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Portal and splanchnic haemodynamics in patients with advanced post-hepatitic

cirrhosis and in healthy adults
H. Dinç a; A. Sari a; H. Resit Gmele a; N. Cihanyurdu b; A. Baki b
a
Department of Radiology, KTU Medical Faculty, Trabzon, Turkey b Department of Medicine, KTU Medical
Faculty, Trabzon, Turkey

Online Publication Date: 01 January 1998

To cite this Article Dinç, H., Sari, A., Gmele, H. Resit, Cihanyurdu, N. and Baki, A.(1998)'Portal and splanchnic haemodynamics in
patients with advanced post-hepatitic cirrhosis and in healthy adults',Acta Radiologica,39:2,152 — 156
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 Acta Radiologica 39 (1998) 152-156 Copyright 0 Acta Radiologicu 1998
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ACTA R A D I OL 0G I C A
ISSN 0284-1851

PORTAL AND SPLANCHNIC HAEMODYNAMICS IN

PATIENTS WITH ADVANCED POST-HEPATITIC
CIRRHOSIS AND IN HEALTHY ADULTS
Assessment with duplex Doppler ultrasound

A. SARII,H. RESIT GUMELEI,

H. DINC~, N. CIHANYURDU~
and A. B A K I ~
Departments of 'Radiology and *Medicine, KTU Medical Faculty, Trabzon, Turkey.
Downloaded By: [UNESP] At: 18:20 25 October 2009

Abstract
Purpose: To assess portal and splanchnic haemodynamics, and splanchnic Key words: Liver, cirrhosis; portal
vascular resistance in patients with advanced post-hepatitic cirrhosis and in vein, superior mesenteric artery,
healthy volunteers, by means of duplex Doppler ultrasound (US). splenic artery; blood flow dynamics;
Material and Methods: The duplex Doppler US examination was performed ultrasonography, Doppler studies.
in 16 patients with cirrhosis and in 24 healthy volunteers. We investigated vessel
diameters, mean flow velocities, and mean blood flows in the portal vein, the Correspondence: Hasan Din$,
superior mesenteric artery (SMA), and the splenic artery (SA), and measured Department of Radiology, KTU
the resistive index values of SMA and SA. Medical Faculty, 61080 Trabzon,
Results: The mean portal venous blood flow in patients with cirrhosis Turkey. FAX+90 462 325 77 15.
(829k264 ml/min) was not statistically different from those in the volunteers
(734k 194 mumin). The ratio of the SMA and $A blood flows (621 ml/min) to Accepted for publication 8 September
the portal venous blood flow (734 mumin) was 0.85 in the control subjects. The 1997.
mean portal venous blood flow (1261 mumin) and the portal venous velocity
(14.6 c d s ) were higher in the patients with recanalized para-umbilical veins
than in the volunteers and in the patients without recanalized para-umbilical
veins. The SMA and SA blood flows were significantly increased in patients
with cirrhosis compared with volunteers. Splanchnic inflow (the sum of the
SMA and SA blood flows) was higher than the portal blood flow in patients
with cirrhosis except in the subjects with recanalized para-umbilical veins. SMA
and SA resistive index values were significantly higher in these patients than in
the volunteers.
Conclusion: Splanchnic blood flow and splanchnic vascular impedance in-
creased significantly in patients with advanced post-hepatitic cirrhosis. Splanch-
nic inflow must not exceed portal venous blood flow in patients with recanalized
para-umbilical veins. Portal vein velocity and portal venous blood flow meas-
urements alone are not useful parameters for discriminating patients with cir-
rhosis from healthy subjects.

