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diseases and some drugs e.

g oral contraceptives predispose to portal and hepatic venous


thrombosis. Examination: Abdominal wall veins are often prominent and rarely, they may
form a caput rnedusae around the umbilicus. Murmurs- A venous hum may be heard over the
collaterals (ruveilhier- !aumgarten syndrome". collaterals radiating occasionally to the
precordium or over liver. A thrill may be felt at the site of maximum intensity. An arterial
systolic murmur suggests primary liver cancer or alcoholic hepatitis. #he paraxiphoid
umbilical veins indicate intrahepatic portal venous hypertension. $pleen- enlarges
progressively, the edge is firm. Massive if presinusoidal portal obstruction, cirrhosis with
hypersplenism, rarely tropical splenomegaly. %iver- &igh pressures are more often associated
with a small, fibrotic liver. A soft liver suggests extrahepatic portal venous obstruction, a
firm liver cirrhosis. Ascites- 'ortal hypertension raises capillary filtration pressure and
increases (uantity of ascitic fluid. )nvestigations: *ltrasound- is the first imaging
investigation. +ailure to demonstrate a normal confluence of hepatic veins at the ), and
elicit a normal -oppler-flow signal are diagnostic. # scan- can demonstrate patchy hepatic
parenchyma in the affected lobes, reflecting areas of venous infarction, oedema. fatty
infiltration and compensatory caudate lobe enlargement. #echnetium- ..m isotope scanning-
may illustrate classical pattern of preferential upta/e of colloid by the hypertrophied caudate
lobe. &epatic venography- (a" ,enogram of ),- 0arrowing of upper ) , due to pressure
of caudate lobe. (b" &epatic venous catheteri1ation- 2$pider web filling of collaterals. instead
of flash filling of rapidly draining hepatic vein. (c" 'ressure measurements of ), are
necessary if surgery is considered. Ascitic fluid- is mostly exudate from lea/ of protein-rich
fluid from hepatic sinusoids, and lymph from the engorged liver. %iver biopsy- &epatic
venous congestion with 3!2s in sinusoids in space of -isse beneath the hepatocyte
basement membranes. !arium swallow- 'resence of varices. $plenoportography
(,enography"- involves contrast study of the portal venous system via percutaneous splenic
puncture. 4ith normal portal circulation. splenic and portal veins are filled and no other
vessels are outlined. )ndications5 6. #o establish patency of portal vein e.g. in diagnosis of
splenomegaly in childhood, and excluding hepatccellular carcinoma in patient with cirrhosis.
7. )nvestigation of cause of portal hypertension. 8. )nvestigation of splenomegaly of
un/nown etiology. 9. !efore shunt surgery and postoperative demonstration of shunt. :.
-iagnosisof chronic hepatic encephalopathy. Absence of large portal collateral circulation
excludes the diagnosis. Abnormal venographic patterns- 6. 'resence of numerous collateral
vessels and gross distortion of intrahepatic pattern (#ree in winter appearance" in cirrhosis. 7.
0umerous collateral vessels (gastro-oesophageal and spleno-portal" in- extra- hepatic, splenic
or portal venous obstruction. 8. +illing defect in portal vein or liver from a space-occupying
lesion. )ndirect angiography- by in;ection of contrast medium through catheter in coeliac
axis. *tility- (6" )t reveals intrahepatic arterial patterns and allows space occupying lesions
and hemangiomas to be identified. (7" A grossly enlarged hepatic artery in cirrhotic patient
carries a favourable prognosis as opposed to reduction in both arterial and portal