William J. Zwiebel, MD #{149}Richard A.

Mountford, MD Michael
#{149} J. Halliwell, PhD
Peter N.T. Wells, DSc, FEng

Splanchnic Blood Flow in Patients

with Cirrhosis and Portal Hypertension:
Investigation with Duplex Doppler US’

PURPOSE: To investigate splanchnic P RESSURE in the portal venous sys- be disrupted In some patients with
blood flow changes in patients with tem is regulated by two factors: advanced liver disease and portal hy-
hepatic cirrhosis and portal hyper- splanchnic blood flow and the resis- pertension (4-6). In healthy individu-
tension. tance to flow within the liver. Portal als, blood flow in the splenic artery
MATERIALS AND METHODS: Du- venous pressure increases in response decreases as blood flow in the SMA
plex Doppler ultrasound (US) was to either an increase in flow or resis- increases, and vice versa; thus, a rela-
used to measure blood flow in the
tance (1-3). tively stable level of portal blood flow
It has long been thought that portal prevails. In patients with advanced
superior mesenteric artery (SMA)
hypertension associated with chronic cirrhosis, however, the sum of SMA
and splenic artery in 20 patients with
liver disease was caused exclusively and splenic artery blood flow may far
biopsy-proved cirrhosis and clinical
by increased resistance in the ana- exceed the normal range.
evidence of portal hypertension, and
in 20 healthy volunteers who were tomically distorted liver. Recent scien- Most of the direct evidence of el-
tific evidence suggests, however, that evated splanchnic blood flow in por-
matched for age and sex.
increased splanchnic blood flow may tal hypertension has come from ani-
RESULTS: Mean SMA and splenic also contribute substantially to portal mal studies (1,2). Evidence based on
artery blood flow was significantly hypertension in patients with chronic studies of splanchnic blood flow in
greater in the patients than in liver disease (1-6). Increased splanch- humans is relatively sparse (6-il). We
healthy subjects. Neither SMA nor nic blood flow, increased systemic are aware of only two studies that
splenic artery blood flow was in- blood flow, expanded plasma volume directly measured SMA and splenic
creased in patients with normal-sized (related to peripheral vasodilatation), artery blood flow in humans with
spleens; however, blood flow was and increased cardiac output have chronic liver disease and clinical evi-
significantly elevated in patients been observed in association with ad- dence of portal hypertension (5,6).
with splenomegaly. Total splanchnic vanced cirrhosis and portal hyperten- Five additional published studies (7-
blood flow in patients was also sig- sion. These hemodynamic alterations 11) report measurement of portal vein
nificantly elevated compared with have become known as the “ hyperdy- blood flow in humans with chronic
healthy subjects. Total splanchnic namic” flow state of cirrhosis. The liver disease and portal hypertension.
blood flow in patients with normal- humoral or neuronal agents that me- These studies were not designed to
sized spleens was not significantly diate the hyperdynamic flow state evaluate splanchnic blood flow, how-
elevated compared with healthy sub- have not, to our knowledge, been elu- ever.
jects, but splanchnic flow was signifi- cidated. To investigate further the changes
cantly increased in patients with In patients with portal hyperten- in splanchnic blood flow that are as-
splenomegaly. sion, increased splanchnic blood flow sociated with chronic liver disease, we
CONCLUSION: Blood flow is in- is largely shunted to the systemic cir- compared prospectively SMA and
creased in the SMAs and splenic ar- culation through portosystemic collat- splenic artery blood flow in healthy
teries of patients with cirrhosis and eral vessels (mntrahepatic and extrahe- individuals and in patients with clini-
portal hypertension. Increased patic) nonetheless, it appears that cally documented cirrhosis and portal
splanchnic blood flow associated increased splanchnic blood flow con- hypertension. The results of this in-
with cirrhosis may occur exclusively tributes substantially to elevation of vestigation are the subject of this re-
in patients with splenomegaly. portal pressure (2). In conjunction port.
with increased splanchnic blood flow,
Index terms: Arteries, mesenteric, 955.12984
the homeostatic regulation of supe-
Arteries, splenic, 954.12984 Blood,
#{149} flow MATERIALS AND METHODS
dynamics Hypertension,
#{149} portal. 95.71 1
rior mesenteric artery (SMA) and
Liver, cirrhosis, 761.794 Ultrasound
#{149} (US), splenic artery blood flow appears to Subjects
Doppler studies
The study was approved by the Bristol
Radiology 1995; 194:807-812 and District Research Ethics Committee
and was conducted at the Vascular Labo-
ratory of the Bristol Royal Infirmary, Bris-
I From the Department of Radiology, Veterans Administration Medical Center, 500 Foothill Blvd,
Salt Lake City, UT 84148 (W.J.Z.); and the Departments of Medicine (RAM.), and Medical Physics
and Bioengineering (M.J.H., P.N.T.W), University of Bristol, Bristol, England. Received May 27, 1994;
revision requested June 28; revision received October 6; accepted October 11. Address reprint re-
quests to W.J.Z. Abbreviation: SMA = superior mesenteric ar-
( RSNA, 1995 tery.

