vein in these subjects significantly (p < 0.01) increased (14 ± 2% and 32 ± 2%) from baseline values after glucose ingestion. Glucose ingestion produced significantly (p < 0.01) smaller changes in cirrhotic patients. The maximum decreases in the peak systolic and end-diastolic velocities in the right hepatic artery were 13 ± 2% and 25 ± 3% from baseline velocities, and the maximum increases in the resistance index of the right hepatic artery and the velocity in the right portal vein were 6 ± 1% and 10 ± 3% from baseline values. Conclusions The decrease in blood flow velocity in the right hepatic artery after glucose ingestion is presumably a homeostatic mechanism to maintain constant hepatic perfusion. This reciprocal response was reduced in cirrhotic patients. © 1998 John Wiley & Sons, Inc. J Clin Ultrasound26:137–142, 1998.

Background Gray-scale ultrasonography (US) is an initial, easy to use and widely available imaging modality for NAFLD, the presence of fat infiltration in the liver in the absence of excessive alcohol consumption and other causes of liver disease, is the most common cause of fatty liver, with a prevalence as high as 15-25% in many populations. Objective to determine the effect of obesity and NAFLD on the Doppler waveform pattern of the liver vascularity. Methods A case control study, conducted at Ain Shams University in the period between july and December 2018 . In both groups, liver span &amp; subcutaneous fat was measured by ultrasonographic examination. Hepatic vein waveform pattern &amp; portal vein mean flow velocity were assessed &amp; hepatic artery resistance index was measured by duplex Doppler ultrasonography examination. Results Our study included 50 patients , 20 were control &amp; 30 were cases.. The mean age of cases was 45.30 ± 10.15 SD &amp; the mean age of control was 32.70 ± 10.95 SD rendering the mean age of cases &amp; control of high statistical significance (p value=0.000). The Subcutaneous fat showed high significant statistical difference between cases &amp; control groups with mean subcutaneous fat in control =0.75 ± 0.14 SD &amp; mean subcutaneous fat in cases= 1.23 ± 0.42 SD with p –value = 0.000. The liver span showed high significant statistical difference between cases &amp; control groups with mean in control =15.11 ± 0.85 SD &amp; mean liver span in cases= 17.46 ± 1.67SD ( p value = 0.000). Hepatic vein wave pattern was normal in all 20 control (100%). In the 30 cases,the Hepatic vein wave pattern was triphasic in 12 patients (40%) &amp; biphasic or monophasic In 18 patients (60%) with high statistical significance (p-value =0.000). There was negative correlation between the hepatic vein velocity &amp; BMI with ( p value=0.0032). There was no statistically significant difference between cases &amp; control as regards all Doppler indices including the Hepatic artery RI(resistive index), Hepatic artery PSV(peak systolic velocity), Portal vein velocity(maximum &amp; minimum)&amp; hepatic vein velocity (maximum velocity) where the p value was more than 0.05. Conclusion Patients with NAFLD have a high rate of abnormal hepatic vein Doppler waveform patterns ,which can be biphasic or monophasic rather than alterations in hepatic artery resistance index values by duplex Doppler ultrasonography. Also the fatty infiltration of hepatocytes can increase liver span &amp; the subcutaneous fat.

To investigate the effect of various degrees of fatty liver infiltration on hepatic hemodynamics using Doppler ultrasonography. We included 40 patients with hepatic steatosis and 20 healthy volunteers. Hepatic steatosis was quantified by a chemical shift MRI. Hepatic artery peak systolic and end-diastolic velocity, resistance index (RI) and pulsatility index (PI), hepatic vein RI and PI, portal vein RI, PI, congestion index, and peak maximum velocity were evaluated by Doppler ultrasonography. The hepatic vein waveforms were classified as triphasic, biphasic, or monophasic. Kruskal-Wallis test was performed for comparing more than two groups. If significant differences were found, Mann-Whitney U test with Bonferroni correction was performed for pair-wise comparisons. Pearson &gch;(2) and Fisher's exact tests were used to compare categorical variables. According to MRI, 15 patients had mild, 14 patients had moderate, and 11 patients had severe fatty infiltration. Portal vein peak maximum velocity was median: 19.8 (range 12-33.3), 21.1 (8-41.8), 16.6 (10.6-24.9), and 29.2 (14.1-40.4) cm/s. Congestion index was 0.05 (0.02-0.16), 0.07 (0.01-0.17), 0.11 (0.06-0.24), and 0.05 (0.02-0.16). Hepatic artery RI was 0.75 (0.56-1.00), 0.66 (0.52-0.87), 0.83 (0.38-1.00), and 0.76 (0.48-2.76), and PI was 1.83 (0.90-3.13), 1.38 (1.04-2.63), 1.97 (0.86-2.90), and 1.82 (0.70-2.90) (p = .046 and p = .036) in the mild, moderate, severe steatosis, and control groups, respectively. The rate of triphasic hepatic vein waveforms was higher in controls than in patients with severe steatosis. Portal vein flow velocity decreases in severe hepatic steatosis when compared with controls.