CT Signs of Hepatofugal Portal Venous Flow in Patients with Cirrhosis

Thomas J. Bryce1 Benjamin M. Yeh1 Aliya Qayyum1 Preeyacha Pacharn2 Nathan M. Bass3 Ying Lu1 Fergus V. Coakley1
OBJECTIVE. We investigated whether CT signs can be used to predict hepatofugal flow in the main portal vein in patients with cirrhosis. MATERIALS AND METHODS. We retrospectively identified 36 patients with cirrhosis, 18 with hepatopetal and 18 with hepatofugal flow in the main portal vein, who underwent contemporaneous abdominal sonography and CT. Two independent observers evaluated the following features on the randomized CT studies: diameter of the portal, splenic, and superior mesenteric veins; spleen size; and the presence of ascites, varices, or arterial phase portal venous enhancement. These data were correlated with the flow direction seen on sonography. RESULTS. A small main portal vein was the only sign significantly (p ≤ 0.05) predictive of hepatofugal flow by univariate and multivariate analyses. Observers 1 and 2 recorded a portal vein diameter of less than 1 cm in eight (44%) and seven (39%) of the 18 patients with hepatofugal flow compared with one (6%) and none of the 18 patients with hepatopetal flow, respectively (p < 0.02). Receiver operating characteristic analysis using the size of the portal vein to predict flow direction revealed an area under the curve of 0.83 for observer 1 and 0.74 for observer 2. CONCLUSION. A diameter of less than 1 cm for the main portal vein is highly specific, although not sensitive, for hepatofugal portal venous flow in patients with cirrhosis. This sign may be useful when sonography is limited, or this sign may prompt sonographic assessment in patients not known to have hepatofugal flow. epatofugal portal venous flow in patients with cirrhosis indicates advanced portal hypertension [1], and cirrhotic patients with hepatofugal flow have greater hepatic dysfunction [2], a higher incidence of hepatic encephalopathy [3], an increased risk of variceal bleeding [2, 4, 5], poorer response of varices to endoscopic ligation [6], and higher mortality [2, 7], compared with cirrhotic patients with hepatopetal flow. The detection of hepatofugal flow in the main portal vein implies the liver is perfused solely by the hepatic artery, which is of therapeutic importance in planning chemoembolization of a hepatocellular carcinoma or placement of a transjugular intrahepatic portosystemic shunt (TIPS). CT arterioportography and portal venous angiography may be ineffective and therefore contraindicated in the presence of hepatofugal portal venous flow [8]. Doppler sonography is the principal technique used to determine the direction of flow in the portal

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Received April 10, 2003; accepted after revision June 26, 2003.
1 Department of Medicine and Department of Radiology, Abdominal Imaging Section, University of California at San Francisco, Box 0628, 505 Parnassus Ave., San Francisco, CA 94143-0628. Address correspondence to F. V. Coakley (fergus.coakley@radiology.ucsf.edu). 2

vein [9, 10], although MRI [11–13] and conventional angiography [14, 15] can also be used. To our knowledge, the role of CT in determining the direction of portal venous flow has not been systematically examined, although patients with cirrhosis frequently undergo CT, particularly when hepatocellular carcinoma is a concern. The establishment of CT criteria for the detection of hepatofugal flow in the main portal vein could be helpful in the evaluation of such patients. Therefore, we undertook this study to determine whether CT signs can be used to predict hepatofugal portal venous flow in patients with cirrhosis.
Materials and Methods
Patients This study was a retrospective single-institution study approved by our institutional review board. Informed consent was not required. We searched our radiology information system (IDXrad [software version 9.7.1], IDX Systems, Burlington, VT)

Department of Radiology, Mahidol University, 2 Prannok Rd., Bangkok, 10700 Thailand.
3

Department of Medicine, Division of Gastroenterology, University of California at San Francisco, Box 0538, 505 Parnassus Ave., San Francisco, CA 94143-0538. AJR 2003;181:1629–1633 0361–803X/03/1816–1629 © American Roentgen Ray Society

