The British Journal of Radiology, 75 (2002), 919–929 E 2002 The British Institute of Radiology

Pictorial review
Colour Doppler ultrasound flow patterns in the portal
venous system
C GÖRG, MD, J RIERA-KNORRENSCHILD, MD and J DIETRICH, MD
Department of Internal Medicine, Philipps-University, Baldingerstraße, 35043 Marburg, Germany

Abstract. Doppler ultrasound is a well established method for assessment of the portal venous
system to detect the direction of portal blood flow. It is helpful for non-invasive diagnosis of
intra-abdominal portosystemic shunts, especially in patients with cirrhosis. Less attention has
been paid to other influences on portal venous flow, e.g. tricuspid regurgitation, increased hepatic
out-flow resistence, respiratory cycle. The aim of this pictorial review is to describe the spectrum
of physiological and pathological Doppler ultrasound flow patterns in the portal venous system.

Several physiological and pathological Doppler Pathological flow patterns

ultrasound flow patterns of the portal vein and/or
Different pathological flow patterns of portal
its branches are known (Table 1).
venous blood flow exist (Table 1). A marked
Principal determinants of portal venous pulsa-
pulsatile hepatopetal or hepatofugal flow in the
tility may include retrograde trans-sinusoidal trans-
portal vein and/or its branches is seen under
mission of atrial pulsation [1], the respiratory cycle
pathological conditions, tricuspid regurgitation,
[2] and transmission of vena caval, hepatic arterial
or splanchnic arterial pulsations [2]. increased hepatic outflow resistance, liver diseases.
Pulsatile flow in the portal vein has predomi-
nantly been found in patients with severe right
Physiological flow pattern heart failure (Figure 4), demonstrating right
atrial pressure negatively correlated with portal
In healthy adults, portal venous flow has been vein pulsatility ratio [6]. All patients with hepato-
described as being continuous hepatopetal on fugal pulsatile flow were in the New York Heart
Doppler ultrasound [3] (Figure 1). Minimal vari- Association (NYHA) Class III or IV [6]. A
ations caused by respiration and cardiac cycle are
pulsatile hepatopetal flow was found more often
evident (Figure 2). Two different scoring systems
in patients with NYHA Class I or II [6]. Patho-
for quantification of portal venous modulation
physiologically tricuspid regurgitation is the pre-
have been used.
dominantly suggested cause for the duplex Doppler
Portal vein pulsatility is characterized by the
ultrasound phenomena of pulsatile portal vein
ratio between minimum and peak portal vein
flow [7].
velocities [4]. A pulsatility ratio .0.54 was
found in over 90% of normal individuals [5].
The venous pulsatility index [(maximum fre-
quency shift2minimum frequency shift)/maximum Table 1. Doppler ultrasound flow patterns in the
frequency shift] was 0.48¡0.31 (mean¡standard portal venous system
deviation) in healthy adults [2].
Physiological flow Pathological flow pattern
Recently, even marked pulsatile hepatopetal pattern
flow of the portal vein has been described, partic-
ularly in thin subjects with a venous pulsatility Continuous Pulsatile hepatopetal or
hepatopetal hepatofugal flow in the
index of .0.5 (Figure 3), with an inverse correla- flow portal vein and/or its branches
tion to body mass [2]. Decreased pulsatility has Pulsatile Respiratory dependent
been observed when the patient is sitting and hepatopetal hepatofugal flow in the
during deep inspiration, and in obese subjects [1]. flow portal vein and/or its
It has been suggested that abdominal pressure is branches
Continuous hepatofugal flow
the common factor affecting portal vein pulsatility in the portal vein trunk
in these subjects [2]. Continuous hepatofugal flow
in branches of the portal vein
Received 29 November 2001 and in revised form 2 April Stagnant or venous ‘‘0’’ flow
2002, accepted 9 May 2002.

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 C Görg, J Riera-Knorrenschild and J Dietrich