807
a. b. c.
Figure 1. Duplex Doppler images depict blood flow measurement technique in the SMA. (a) Longitudinal image with the sample volume po-
sitioned just beyond the “bend” in the SMA. The sample volume encompasses the entire vessel and the Doppler angle cursor is aligned with
the arterial wall. (b) Longitudinal and (c) transverse images illustrate the measurement of the inside diameter of the SMA.

tol, England. The cohort of healthy sub-

jects consisted of 12 men (age range, 36-79
years; mean 56.1 years) and eight women
(age range, 39-70 years; mean, 53.5 years)
who did not have a history of excessive
alcohol consumption or liver disease. The
mean age of the healthy volunteers was 55
years (range, 36-79 years). The patient co-
hort consisted of 11 men (age range, 42-74
years; mean, 55.9 years) and nine women
(age range, 39-72 years; mean, 53.7 years)
who had biopsy-proved hepatic cirrhosis.
The mean age of the patient cohort was 55
years (range, 39-74 years). In these pa-
tients, there was clinical evidence of portal
hypertension as demonstrated by large
esophageal varices (observed endoscopi-
cally) and at least one episode of upper
gastrointestinal hemorrhage related to
variceal rupture (treated endoscopically).
In the cohort of patients, 16 had alcohol-
related cirrhoses, one had primary biliary
cirrhosis, and one had posthepatic cirrho-
sis. The cause of cirrhosis in two patients Figure 2. Duplex Doppler image shows typical sample volume
could not be ascertained. position for measurement of splenic artery flow (transverse image).

Flow Measurements
tion was adjusted to afford the best pos- minute off-line by the PC-Dop 840 instru-
After an overnight fast, measurements sible Doppler angle. The Doppler angle ment from the stored velocity and diam-
of blood flow were obtained by using du- was 50#{176}-60#{176}
for six blood flow calculations eter data. All measurements of blood flow
plex Doppler ultrasound (US) while the in six subjects in the healthy cohort and were made by one of us (W.J.Z.). No fewer
patient was in the supine position. Respi- for 10 blood flow calculations in 10 pa- than four Doppler spectral measurements
ration was suspended for up to 10 seconds tients in the patient cohort. For all other of the SMA were obtained (range, 4-12
during Doppler measurements. Blood flow calculations, the Doppler angle was measurements) in each subject. These
flow in the SMA was interrogated just less than 50#{176}. The highest possible pulse Doppler spectral samples were stored
distal to the point at which the vessel repetition frequency was used in all in- digitally, permitting the selection of the
changes course from an anterior to a cau- stances, and the wall filter was kept as low highest-quality waveforms for subsequent
dal direction (Fig 1). If a distinct angle was as possible (100 Hz). The sample volume calculations of blood flow. Each
Doppler
not present in the SMA, blood flow was was adjusted to include the entire diam- spectral sample consisted to eight
of one
interrogated approximately 2 cm from its eter of the vessel (Fig 1). cardiac cycles. Samples that contained sev-
origin. This measurement site in the SMA Angle-corrected Doppler velocity spec- eral cardiac cycles were preferred so that
was chosen to (a) reduce the possibility tra were then obtained and stored digi- beat-to-beat variation in average blood
that blood flow could be measured be- tally by using a personal computer-based flow velocity could be accommodated. In
yond the first branch of the SMA and spectral storage device (PC-Dop 840; some cases, however, only a single high-
(b) provide an easily identified point for SciMed, Bristol, England). The diameter of quality cardiac cycle could be obtained
subsequent measurement of the diameter the SMA was then measured (described from a given Doppler sample. Off-line as-
of the SMA. below) and the diameter was entered into sessment of Doppler spectral data with the
When the desired measurement site was the PC-Dop 840 system. Blood flow (vol- PC-Dop 840 system permitted critical as-
identified in the SMA, the transducer posi- ume) was calculated in milliliters per sessment of each arterial flow series. The