AJR:181, December 2003

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0–97 days) in the hepatofugal group. Of those patients without histologic confirmation. 2). 1630 AJR:181. two patients and one patient. nonalcoholic steatotic hepatitis. cirrhosis was diagnosed by a gastroenterologist in all but two.05 or less required for factors to remain in the model. Cirrhosis was cryptogenic in two patients with hepatopetal flow. respectively. We then randomly selected an additional 18 patients with hepatopetal flow who also met these criteria to form the final study population of 36 patients. included the following: chronic viral hepatitis. measured on the first image that was clearly inferior to the splenoportal confluence. hypoalbuminemia. the sensitivity of this sign for predicting hepatofugal flow was 44% and the specificity was 94%. The mean age of patients in the hepatopetal group was 59 years (range. WI). hepatofugal group. ethanol abuse alone. Observer 1 found that the main portal vein measured less than 1 cm in eight (44%) of 18 patients with hepatofugal flow. All additional sonographic studies evaluated confirmed the flow direction seen on the initial study. Agfa. Additional studies were not available for the remaining three hepatopetal and two hepatofugal patients. We identified 18 patients with hepatofugal flow in the main portal vein who met these criteria. Arterial phase enhancement of the portal vein was seen in only one patient. 11 and four patients. 2). cirrhosis was established by histology in five patients and on clinical grounds in 13. given that both observers measured the main portal vein at or slightly above 1 cm in several patients with hepatopetal flow (Fig. absence of TIPS or thrombosis of the main portal vein. for a sensitivity of 39% and a specificity of 100%. Results The CT signs recorded by each observer showed high interobserver consistency for all measurements other than the presence of varices and the size of the spleen.01). if CT had not been performed between the sonographic examinations. hepatofugal group. If sonography had been performed more than 48 hr before or after the CT examination (hepatopetal group. and for the two patients with hepatofugal flow.e.01) with hepatofugal flow by univariate and multivariate analyses (Fig. presence or absence of varices. n = 9). direction of flow in the main portal vein described in the sonography report. December 2003 . Cary. contemporaneous (within 5 months) abdominal CT. primary sclerosing cholangitis. n = 2. Mortsel. A lower threshold would reduce sensitivity without significantly increasing specificity. in the hepatofugal group. The univariate analyses were performed separately for the data for each observer. one and three patients.5-mm slice collimation) in 20 of these patients. The causes for cirrhosis in the group with hepatopetal flow and in the group with hepatofugal flow. cirrhosis was diagnosed on the basis of clinical evidence including a history of severe alcohol abuse. NC). A representative case illustrates the finding of a small portal vein in a patient with hepatofugal flow (Fig. Noncontinuous data (all other categories) were examined using Fisher’s exact test. Acuson Solutions) or a 2. Alternatively. both of whom had hepatofugal portal venous flow. NJ). Thirty-four of the 36 patients received 150 mL of IV iohexol (Omnipaque 350. in that patient. n = 9. one patient and 0 patients. maximum short-axis diameter of the superior mesenteric vein. Color Doppler sonography of the direction of flow in the main portal vein was performed using a scanner (Sequoia 512. 3).05 or less were considered significant.to 4-MHz sector transducer (4V2. 4). Continuous data (vessel diameters and spleen size) were examined by univariate analysis using the two-tailed Cochran t test. General Electric Medical Systems. n = 2). Imaging Technique All CT examinations were performed on multidetector scanners (LightSpeed or HiSpeed. Nycomed Amersham. In these two patients. Interobserver agreement for continuous data was assessed using Bland-Altman regression [17] with Bradley-Blackwood p values [18]. None of the patients was assigned a Child-Pugh class because not all required data were available retrospectively. Parameters were selected in a stepwise fashion with a type 3 significance level of 0. which was measured midway between the splenoportal confluence and the portal vein bifurcation in the porta hepatis. n = 14. and spleen size. autoimmune hepatitis. In the hepatopetal group. gross findings of cirrhosis on imaging studies. 44–80 years) versus 51 years (range.5. SAS. Belgium). and a higher threshold would greatly reduce specificity with only mildly increasing sensitivity (Fig. Nycomed Amersham). flow in the portal vein was hepatopetal on sonography 1 day before CT (Fig. Both observers recorded the following CT signs: short-axis diameter of the main portal vein.1. hepatofugal group. measured adjacent to the midportion of the pancreatic tail. presence or absence of ascites. and coagulopathy. Milwaukee. we identified a second Doppler sonographic study of flow direction in the main portal vein for each patient so that sonography occurred before and after the CT examination (hepatopetal group. ascites. All images were contiguous. for multiphase CT examinations (n = 20). diameter of the splenic vein. arterial phase) enhancement of the main portal vein was recorded. 0–148 days) in the hepatopetal group and 3 days (range. but in only one (6%) of 18 patients with hepatopetal flow (p < 0. 0 and six patients. one and three patients. Princeton. Observer 2 found that the main portal vein measured less than 1 cm in seven (39%) of 18 patients with hepatofugal flow and 0 of 18 patients with hepatopetal flow (p < 0. and the hepatofugal group comprised seven men and 11 women. In addition.83 for observer 1 and 0. recorded as the maximum axial diameter. All patients received oral diatrizoate meglumine (Hypaque. Thus. ROC analysis using the diameter of the main portal vein to predict hepatofugal flow revealed an Az of 0. The hepatopetal group comprised 10 men and eight women. n = 5). CA) with a 1.02). Observers were unaware of clinical and sonographic findings. In these patients. and large varices. Mountain View.Bryce et al. Images were also acquired in the arterial phase of enhancement (45-sec scan delay with 2. 1)..75. Receiver operating characteristic (ROC) analysis and area under the ROC curve (Az) calculations were performed to evaluate predictive models. 1). and images were acquired in the portal venous phase of enhancement (70-sec scan delay with 5-mm slice collimation). we identified the two sonographic examinations closest in time to the CT examination (hepatopetal group. and histologic diagnosis of cirrhosis (n = 11) or a clear clinical diagnosis of cirrhosis documented in the medical record (n = 25). Data Analysis Statistical analysis was performed using statistical analysis software (SAS version 8. No other signs achieved significance by either method. the presence or absence of early (i. the diagnosis of cirrhosis was established by histology in six patients and on clinical grounds in 12. The 1-cm measurement was the largest (most sensitive) threshold that could be used to predict hepatofugal flow without significantly reducing specificity.74 for observer 2 (Fig.to 4-MHz sector transducer (4V1. 17–73 years) in the hepatofugal group. 0 and one patient. The median time between sonography and CT was 23 days (range. Acuson Solutions). Multivariate analysis was performed using logistic regression with a generalized linear model to account for the presence of two observers. and cystic fibrosis.1]. Interobserver agreement for categorical data was measured with kappa statistics [16]. viral hepatitis and ethanol abuse. CT Interpretation Two radiologists independently reviewed the randomized CT images of all 36 patients on a PACS (picture archiving and communication system) workstation (Impax DS 3000 [release 4. A small main portal vein correlated strongly (p < 0. and medical records for the period of October 1998 to March 2002 to identify patients meeting the following sequential criteria: abdominal sonography report containing the term “cirrhosis”. All p values of 0. the lag was 37 and 62 days. Acuson Solutions. the time lag between CT and sonography for the two patients with hepatopetal flow was 3 and 31 days. Two patients (one with hepatopetal and one with hepatofugal flow) did not receive IV contrast material.