Additionally, portal vein–hepatic vein fistula [8] being with shunts [16]. Analysis of the direction
and portocaval shunts may cause pulsatile portal of flow in the portal vein is therefore strongly
flow [9]. warranted in assessing portal hypertension. Various
Recently it has been assumed that severe pulmon- haemodynamic patterns with reversed flow do
ary hypertension is responsible for a second exist (Figures 15 and 16). The clinical significance
pathophysiological mechanism that may induce of this Doppler phenomenon is still unclear, but it
hepatopetal or hepatofugal pulsatile portal vein may play a protective role against future risk of
flow, irrespective of degree of tricuspid regurgita- bleeding [14].
tion [10, 11]. In cases with constrictive pericarditis Additionally, continuous reversed portal flow
(Figure 5) and mediastinal haematoma (Figure 6), has been described in iatrogenic portosystemic
pericardial cyst, pericardial effusion (Figure 7) shunts (Figure 17), Budd–Chiari syndrome [17]
or right atrial tumour (Figure 8), the high right (Figure 18), cavernous transformation of the main
atrial pressure is presumably responsible for a portal vein (Figure 19) and veno-occlusive liver
pressure-related hepatic venous out-flow block disease after bone marrow transplantation [18].
with subsequent trans-sinusoidal hepatoportal Continuous hepatofugal flow in branches of
shunting, similar to the mechanical outflow block the portal vein is a specific sign for portal hyper-
that causes reversed pulsatile flow in liver cirrhosis tension [16]. Portosystemic collateral blood
(Figure 9) [12]. In patients with chronic hepatitis C, vessels develop from pre-existing small portal
marked pulsatility in the portal vein has been vessels and may lead to portosystemic shunting
associated with inflammation but not with other [14]. Depending on collateral size and amount
parameters of the histological activity index or of blood drainage from the portal venous system,
intrahepatic fat deposition [13]. hepatofugal portal venous flow may be found in
A less well understood mechanism for reversed the portal venous trunk, sections of the portal
portal flow leads to hepatofugal flow in the portal
venous systems or only in small portal venous
vein and/or its branches. It is well known that the
branches, e.g. left gastric vein (Figure 20,
respiratory cycle modulates portal venous flow via
Figure 21) [19].
intra-abdominal pressure (Figure 10) [1, 2]. High
A stagnant or venous ‘‘0’’ flow may occur
abdominal pressure during deep inspiration may
in cirrhotic patients. Very slow velocities (less
cause reversal flow in patients with severe right
than 2 cm s21) cannot be detected because the
heart failure or liver disease (Figure 11) and may
Doppler signal is lower than the threshold of
be seen only in peripheral branches of the portal
the equipment receiver [6] (Figure 22). Addi-
venous system (Figure 12). Under certain circum-
tional respiratory modulation can be observed
stances, even in patients with the absence of cardiac
and liver disease a short time reversed portal vein (Figure 23). There is some evidence that ultra-
flow can be seen during deep inspiration using sound contrast enhancement is useful for assess-
color Doppler ultrasound (Figure 13). ment of blood flow direction with regard to the
It is generaly accepted that colour Doppler discrimination on stagnant or venous ‘‘0’’ flow
ultrasound enables the detection of the presence [20].
and direction of blood flow in the portal venous
system. Continuous hepatofugal flow in the portal
vein trunk is found with an overall prevalence
of 8.3% in patients with liver cirrhosis [14]
(Figure 14). Prevalence did not differ in relation
to the aetiology of liver cirrhosis. However,
reversed flow was found more often in patients
classified as Child’s B and C cirrhosis than those
classified as Child’s A cirrhosis [14]. Reversed
portal venous blood flow develops when the
intrahepatic resistance is greater than the resis-
tance of portosystemic collaterals. It is likely
that the increase of intrahepatic resistance owing
to structural abnormalities, i.e. hepatic vein
sclerosis, Disse space collagenization and hepato-
cyte enlargement, plays the predominant role
in the developement of reversed portal flow [15].
A possible association has been found between
abnormal flow direction and the presence of
oesophageal varices, ascites and spontaneous Figure 1. Doppler ultrasound of the portal vein with
portosystemic shunts, with the strongest association a continuous hepatopetal flow in a healthy adult.

920 The British Journal of Radiology, November 2002

Pictorial review: Portal venous flow patterns

Figure 2. Doppler ultrasound of the portal vein with Figure 3. Doppler ultrasound of the portal vein with
minimal pulsatile modulation of the portal flow in a marked pulsatile modulation of the portal flow in a
healthy adult. thin, healthy adult.

Figure 4. Colour Doppler ultrasound of the hepatic vein and portal vein in a patient with heart failure, New
York Heart Association Calss III and tricuspid regurgitation (left), having a triphasic flow in the hepatic vein
(middle) and a marked pulsatile flow of the portal vein (right).

Figure 5. Colour Doppler ultrasound in a patient with constrictive pericarditis (arrows) (left). A triphasic flow is
seen in the hepatic vein (middle) and pulsatile flow in the portal vein (right). RV, right ventricle.

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 C Görg, J Riera-Knorrenschild and J Dietrich

Figure 6. Colour Doppler ultrasound of the hepatic vein and portal vein in a patient with mediastinal haema-
toma. A triphasic flow is seen in the hepatic vein (left) and a pulsatile flow with a reversed component of the
portal vein (right).

Figure 7. Colour Doppler ultrasound in a patient with pericardial effusion (left), and triphasic flow in the liver
vein (middle) and pulsatile flow in the portal vein (right).

Figure 8. Colour Doppler ultrasound in a patient with primary cardial lymphoma with a tumour in the right
atrium (left), triphasic flow in the hepatic vein (middle) and pulsatile flow in the portal vein (right).