808 Radiology
#{149} Mri4i 1QQ
quality of each Doppler waveform series samples in five patients. In all other in- splenic artery flow
values), and splenic
was judged subjectively, and poor-quality stances, the Doppler angle was less than length were tabulated
for each subject.
waveforms were excluded. The following 500. In 15 healthy subjects and 14 patients, From these data, mean flow values, stan-
features defined high-quality waveforms: flow measurements were based on samples dard deviation, and range of flow values
(a) adequate signal strength; (b) lack of obtained with a single splenic artery were calculated for SMA, splenic artery,
“noise” caused, for example, by arterial sample volume position and a single Dop- and splanchnic blood flow for the mdi-
“thump” and peristalsis; (c) lack of dis- pler angle. In two healthy subjects and viduals in the two cohorts. The statistical
turbed flow (turbulence); and (d) a well- three patients, more than one Doppler significance of differences in flow values
defined upper spectral border (envelope). angle or sample volume position in the between the cohorts of healthy subjects
In five healthy subjects and seven pa- splenic artery was used. The maximum and patients was judged by using the Stu-
tients, blood flow calculations were made blood flow value from each of these sites dent t test for unpaired data and unequal
from data obtained at only one sample was averaged. variances.
volume position in the SMA and with only The maximum longitudinal dimension
one Doppler angle. In such instances, the of the spleen was measured from coronal
digitally recorded Doppler series that images obtained in each subject in the RESULTS
yielded the highest mean velocity was se- study. Spleens that measured 13 cm or less
lected for blood flow calculation. Duplex in length were considered normal, and Mean blood flow in the SMA in the
Doppler data from a single site and single spleens that exceeded this length were patient cohort (574 mL/min) was sig-
Doppler angle were chosen if (a) it was considered enlarged, as based on the data nificantly greater (P < .02) than that
possible to obtain Doppler data from only of Senecail (12). Although numerous in healthy subjects (445 mL/min)
one site and with a single Doppler angle methods for measuring spleen size with (Table 1). This difference was due
or (b) the waveforms from a single site and US have been devised, a standard method largely to a marked increase in SMA
Doppler angle were optimum, as judged has not been established. We chose to use
flow in eight patients with spleno-
on subjective evaluation of waveforms (as the maximum longitudinal dimension
megaly. In these eight patients, mean
described above). In 15 healthy subjects because (a) this measurement is easily
SMA flow (705 mL/min) was signifi-
and 13 patients, more than one high-qual- achieved and (b) it is well documented
ity Doppler waveform series was obtained that the maximum length of the spleen in cantly greater (P < .04) than that in
by using different SMA sample volume healthy adults does not exceed 13 cm (12). the healthy subjects (445 mL/min);
positions or different Doppler angles. In however, mean SMA flow in the pa-
these cases, the highest flow value from tients with normal spleen size (471
each high-quality Doppler series was cho- Equipment mL/min) was not significantly greater
sen, and these values were averaged. (P > .4) than that in the healthy sub-
A US instrument (ATL Mark 9; ATL,
The diameter of the SMA lumen was jects.
Bothell, Wash), equipped with a 2-MHz,
measured carefully at the Doppler exami-
phased-array transducer and color Dop- The findings for splenic artery
nation site by using electronic calipers and
pler flow imager, was used to measure blood flow paralleled the findings for
a magnified image (Fig 1). Measurements
blood flow. A flow rig (described below) SMA flow (Table 1). Mean splenic ar-
were obtained in longitudinal and trans-
was used to confirm the accuracy of the tery blood flow (599 mL/min) was