5 0. Note that at appropriate operating points.—Diagram shows diameters of main portal vein in patients with hepatopetal flow versus hepatofugal flow.74 for observer 2.5 1 Diameter of Main Portal Vein (cm) 2 0. Fig. Sonogram shows hepatofugal flow in main portal vein. this sign is highly specific for hepatofugal flow. December 2003 1631 .8 1 Observer 1 Observer 2 False-Positive Fraction Fig. 3. Operating points achieved by predicting hepatofugal flow when main portal vein diameter was less than 1 cm are shown for observer 1 (×) and observer 2 (Δ).—73-year-old woman with cirrhosis due to alcohol abuse. A Fig. B.CT Signs of Hepatofugal Portal Venous Flow 2.2 0 0 0 0. 1. B AJR:181.8 True-Positive Fraction Hepatopetal Hepatofugal Hepatopetal Hepatofugal 1. A.6 0. Area under ROC curve (Az) was 0.4 0. this finding strongly correlates with hepatofugal flow.4 0. 2.6 1 0.—Diagram shows receiver operating characteristic (ROC) values achieved using small main portal vein diameter to predict hepatofugal flow in main portal vein in patients with cirrhosis.83 for observer 1 and 0.5 0. Note that main portal vein diameter of less than 1 cm is highly specific for hepatofugal flow.2 0. Axial CT scan obtained during portal venous phase shows small (8 mm in diameter) main portal vein (arrow).