Several methods have been developed for measur-
ing portal and splanchnic haemodynamics. One of
these techniques is duplex Doppler ultrasound
(US), a modality that allows the non-invasive
measurement of flow in the portal vein and
splanchnic vessels (8, 18, 21). In healthy subjects,
the superior mesenteric artery (SMA) and splenic
artery (SA) blood flows constitute most of the por-
tal venous inflow. Under physiological conditions,
the venous flow derived from the splanchnic or-
gans drains almost entirely into the portal trunk.
For this reason, the portal venous inflow nearly

152
 PORTAL AND SPLANCHNIC HAEMODYNAMICS BY DUPLEX DOPPLER
equals the portal venous flow. Therefore the sum
of the SA and SMA blood flows in healthy subjects
should be slightly lower than the measured portal
venous flow (21).
There have been few studies in which duplex
Doppler US was used in simultaneously measuring
the portal, SMA and SA blood flows in humans
(10, 21, 26). And to our knowledge, there is no
study in which the portal venous blood flow,
splanchnic blood flow, and splanchnic vascular re-
sistance have been studied in order to evaluate the
splanchnic haemodynamics in patients with cir-
rhosis. Our aim was to assess the portal, SA, and
SMA blood flows, and splanchnic vascular resist-
ance in patients with advanced post-hepatitic cir-
rhosis and in healthy subjects, by means of duplex
Doppler US.
Material and Methods
Subjects: Patients with splenorenal shunt and tor-
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tuousity of the SA were excluded from the study.
The study thus comprised 16 patients with cir-
rhosis (all men, aged 32-61 years, mean 46 years)
and 24 control subjects (20 men, 4 women, aged
35-59 years, mean age 44 years). The aetiology of
cirrhosis was the hepatitis-B virus. The diagnosis
of liver cirrhosis was based on clinical and labora-
tory findings in 10 patients, and on liver biopsy
in 6. The clinical and laboratory findings showed:
hypoalbuminaemia, prolonged protrombin time,
hypergammaglobulinaemia, positive HBsAg,
oesophageal varices at endoscopy, spider angioma,
portosystemic shunts, splenomegaly, and ascites at
US. All 16 patients had oesophageal varices at
endoscopy (1 1). Of the 16 patients, 13 were classi-
fied as F2, and 3 as F3. According to the Child
classification (22), all 16 patients had class-C cir-
rhosis. The criteria for their inclusion in the study
were: hepatopedal flow on Doppler US; absence of
portal and hepatic vein thrombosis (Budd-Chiari
syndrome) at US; no previous variceal bleeding;
no evidence of alcohol consumption; or of hepato-
cellular carcinoma.
Duplex Doppler sonography was performed with
a combined US system consisting of a 3.5-MHz
convex array (Hitachi, EUB-515A) and a 3.75-
MHz sector scanner (General Electric 625 L, col-
our duplex Doppler equipment). The study was
performed by the same examiner to avoid inter-
observer variability. All Doppler examinations
were performed after overnight fasting, with the
patientdsubjects in the supine position, and with
breath-holding after shallow inspiration. Study
parameters were: vessel diameters, mean flow velo-
cities, and blood flows in the portal vein, SMA and
SA. The resistive index (RI) values of SMA and
SA were also calculated.
The portal trunk was scanned longitudinally
and the sample volume cursor was then placed in
the centre of the lumen, 1 or 2 cm before the bi-
furcation of the portal vein (21). SMA flow vel-
ocity waveform was obtained in the proximal 1- or
2-cm segment. The SA was not always visualized
in the proximal segment in ascitic or obese pa-
tients. For this reason, SA measurements and
Doppler spectral waveforms were obtained in the
distal segment of the artery near the splenic hilus.
Since the portal vein is not round but rather
oval, the diameters of the vessel are obtained from
longitudinal sections of the vessel and it is assumed
that the vein has a circular structure. The portal
venous mean velocity was calculated by using a
correcting factor in the following equation: portal
venous mean velocity =portal venous maximum
velocityX0.57 (10). The blood flow was calculated
from the mean velocity multiplied by the cross-sec-
tional area (A) of the vessels. The cross-sectional
area was calculated with the following formula:
A=nXR2/4 (R=diameter of the vessel).
The mean blood flow velocities in SMA and SA
and the RI values were calculated directly by the
dedicated software supplied with the Doppler
equipment. Spectral waveforms were obtained at
measured angles of insonation between 30" and
60". The smallest possible velocity scale that did
not promote aliasing and the lowest possible wall
filter (50-100 Hz) were used. The mean of 3 suc-
cessive cardiac cycles was obtained for each group
of waveforms.
We investigated the following according to the
techniques described above: collateral circulation
via gastro-oesophageal and umbilical varices, the
coronary vein, and the left gastric and short gastric
veins; and the peripancreatic, retroperitoneal-para-
vertebral, omental and splenorenal collaterals (13,
17, 23).
Statistics: The STATGRAF version 5.0 statisti-
cal package program was used to compute the sta-
tistics. In order to assess the statistically significant
differences for independent data, the Student's t-
test was used when the observations were distri-
buted normally. The Wilcoxon rank-sum test
(Mann-Whitney U-test) was used when the obser-
vations were not distributed normally. The results
were given as means+SD.
Results
The Table and Figs 1 and 2 summarize the portal
and splanchnic haemodynamic changes in patients
and volunteers as shown by B-mode and Doppler
153
 H. DING ET AL.

