Gastrointest Radiol 17:141-144 (1992)
Gastrointestinal
Portal Vein Reflectors: Duplex Sonographic Appearance
Janis Gissei Letourneau, John E. Carlson, Deborah G. Longley, Joseph W. Yedlicka, Jr.,
and Wilfrido R. Castafieda-Zt~fiiga
Department of Radiology. University of Minnesota. Minneapolis, Minnesota. USA
Abstract. Duplex sonography has established utility
in the noninvasive evaluation of the portal venous
system. Recently, the duplex sonographic features
of suspected portal venous air have been described.
We report on an experimental study in dogs under-
taken to establish if the same sonographic features
could be reproduced in a laboratory setting and to
determine if small fragments of clot emboli could
produce similar gray-scale and Doppler findings. In-
jections of microbubbles of air and clot fragments
into the portal venous system were monitored using
duplex ultrasound. The gray-scale and Doppler fea-
tures of flow in the main portal vein were indistin-
guishable in both microbubble and clot injections.
Superimposition of high-amplitude spikes on the
normal portal venous waveform was seen in 19 of 24
(79%) microbubble and t3 of 23 (56%) clot fragment
injections. We conclude that the appearance of rap-
idly moving, bright intraluminal echoes coupled with
spike-like aberrations of the portal venous waveform
can be associated with portal venous air bubbles or
small blood clot emboli.
Key words: Portal vein, g a s l P o r t a l vein, US stud-
ies--Portal vein, abnormalities.
Duplex sonography is currently a widely accepted
technology for evaluation of the portal venous sys-
tem. Diagnostic applications exist for determining
vascular patency, direction of flow, and presence of
portosystemic collaterals. Clinical settings in which
this technology is useful include portal venous hy-
pertension, malignancy, and surgical portosystemic
Address ~(fprint requests to: Janis Gissel Letourneau, M.D.. De-
partment of Radiology, University of Minnesota Hospital, 420
Delaware Street S.E., Box 292 UMHC. Minneapolis, MN 55455.
USA
Radiology
9 Springer-Verlag New York Inc. 1992
shunts; additionally, vascular complications of he-
patic surgery, particularly subtotal hepatectomy and
liver transplantation, can be defined with this nonin-
vasive modality [I-13]. Real-time gray-scale and du-
plex sonographic features of air within the portal
vein in native and transplanted livers have been de-
scribed [14-17].
Sonographic features of portal venous air include
intermittently visible high-amplitude echoes within
the portal vein that move in the direction of blood
flow. Poorly defined echogenic foci can also be seen
within the hepatic parenchyma in nondependent re-
gions. These small echogenic foci, thought to repre-
sent air bubbles, produce characteristic Doppler
spectra with spike-like "blips" superimposed on the
normal, even and continuous signal from red blood
cells flowing within the portal vein.
We undertook an experimental study in dogs to
verify these duplex sonographic features of portal
venous air and to determine if microembolic autolo-
gous blood clot fragments could produce similar du-
plex findings.
Materials and Methods
Eight mongrel dogs (25-35 kg) were lightly anesthetized with in-
travenous sodium thiamylal. The dogs were then intubated, venti-
lated, and monitored throughout the experiment. Through a right
subcostal incision, small intestine and superior mesenteric venous
branches were exposed. A branch of the superior mesenteric vein
within the small bowel mesentery was cannulated with an 18-
gauge intravenous catheter (Fig. I).
Preliminary examination of the main portal vein using duplex
Doppler ultrasound (5.0-MHz sector transducer, Acuson, 128,
Acuson Computed Sonography, Mountain View, CA, USA) was
performed to verify patency. Microbubbles of air, with an average
diameter of 75/zm, were produced by to-and-fro syringe agitation
of 50% dextrose [18]. The suspensions of microbubbles were then
injected at 10 ml/min through the intravenous catheter. All injec-
tions were directly monitored by duplex sonography of the main
portal vein or its major branches using the liver as an acoustic
142
Fig. 1. Schematic diagram showing surgical exposure and cannu-
lation of a branch of the superior mesenteric vein. Duplex exami-
nation of the main portal vein was performed by scanning with the
transducer directly on the surface of the liver.
window, scanning directly on the hepatic surface. Because of
technical constraints on imaging of the superiorly and trans-
versely oriented canine liver, it was not possible to image, or
interrogate with Doppler, peripheral areas of the liver. Three
hand injections of microbubbles were performed on each dog with
complete clearance of gray-scale and Doppler changes between
injections (Fig. 2A). Duplex examinations were recorded with
video and film archiving.