Therefore. such as due to breath-hold technique or bolus administration of IV contrast material. Disturbance of baseline physiology during abdominal CT. but these differences did not achieve statistical significance. Doppler sonogram obtained 1 day earlier than A. Our study has several limitations. and the subsequent increased shunting of hepatic arterial blood into the portal venous system may result in temporary hepatofugal flow. December 2003 . the portal vein is supplied only by the hepatic artery. Arterial phase enhancement of the portal vein has been reported as a sign of hepatofugal flow [1. 22]. Discussion Our finding that a relatively small main portal vein in patients with cirrhosis indicates hepatofugal flow is consistent with the physiology of hepatofugal flow in the cirrhotic liver. Normally. 4.Bryce et al. This decrease in flow volume could explain the decreased diameter of the portal vein. This sign is thought to indicate hepatofugal portal venous flow. For example. Such flow changes can occur spontaneously in cirrhotic patients [23]. and during hepatic arteriography [26]. The sample size was small and may have restricted the power of the study to detect differences between the hepatopetal and hepatofugal groups. the prevalence of ascites and varices was higher in patients with hepatofugal flow. it is reasonable to expect that the direction of flow at the time of CT would be accurately predicted by the contemporaneous sonographic examination that was evaluated. Possible explanations for the limited sensitivity may include a tendency for the vein to remain patulous after enlarging in earlier stages of portal hypertension and the possibility that portal hypertension may provide a continuing impetus for venous enlargement. A Fig. These factors might exhibit an association with hepatofugal flow in a larger study. which also supplies the hepatic veins. a main portal vein of less than 1 cm can be considered relatively small in a cirrhotic patient because portal hypertension tends to increase portal vein size [20]. In patients with cirrhosis and hepatofugal flow in the main portal vein. The lag between the examinations may have lowered the sensitivity of the study for additional predictors of hepatofugal flow. although the possible effects of the time difference would be expected to apply to both hepatopetal and hepatofugal groups of patients.—49-year-old man with cirrhosis due to chronic hepatitis C infection. in the postprandial state [24. In our study. contrast administration might elevate right heart and hepatic vein pressures. B 1632 AJR:181.) Although specific for hepatofugal flow. 25]. this sign was present in only one of 20 patients undergoing CT with arterial phase contrast enhancement.0 cm [19]. CT and sonography were not immediately contemporaneous. this sign was of only moderate sensitivity in our study group. reveals hepatopetal flow. For example. CT scan obtained during arterial phase shows contrast enhancement of portal vein. The lag between studies would not be expected to generate spurious associations and should not detract from the finding that a small portal vein size is associated with hepatofugal portal venous flow. The finding of arterial phase enhancement of the portal vein on CT in a patient with hepatopetal portal venous flow on sonography is puzzling but might be explained by transient changes in flow direction in the portal venous system. the portal vein receives flow from the superior mesenteric vein and the splenic vein. despite a reduction or reversal in flow. A. The average size of the main portal vein in healthy adults has been found to be 1. and Doppler sonography of this patient 1 day before CT showed hepatopetal flow. B. however. (A small main portal vein in cirrhotic patients has been associated with spontaneous splenorenal shunts [21]. Analysis of additional sonography examinations of the study population provided evidence that the direction of portal venous flow in our subjects was stable. may alter portal venous hemodynamics. a phenomenon that would also be expected to reduce hepatic portal venous perfusion.

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