Table
Doppler US measurements ofportal and splanchnic vessels in patients with cirrhosis and in healthy
subjects
Parameters Cirrhosis, n= 16 Controls, n=24 p-value
Systolic blood pressure, m m Hg 12029.6 11926.8 NS
Diastolic blood pressure, mm Hg 72.828.9 77.528.9 NS
Portal vein diameter, mm 13.2522.5 9.820.94 p<0.00001
Portal vein velocity, c d s 10.0322.84 16.2522.67 p<o.o001
14.6?3*
Portal venous blood flow. ml/min 829+264 7342 194 NS
12612141*
Superior mesenteric artery diameter, mm 6.520.89 5.9121.05 NS
Superior mesenteric artery mean velocity, cm/s 28.1 2 4 23.824.3 p<O.OOI
Superior mesenteric artery blood flow, mumin 5592146 3922 172 p<O.OOl
4822 132* -
Splenic artery diameter, mm 520.6 3.7720.35 p<0.00001
Splenic artery mean velocity, cm/s 34.724.1 34.227.4 NS
Splenic artery blood flow, ml/min 4092131 229253 p<o.oooo 1
4832178* -

Splenic artery resistive index 0.6920.05 0.5520.04 p<0.00001

Superior mesenteric artery resistive index 0.8650.04 0.7920.05 p<o.oooo 1
* Values obtained from patients with cirrhosis with recanalized para-umbilical veins.
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examination. Fourteen patients had oesophageal
varices at US. In 4 patients, the mean diameter of
the coronary vein was 5 mm or more. In 3 patients,
para-umbilical vein recanalization was observed.
Left gastric and short gastric veins were seen in 2
patients.
The splanchnic arterial resistance was higher in
patients than in healthy subjects (Table). The mean
portal blood flow was 7342 194 d m i n in the con-
trols and 8295264 ml/min in the patients. A com-
parison of the portal blood flow in volunteers and
patients showed no statistically significant differ-
ence although the portal vein diameter was greater
in the patients. Portal vein velocity was lower in
patients than in volunteers (Table). The mean por-
tal blood flow (1 2612 141 mumin) and portal ve-
locity (14.623 crn/s) were higher in patients with
recanalized para-umbilical veins than in patients
without recanalization (blood flow=7202 157 ml/
min; portal vein velocity=9.6+2.4 cm/s) @<0.05).
There was no significant difference in portal vein
velocity between patients with recanalized para-
umbilical veins and control subjects (p0.05).
In the control subjects, the ratio of the sum of
the SMA and SA blood flows (average 621 ml/min)
to the portal flow (average 734 ml/min) was 0.85;
the ratio of SMA blood flow to portal blood flow
was 0.53. In the cirrhotic subjects, the portal inflow
(the sum of the SMA and SA blood flows=968 ml/
min) showed a marked increase in comparison
with volunteers (621 rnl/min) @<0.001). Portal in-
flow exceeded portal blood flow by 139 mumin in