verse planes with the center of the sector
image-display representation of the Dop- significantly increased (P < .05) in
image perpendicular to the axis of the ar-
pler sample volume. With the sample vol-
tery. The dynamic range was adjusted at a patients as compared with healthy
ume set at its maximum size, the length
low level to enhance definition of the edge subjects (413 mL/min). Splenic artery
(range) of the sample volume display cor-
of the arterial wall. Diameter measure- flow was particularly increased in the
related to ± I mm with the actual (func-
ments were repeated until a value could eight patients with splenomegaly
tional) length of the sample volume. The
be reproduced consistently. This diameter (mean, 755 mL/min; P < .05). In pa-
width (z axis) of the sample volume mea-
was used to calculate blood flow.
sured no more than 5 mm. A calibration tients with normal-size spleens, how-
The measurement of splenic artery
phantom was used to confirm that the ac- ever, mean splenic artery flow (460
blood flow was possible in 17 healthy sub-
curacy of the electronic calipers was ±1 mL/min) was not significantly in-
jects and 17 patients. Technical difficulties
mm. The accuracy of the entire system creased (P > .05).
precluded the measurement of splenic ar-
(AlL Mark 9 and PC-Dop 840 system) in Total splanchnic blood flow (SMA
tery blood flow in a total of six healthy
measuring blood flow was confirmed with
subjects and patients with disease. Dop- plus splenic artery flow) in the pa-
flow rig trials. The flow rig consisted of a
pler measurements of the splenic artery tients (mean, 1,195 mL/min) was
rubber tube of uniform caliber suspended
were generally made just beyond the on- significantly increased (P < .01) com-
in a water bath. A fluid that mimicked
gin of the splenic artery, at a point where pared with that in the healthy sub-
blood was pumped through the tube into
the vessel is directed dorsally and is on-
a graduated cylinder, providing a direct jects (mean, 853 mL/min) (Table 1),
ented nearly parallel with the ultrasound
measure of volume flow. The volume of which is in agreement with the results
beam (Fig 2). In some cases, Doppler mea-
blood flow as measured at duplex Doppler cited previously. Total splanchnic
surements of the splenic artery were made
was 2%-10% less than actual flow vol- blood flow was not significantly in-
nearer to the origin of the vessel, but this
umes over a range of 330-860 mL/min. creased (P > .11) in the patients
site was avoided due to the possibility of
The US instrument was more accurate in whose spleens were normal in size
inadvertent movement of the sample vol-
measuring lower levels of blood flow than
ume into the hepatic artery or celiac ar- (mean, 958 mL/min) but was signifi-
higher levels of blood flow. The following
tery. Other details referable to the mea- cantly increased (P < .03) in patients
values were recorded in the flow rig trial
surement of mean flow velocity, arterial with splenomegaly (mean, 1,195 mL/
(actual flow, milliliters per minute; Dop-
diameter, and blood flow were similar to mm) (Table 1).
pler flow, milliliters per minute; and per-
those described above for SMA measure-
centage of difference from actual flow): 330,
ments.
324, -2%; 445, 423, -5%; 550, 528, -4%; 655,
One to eight Doppler spectral samples DISCUSSION
615, -6%; 748, 673, - 10%; and 860, 798,
were obtained in each healthy subject or
-7%.
patient with disease during assessment Healthy Subjects
of splenic artery blood flow. Each of
these series contained one to eight cardiac The values for SMA blood flow in
Tabulation and Statistical Analysis
cycles. The Doppler angle was 50#{176}-60#{176}
for the healthy subjects in our study are
three Doppler samples in three healthy SMA and splenic artery blood flow, comparable with previously pub-
subjects and was 50#{176}-60#{176}
for five Doppler splanchnic blood flow (total of SMA and lished duplex Doppler data (6,13-17)