922 The British Journal of Radiology, November 2002

Pictorial review: Portal venous flow patterns

Figure 9. Colour Doppler ultrasound of the hepatic vein (LV) and portal vein (VP) in a patient with liver cirrho-
sis having a monophasic flow in the hepatic vein (left) and a marked pulsatile flow of the portal vein (right).

Figure 10. Colour Doppler ultrasound of the portal vein (left and middle) in a patient with heart failure, New York
Heart Association Calss III, having a marked pulsatile flow with reversed flow during deep inspiration (arrows) (right).

Figure 11. Doppler ultrasound in a patient with a pericardial effusion (PE) (left) and a pulsatile flow in the portal vein
with a short reversed flow during deep inspiration (arrow) (right). RV, right ventricle; LV, left ventricle.

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 C Görg, J Riera-Knorrenschild and J Dietrich

Figure 12. Colour Doppler ultrasound of the splenic vein (left and middle) in a patient with liver cirrhosis, oeso-
phageal varices and ascites. Arrows indicate flow direction. A marked pulsatile flow was seen in the portal venous
system with reversed flow in the hilar splenic vein during deep inspiration (arrow, right).

Figure 13. Colour Doppler ultrasound of the portal vein (left and middle) in a patient 1 week post-gastrectomy.
Arrows indicate flow direction. During normal inspiration (arrow A) a breath dependent reversed flow was seen
(right).

924 The British Journal of Radiology, November 2002

Pictorial review: Portal venous flow patterns

(a)

(b)

Figure 14. (a) Colour Doppler ultrasound of the portal venous system in a patient with alcoholic fatty liver cir-
rhosis and continuous hepatofugal flow in the portal vein (the arrows indicate flow direction). (b) The same
patient had hepatofugal flow in the mesenteric vein (left) and regular hepatopetal flow in the splenic vein (right).
Arrows indicate flow direction.

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 C Görg, J Riera-Knorrenschild and J Dietrich

Figure 15. Four different haemo-

dynamic flow patterns of continu-
ous flow in the portal vein, the
splenic vein and the mesenteric vein
(Gaiani S, et al. 1991 [14]). (a)
Isolated reversed flow in the mesen-
teric vein. (b) Isolated reversed flow
in the splenic vein. (c) Reversed flow
in the portal vein and the splenic
vein. (d) Reversed flow in the
portal vein and the mesenteric vein.

(a)

(b)

Figure 16. (a) Colour Doppler ultrasound of the portal venous system in a patient with liver cirrhosis and contin-
uous hepatofugal flow in the portal vein (left) and hepatopetal flow in the mesenteric vein (VMS) (right). Arrows
indicate flow direction. (b) The same patient had reversed flow in the splenic vein (left). The splenic vein (VL)
drained into a large perirenal collateral. Arrows indicate flow direction.

926 The British Journal of Radiology, November 2002

Pictorial review: Portal venous flow patterns

Figure 17. Colour Doppler ultrasound of the portal vein in a patient with liver cirrhosis and a transjugular intra-
hepatic portosystemic shunt (TIPS) (left). In the umbilical segment of the portal vein a reversed flow was seen
(right). Arrows indicate flow direction.

Figure 18. Colour Doppler ultrasound of the portal vein in a patient with breast cancer, diffuse metastative dis-
ease of the liver and occlusion of the hepa-tic veins (Budd-Chiari syndrome) (arrows left). In the portal vein a
reversed flow was seen (middle, right). Arrows indicate flow direction. VC, vena cava.

Figure 19. Colour Doppler ultrasound in a patient with cavernous transformation of the portal vein (left) having
reversed flow in the splenic vein (middle) and a large perisplenic collateral (right). Arrows indicate flow direction.
P, pancreas; Co, confluens.

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 C Görg, J Riera-Knorrenschild and J Dietrich

Figure 20. Colour Doppler ultra-

sound in a patient with liver cirrho-
sis and portal hypertension and
reversed flow in the left gastric vein
(VCV). VP, portal vein.

Figure 21. Colour Doppler ultrasound of the spleen in a patient with liver cirrhosis. Trans-splenic vessels were
seen (middle) with a hepatofugal venous flow (right). Arrows indicate flow direction.

Figure 22. Colour Doppler ultra-

sound of the portal vein in a
patient with fatty liver cirrhosis and
a ‘‘0’’ flow in the portal vein (VP).

Figure 23. Colour Doppler ultra-

sound in a patient with alcoholic
fatty liver cirrhosis with a hepato-
petal flow during expiration (left)
an a venous ‘‘0’’ flow in the portal
vein during inspiration (right).

928 The British Journal of Radiology, November 2002

Pictorial review: Portal venous flow patterns
Conclusion
Color Doppler ultrasound of the portal vein and
its branches shows a wide spectrum of different flow
patterns.
In patients with liver cirrhosis, assessment of the
direction of portal flow is helpful for diagnosis of
portal hypertension. Various other conditions, such
as cardial and respiratory cycles, may influence
portal venous flow.
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