Fig. 1. Portal vein diameter (PVD), portal vein velocity (PVV), Fig. 2. Portal vein blood flow (PVBF), SMA blood flow
SMA diameter (SMAD), SMA mean velocity (SMAMV), SA (SMABF) and SA blood flow (SABF) in cirrhotic and healthy
diameter (SAD), and SA mean velocity (SAMV) in cirrhotic subjects. Grey - cirrhosis. Black - controls.
and healthy subjects. Grey - cirrhosis. Black - controls.
 PORTAL AND SPLANCHNIC HAEMODYNAMICS BY DUPLEX DOPPLER
the cirrhotic subjects. The portal venous blood
flow was 720 ml/min and the portal inflow was 988
mVmin in patients without recanalized para-um-
bilical veins. In patients who did not show para-
umbilical vein recanalization, the difference be-
tween portal inflow and portal blood flow was 268
ml/min.
Discussion
In the literature, the reported portal blood flow
ranges from 779 ml/min to 1410 ml/min for pa-
tients with cirrhosis; values for the healthy subjects
range from 648 ml/min to 1 110 mumin (6, 14-16,
21). Many studies suggest that the portal venous
blood flow decreases in chronic liver disease (4, 5,
7). DE VRIESet al. (6) demonstrated that no re-
lation between portal flow and duration of cir-
rhosis, or between portal flow and Child’s classifi-
cation, was found in their study. ZIRONIet al. (25)
showed that portal venous velocity was 11.022.4
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cm/s in the Child-Pugh C-class. In their study, the
value of 15 c d s was considered the best cut-off
value for the diagnosis of portal hypertension,
showing a sensitivity of 88% and specificity of 96%.
In our present study, portal vein velocity was
10.0322.84 c d s in patients with cirrhosis and
16.2522.67 c d s in volunteers. Our results suggest
that in most cirrhotic patients, the portal blood
flow in chronic liver disease is stable and not re-
duced, despite the presence of portal collateral cir-
culation. Thus, portal vein velocity or portal blood
flow measurements alone are not useful parameters
for differentiating cirrhotic from healthy subjects.
Our figures for the sum of the SA and SMA
blood flows (62 1 ml/min) were slightly lower (15%)
than those for the portal venous inflow (734 ml/
min) in volunteers. IWAOet al. (10) found the por-
tal inflow 14% lower than the portal venous blood
flow in control subjects. SATOet al. (21) found that
the average portal flow was 648 ml/min, and the
sum of the SA and SMA blood flows was 578 ml/
min. In their study, SMA alone consisted of 59%
of portal blood flow. The ratio of the SA and SMA
blood flows to portal flow was 0.85 in our present
study, and 0.89 in the report of SATOet al. (21).
SA and SMA blood flows have been shown to
be significantly increased in cirrhotic subjects (10,
21, 26). In our present study, the increase in the
SMA blood flow was caused by an increase in the
SMA diameter and flow velocity. The increase in
the SA blood flow could also be explained by an
increase in the SA diameter and by splenomegali.
Apart from cirrhosis, other reasons for this include
increased systemic blood flow, expanded plasma
volume, and increased cardiac output (26).
The mean diameter of SA in our patients (5 mm)
and in our volunteers (3.77 mm) was lower than
those in previous studies (10, 21, 26). This discrep-
ancy could be due to the fact that we performed
the measurements in the distal segment of the SA.
In patients with cirrhosis, the calculated splanch-
nic inflow exceeds the portal venous flow owing to
an increased splanchnic blood flow and shunting
to the systemic circulation through the hepatofugal
portal collateral vessels. As regards theory, the col-
lateral blood flow is calculated as the difference
between the splanchnic inflow and portal venous
blood flow (10). In our cirrhotic subjects, the cal-
culated splanchnic blood flow was 968 ml/min
whereas the difference between the splanchnic in-
flow and portal venous blood flow was 139 ml/min.
When patients who did not show a recanalized
para-umbilical vein were assessed on their own,
this difference was 268 ml/min.
The portal inflow in patients with recanalized
para-umbilical veins did not exceed the portal
blood flow. In our study, we did not measure the
para-umbilical vein blood flow separately and
therefore our portal venous flow measurements in-
cluded both the recanalized para-umbilical vein
blood flow and the portal venous flow. For this
reason, the portal venous blood flow was higher in
patients with recanalized para-umbilical veins than
in patients without recanalization. In contrast to
our present study, SACERDOTI et al. (20) found the
portal blood flow to be lower in patients with pa-
tent para-umbilical veins than in those without.
They concluded that in the evaluation of portal
venous velocity and blood flow in cirrhotic pa-
tients, the patent para-umbilical veins might give
misleading results and an underestimation of the
degree of portal hypertension (20).
The Doppler examination of the portal and
splanchnic vessels might be the source of some
error. The vessel diameter (and consequently portal
flow measurements) is a potential source of error
since the shape is usually oval and not round as as-
sumed. The mean velocity in the portal vein may be
affected by the non-uniform velocity of the flowing
blood across the lumen of the vessel or by the non-
uniform velocity in time. Therefore, in order to ob-
tain uniform portal velocity measurements, the
sample volume taken was large (9). In the Doppler
examination of the portal vein velocity and portal
blood flow, interobserver variability is reported to
be 32% and interequipment variability 5y0(19). It
has been suggested (19) that a cooperative training
programme on direct measurements would signifi-
cantly reduce interobserver variability in portal
measurements. Interequipment variability was not
measured in our present study.
155
 H. DING ET AL.