Autologous microclots were produced by coagulating blood in
the presence of bovine thrombin in two 6-ml syringes and frag-
mented by suspending the clot in 50 ml of normal saline and
forcing the clot through a syringe tip. The average diameter of the
microclots, determined by the use of an hemocytometer under
microscopic observations, was 100 ~m. Three hand injections at
10 ml/min of autologous microclots were then performed in each
dog, again allowing for gray-scale and Doppler clearance of any
abnormalities between injections. In one dog, only two injections
of microclots were done due to insufficient volume of available
microclots.
In total, 24 injections of air microbubbles and 23 injections of
microclots were performed.
Two additional control dogs were studied. The dogs were pre-
pared identically as in the previous experiments. Solutions of
normal saline and 50% dextrose were each injected at l0 ml/min.
A total of l0 injections of normal saline and nine injections of 50%
dextrose were observed in the two dogs.
Results
Injection of both air microbubbles and autologous
clot fragments caused the appearance of rapidly
J.G. Letourneau et al.: Portal Vein Reflectors
flowing, bright intraluminal echoes within the main
portal vein on real-time scanning in every instance;
these bright intraluminal echoes were innumerable,
filling the lumen of the portal vein. The gray-scale
appearances of these different intraluminal echoes
were indistinguishable (Figs. 2B and 3).
Simultaneous Doppler examination of the main
portal vein during these injections showed superim-
position of high-amplitude, narrow spikes, or
"blips," on the expected, normal portal venous
waveform with 19 of 24 (79%) air microbubble injec-
tions and 13 of 23 (56%) clot fragment injections.
Spectral waveforms of air microbubble and clot frag-
ment injections were also indistinguishable (Figs. 2
and 3).
Control injections occasionally produced spo-
radic luminal echoes in the portal vein lumen; this
was seen in five of the 19 control injections and, in
all instances, was strikingly less prominent than the
appearance of intraluminal echogenicity seen during
experimental injections. In the first control animal a
small amount of air bubbles was lbund in the injec-
tion system and thought to have been completely
cleared from the line: it is possible that minimal air
remained in the line for the remainder of injections
with this animal as three of the injections (two sa-
line, one dextrose) resulted in occasional moving in-
traluminal echoes. In only one instance were any
aberrations noted in the Doppler spectrum, an in-
stance of injection of normal saline; this was seen on
the first injection marred by air bubbles that were
apparently drawn into the syringe inadvertently.
Discussion
Portal venous air is an uncommon finding that is
seen in association with bowel infarction; inflamma-
tory disease of the bowel, such as ulcerative colitis,
appendicitis, cholangitis, and necrotizing enterocoli-
tis; intraabdominal abscess; small bowel obstruc-
tion; and gastric ulcer: and, more recently, after
liver transplantation [14-17, 19-22]. In a recent re-
port, seven (18%) of 39 liver transplant recipients
were thought to have intraluminal portal vein air in
the first 2 weeks after transplantation [14]. Signifi-
cant clinical data indicated that this duplex finding
was associated with sepsis, Clostridium intestinal
colonization, postoperative ileus, and primary graft
failure in one patient each. No associated posttrans-
plant complications were thought to exist in the re-
maining three patients. None of the seven affected
patients had clinical evidence of bowel infarction or
necrosis. The authors of this study concluded that
portal venous air can be commonly observed after
liver transplantation and that its presence may not
portend a poor prognosis for the recipient. Similar
duplex findings have been reported in the literature