Volume 194 Number

#{149} 3 Radiology 809
#{149}
(Table 2). Whereas splenic artery
Table 1
blood flow was greater in the healthy
subjects in our study than in the sub-
SMA and Splenic Artery Blood Flow Data in Patients and Healthy Subjects
jects of Sato et al (6), our values were Mean ± SD Range
concordant with the findings of Naka- Characteristics (mL/min) (mL/min)
mura et al (13). We have no explana- SMA blood flow
tion for the discrepancy of the flow Patients with cirrhosis and portal hypertension
values described by Sato et al (6) rela- All (n = 20) 574 ± 220 338-1,316
tive to the other data on splenic artery Normal spleensize (n = 12) 471 ± 96 338-659
Large spleen (n = 8) 705 ± 282 464-1,316
blood flow. Healthy subjects (n = 20) 445 ± 63 343-591
Splenic artery blood flow
Patients with drrhosis and portal hypertension
Patients with Cirrhosis and Portal All (n = 17) 599 ± 340 245-1,627
Hypertension Normal spleen size (n = 9) 461 ± 200 245-770
Large spleen (n = 8) 755 ± 407 364-1,627
The findings of our study support Healthy subjects (n = 17) 413 ± 110 239-584
the existence of an increase in SMA and splenic artery blood flow
splanchnic blood flow in patients Patients with cirrhosis and portal hypertension
All (n = 17) 1,130 ± 551 713-2,452
with cirrhosis and clinical evidence of
Normal spleen size (n = 9) 958 ± 167 713-1,243
portal hypertension. Mean values Large spleen (n = 8) 1,463 ± 574 940-2,452
for SMA, splenic artery, and total Healthy subjects (n = 17) 853 ± 108 615-1,043
splanchnic blood flow (Table 1) were
Note.-SD = standard deviation.
significantly greater in the patient
cohort than in the cohort of healthy
subjects. These results are similar to
those published by Sato et al (6), who hypertension (4,5). SMA blood flow
Table 2
detected increased SMA and splenic (705 mL/min) was significantly in-
flow in patients cirrhosis.
Representative Series on Blo od Flow
artery with creased (P < .04) in our patients
Data in Healthy Subjects
It is interesting that Sato et al did not whose spleens were enlarged, even
find increased SMA flow in patients though splenic artery blood flow also Splenic
Artery
with chronic active hepatitis who did was significantly increased in this
SMA Flow Flow
not have histologic evidence of cir- population of patients. Thus, the Study (mL/min) (mL/min)
rhosis. Ohnishi et al (5) also did not presence of increased splenic artery
find increased SMA and splanchnic blood flow (related to splenomegaly) Present study 445 ± 63 413 ± 110
Sato et al (6) 383 ± 90 179 ± 37
blood flow in a group of patients with did not reduce SMA blood flow as
Nakamura et al (13) 487 ± 166 370 ± 181
idiopathic portal hypertension (a might normally be expected. Similar Scheurlen et al (14) 377 ± 166 ND
noncirrhotic condition). It appears, observations have been made by Moneta et al (15) 538 ± 30 ND
therefore, that increased SMA blood other investigators (5,6). Jager et al (16) 378 ± 156 ND
flow may be a feature of cirrhosis Qamar and Read
It has been postulated that in-
(17) 550±30 ND
and not of other forms of chronic creased splanchnic blood flow in por-
liver disease or of portal hyperten- tal hypertension occurs only in mdi- Note.-All values are presented as mean ±
sion per se. viduals with severe liver disease standard deviation. ND = no data available.

In our study, SMA, splenic artery, (1,2,4,5). On the basis of this hypoth-
and total splanchnic blood flow was esis, the broad range in splanchnic
increased only in those patients with blood flow values in our patients is
was represented by recovered alco-
splenomegaly. This finding was not noteworthy. In our patients, the
holics with only one instance of gas-
anticipated in the original study de- ranges for blood flow were as follows:
trointestinal bleeding, normal liver
sign. It is understandable that splenic SMA blood flow, 338-1,316 mL/min
artery blood flow would be increased
function, and normal hepatic mor-
(mean, 574 mL/min); splenic artery
phology (as determined with US).
only in subjects with splenomegaly; blood flow, 245-1,627 mL/min (mean,
The other end of the clinical spectrum
however, there is no empirical reason 599 mL/min); and total splanchnic
was represented by relapsing alcohol-
to expect a link
between SMA blood blood flow, 713-2,452 mL/min (mean,
ics with encephalopathy, ascites,
flow and spleen
size. The association 1,130 mL/min) (Table 1). These ranges
of increased SMA flow and spleno- were much broader than those in our marked liver function abnormalities,
and severely abnormal hepatic mor-
megaly suggests that the hyperdy- healthy subjects: 343-591 mL/min
namic circulatory state of cirrhosis phology (consistent with far-ad-
(mean, 445 mL/min) for SMA blood
vanced cirrhosis). We attribute the
and portal hypertension is temporally flow, 239-584 mL/min (mean, 413
wide spread of splanchnic blood flow
or etiologically linked with spleno- mL/min) for splenic artery blood
values in our patients to the broad but
megaly. To our knowledge, the asso- flow, and 615-1,043 mL/min (mean,
clinically undefined spectrum of liver
ciation of splenomegaly and in- 853 mL/min) for total splanchnic
disease in these individuals (see be-
creased SMA and splanchnic flow in blood flow. The broad ranges of flow
low).
patients with cirrhosis has not been values suggest that considerable clini-
reported previously, and this observa- cal diversity existed in the subjects
tion may warrant additional investi- with liver disease, even though all of Limitations
gation. these individuals had biopsy-proved
Our data support the previously “advanced cirrhosis” and all had ex- This study
subject wasto five im-
stated hypothesis that SMA and perienced hemorrhage from large portant limitations.
First, the accuracy
splenic artery homeostasis is out of esophageal varices. One end of the of duplex Doppler flow measure-
order in some patients with portal clinical spectrum in the patient cohort ments may be affected by several