Doppler indices are the indirect expressions of 9. GIBSON R. N., GIBSONF? R., DONLAN J. D. et al.: Modified
vascular impedance or resistance and inversely re- Doppler flowmetry in the splanchnic circulation. Gastro-
enterology 105 (1993), 1029.
lated to blood flow (24). The splanchnic arterial 10. IWAOT., TOYONAGA A., OHO K. et al.: Postprandial
resistance was higher in cirrhotic than healthy sub- splanchnic hemodynamic response in patients with cir-
jects (Table). Various factors may be the reason, rhosis of the liver. Evaluation with triple-vessel duplex US.
many of which change during the evolution of liver Radiology 201 (1996), 7 11.
11. JAPANESE RESEARCHSOCIETY FOR PORTAL HYPERTENSION:
disease (1, 3, 12). Alterations in the metabolisms The general rules for recording endoscopic findings on
of endogeneous substances, increased adrenergic esophageal varices. Jpn. J. Surg. 10 (1980), 84.
activation, and increased cardiac output in cir- 12. KROEGER R. J. & GROSZMANN R. J.: Increased portal ve-
rhotic subjects might partly explain the increased nous resistance hinders portal pressure reduction during
vascular resistance (2). An increased portal venous the administration of P-adrenergic blocking agents in a
portal hypertensive model. Hepatology 5 (1989, 97.
resistance (portal outflow obstruction) could also 13. MOSTBECK G. H., WITTICH G. R., HEROLD C. et al.: Hemo-
be a reason for increased splanchnic vascular re- dynamic significance of the paraumbilical vein in portal
sistance. hypertension. Assessment with duplex US. Radiology 170
Conclusion: The mean portal blood flow did not (1989), 339.
14. OHNISHI K., SAITOM., NAKAYAMA T. et al.: Portal venous
decrease in patients with advanced post-hepatitic hemodynamics in chronic liver disease. Effects of posture
cirrhosis in spite of the presence of portal col- change and exercise. Radiology 155 (1989, 757.
laterals. Portal blood flow and portal venous ve- 15. OHNISHIK., SATOS., PUGLIESE D. et al.: Changes of
locity were higher in patients with recanalized splanchnic circulation with progression of chronic liver dis-
para-umbilical veins than in patients who had no ease studied by echo-Doppler flowmetry. Am. J. Gastro-
enterol. 82 (1987), 507.
para-umbilical vein recanalization. SMA and SA 16. OKAZAKI K., MIYAZAKI M., OHNISHIS. et al.: Effect of
Downloaded By: [UNESP] At: 18:20 25 October 2009

blood flows and RI values or vascular impedance food intake and various extrinsic hormones on portal
increased in patients with cirrhosis compared with blood flow in patients with liver cirrhosis demonstrated by
the volunteers. pulsed Doppler with the Octoson. Scand. J. Gastroenterol.
21 (1986), 1029.
17. PATRIQUINE H., LAFORTUNE M., BURNSE! N. et al.: Duplex
ACKNOWLEDGEMENT Doppler examination in portal hypertension. Technique
and anatomy. AJR 149 (1987), 71.
We thank Ali Osman Kilic for skilful assistance. 18. SABBA C., FERRAIOLI G., BUONAMICO F? et al.: Echo-Dopp-
ler evaluation of acute flow changes in portal hypertensive
patients. Flow velocity as a reliable parameter. J. Hepatol.
REFERENCES 15 (1992), 356.
19. SABBAC., MERKEL C., ZOLIM. et al.: Interobserver and
1. BENOIT J. N., BARROWMAN J. A., HARPERS. L. et al.: Role interequipment variability of echo-Doppler examination of
of humoral factors in the intestinal hyperemia associated the portal vein. Effect of a cooperative training program.
with chronic portal hypertension. Am. J. Physiol. 247 Hepatology 21(1995), 428.
(1984), G486. 20. SACERDOTI D., BOLOCNESI M., BOMBONATO G. et al.: Pa-
2. BRAILLON A., CALESl?, VALLAD. et al.: Influence of the raumbilical vein patency in cirrhosis. Effect on portal
degree of liver failure on systemic and splanchnic hemody- hemodynamics evaluated by Doppler ultrasonography.
namics and on response to propranolol in patients with Hepatology 22 (1995), 1689.
cirrhosis. Gut 27 (1986), 1204. 21. SATOS., OHNISHIK., SUGITAS. et al.: Splenic artery and
3. BRAILLON A., GAUDINC., Po0 J. L. et al.: Plasma catechol- superior mesenteric artery blood flow. Nonsurgical Dopp-
amine concentrations are a reliable index of sympathetic ler US measurement in healthy subjects and patients with
vascular tone in patients with cirrhosis. Hepatology 15 chronic liver disease. Radiology 164 (1987), 347.
(1992), 58. 22. SHERLOCK S. & DOOLEY J.: Disease of the liver and biliary
4. BROWNH. S., HALLIWELL M., QAMARM. et al.: Measure- system. The portal venous system and portal hypertension.
ment of normal portal blood flow by Doppler ultrasound. Blackwell Scientific Publication, London 1993.
Gut 30 (1989), 503. 23. SUBRAMYAN B. R., BALTHAZAR E. J., MADAMBA M. R. et
5. CARLISE K. M., HALLIWELL M., READA. E. et al.: Esti- al.: Sonography of portosystemic venous collaterals in por-
mation of total hepatic blood flow by duplex ultrasound. tal hypertension. Radiology 146 (1983), 161.
Gut 33 (1992), 92. 24. TAYLOR K. J. W. & HOLLAND S.: Doppler US. Part I. Basic
6. DE VRIESl? J., HOEKSTRA J. B. L., DE HWE P. et al.: principles, instrumentation, and pitfalls. Radiology 174
Portal venous flow and follow-up in patients with liver dis- (1990), 297.
ease and healthy subjects. Assessment with duplex Dopp- 25. ZIRONIG., GAIANIS., FEW D. et al.: Value of measure-
ler. Scand. J. Gastroenterol. 29 (1994), 172. ment of mean portal flow velocity by Doppler flowmetry
7. DE VRIESF? J., VANHATTUM J., HOEKSTRA J. B. L. et al.: in the diagnosis of portal hypertension. J. Hepatol. 16
Duplex Doppler measurement of portal venous flow in (1992), 298.
normal subjects. Inter- and intra-observer variability. J. 26. ZWIEBEL W. J., MOUNTFORD R. A., HALLIWELL M. J. et al.:
Hepatol. 13 (1991), 358. Splanchnic blood flow in patients with cirrhosis and portal
8. DINGH., KAPICIOCLU S., CIHANYURDU N. et al.: Effect of hypertension. Investigation with duplex Doppler US. Radi-
verapamil on portal and splanchnic hemodynamics in pa- ology 194 (1995), 804.
tients with advanced posthepatitic cirrhosis using duplex
Doppler ultrasound. Eur. J. Radiol. 23 (1996), 97.

156