810 Radiology
#{149} March 1995
methodologic problems, as outlined ences in blood flow between our The final limitation of this study is
by Gill (18) and commented on by healthy subjects and patients, since the lack of a convenient means by
Burns and Blei (19). Although great the error was greatest at high levels of which systemic blood flow or cardiac
care was taken to measure blood flow blood flow, which are representative output could be assessed. Had we
accurately in this study, and although of the latter group. In other words, been able to evaluate systemic blood
the measurements were made by a the differences in blood flow between flow or cardiac output, we might have
single individual (W.J.Z.) (thereby the healthy subjects and the patients investigated the relationship between
eliminating interobserver variability), were probably greater than our re- the changes in systemic and splanch-
the blood flow statistics included sults suggest. nic blood flow in the patients with
herein must be regarded as estimates. The second limitation of this study cirrhosis and portal hypertension. It is
In vivo studies that compare duplex concerns our inability to quantify the assumed that an increase in systemic
Doppler and electromagnetic arterial severity of liver disease in our pa- and splanchnic blood flow occurs simul-
flow measurements show a high de- tients. We tried to correlate splanch- taneously in patients with portal hyper-
gree of correlation (range, 0.93-0.96); nic flow rates with the severity of tension, but to our knowledge this hy-
however, these studies were con- liver disease by using a clinical index pothesis has not been investigated in
ducted on surgically exposed arteries that included hepatic histologic find- any detail in humans (1,2,4-6). #{149}
in highly controlled circumstances ings, liver morphology (as identified
(6,13). These controlled conditions are with US), biochemical test results, and Acknowledgments: We sincerely appreciate
not possible when blood flow is mea- historic data (eg, history of encepha- the efforts of numerous individuals who as-
sured with percutaneous duplex Dop- lopathy). Unfortunately, no correla- sisted with this study directly or indirectly. In
particular, we extend our thanks to the follow-
pler flow imaging. Nakamura et al tion was evident between the mea-
ing individuals: Susan Cole, technical director of
(13) estimate that the rate of maccu- surements of blood flow and the results the Bristol Royal Infirmary Vascular Laboratory,
racy for percutaneous duplex Dop- of our scoring system. Apparently, this for technical and administrative assistance; An-
pler measurement of splanchnic was because our clinical assessment sys- gela Bently of the Bristol Royal Infirmary, De-
partment of Medicine, for assistance with identi-
blood flow in adults may be as great tem was too crude and, in many cases,
fying and scheduling subjects; Janet Came of
as ±20%. It is clear that our measure- not current (eg, a liver biopsy might the Bristol General Hospital, Department of Medi-
ment error exceeded 10% in some in- have been performed 2-4 years before cal Physics and Bioengineering, for secretarial assis-
stances, as based on our flow rig trials the study). We believe that increased tance; Dixie Zumwalt of the Salt Lake City Veter-
SMA and splenic artery flow occurs only ans Affairs Medical Center, Department of
(see Materials and Methods). Further-
Radiology, for secretarial assistance; and Kathryn
more, the intrasubject variation for in patients with advanced liver disease, Morton, MD, ofthe Salt Lake City Veterans Affairs
measurements of blood flow was as suggested by others (1-5); unfortu- Medical Center, Department of Nuclear Medicine,
large (calculated as range of blood nately, we could not directly substanti- for assistance with statistical analysis.
flow values for one patient divided by ate this hypothesis.
the mean blood flow value for that The third limitation concerns the References
patient multiplied by 100). The aver- small size of our study population. 1. Mahl TC, Groszmann RJ. Pathophysiol-
ogy of portal hypertension and variceal
age intersubject variation in SMA Although the number of subjects was
bleeding. Surg Clin North Am 1990; 70:
blood flow measurements was 14% sufficient to demonstrate substantial 251-266.
(range, 0.5%-30%) for the entire study population differences, as described 2. Bosch J, Pizcueta P, Feu F, Mercedes F,
population. The average intrasubject above, a larger series might have re- Garcia-Pagan JC. Pathophysiology of por-
variation for the measurement of splenic vealed additional important features tal hypertension. Gastroenterol Clin North
Am 1992; 21:1-14.
artery blood flow was 7% (range, 2%- of the hyperdynamic flow state of cir- 3. Fern#{225}ndez-Rodriguez CM, Prieto J, Zozaya
11%) for the entire study population. In rhosis. The same limitation applies to JM, Quiroga J, Guiti#{225}nR. Arteriovenous
addition to this random, intrasubject the findings reported in studies of shunting, hemodynamic changes, and re-
error, our flow rig trials suggest that our splanchnic blood flow
in patients nal sodium retention in liver cirrhosis. Gas-
troenterology 1993; 104:1139-1145.
duplex Doppler system caused system- with chronic liver disease published 4. Nishida 0, Asu FM, Nakamura T, et al.
atic underestimation of blood flow. At previously. A large-scale study of this Relationship between splenic and superior
higher flow rates, measured blood subject is desirable. mesenteric venous circulation. Gastroen-
flow was as much as 10% less than The fourth limitation concerns the terology 1990; 98:721-725.
5. Ohnishi K, Sato 5, Nomura F, lida S.
actual blood flow. relationship between splenomegaly
Splanchnic hemodynamics in idiopathic
Fortunately, the adverse effects of and increased splanchnic blood flow. portal hypertension: comparison with
the inaccuracy of Doppler-based The correlation between increased chronic persistent hepatitis. Am J Gastroen-
blood flow measurements is dimin- splanchnic flow and splenomegaly terol 1989; 84:403-408.
6. Sato 5, Ohnishi K, Sugita 5, Okuda K.
ished somewhat in a study such as discovered in this study was not an-
Splenic artery and superior mesentenic ar-
ours in which two groups of subjects ticipated in the original study design. tery blood flow: nonsurgical Doppler US
were compared. In this setting, rela- Had this relationship been antici- measurement in healthy subjects and pa-
tive differences between populations pated, a technique for volumetric tients with chronic liver disease. Radiology
may be regarded as substantial even if spleen measurement might have been 1987; 164:347-352.
7. Miyauchi 5, Yasuhara Y, Ohta Y, et al.
the Doppler-based blood flow mea- used that theoretically could yield Clinical significance of the measurement of
surements are imprecise. We believe, superior differentiation between nor- hepatic blood flow: xenon 133 and balloon
therefore, that the differences in mal and enlarged spleens. Also, a catheter in patients undergoing treatment
blood flow between the two cohorts population of patients with spleno- for hepatocellular carcinoma. Eur J NucI
Med 1991; 18:241-246.
demonstrated are valid, de-
herein megaly but without cirrhosis and por- 8. Ohnishi K, Masayuki 5, Nakayama T, et al.
spite the limitationsof the Doppler tal hypertension could have been in- Portal venous hemodynamics in chronic
method used. The potential for sys- cluded in the study to ascertain liver disease: effects of posture change and
tematic underestimation of blood flow whether increased splanchnic blood exercise. Radiology 1985; 155:757-761.
9. Gaiani 5, Bolondi L. Effect of meal on
at higher flow rates, as cited above, is flow may be a manifestation of sple-
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duced the significance of the differ- of cirrhosis and portal hypertension. Hepatology 1989; 9:815-819.

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