Case Report

Partially Reversed Intrasplenic Venous Blood

Flow Detected by Color Doppler Sonography
in Two Patients with Hematologic Diseases
and Splenomegaly

Isabel Restrepo-Schäfer, MD,1 Birgit Wollenberg, MD,2 Jordi Riera-Knorrenschild, MD,2

Christian Görg, MD2

1
Department of Hematology, Immunology, and Oncology, University Clinic of the Philipps University Marburg,
Baldingerstrasse, 35033 Marburg, Germany
2
Department of Gastroenterology, Metabolism, and Endocrinology, University Clinic of the Philipps University
Marburg, Baldingerstrasse, 35033 Marburg, Germany

Received 11 January 2000; accepted 4 December 2000

ABSTRACT: We report on 2 patients with hematologic
diseases (1 follicular lymphoma and 1 myeloprolifera-
tive syndrome) and splenomegaly who had partial in-
trasplenic portosystemic shunting demonstrated by
color Doppler sonography. Intrasplenic venous blood
flow was in the normal direction at the hilum of the
spleen but in a reversed direction at the periphery of
the spleen. This type of reversed intrasplenic flow pat-
tern results in portosystemic shunting and might be
detected more frequently when careful color Doppler
mapping of the entire splenic parenchyma is per-
formed in patients with portal hypertension. The clini-
cal significance of this phenomenon, however, is still
unclear. © 2001 John Wiley & Sons, Inc. J Clin Ultra-
sound 29:294–297, 2001.
Keywords: spleen; portal hypertension; color Doppler
ultrasonography; portosystemic shunt
and may lead to portosystemic shunting. In-
creased arterial flow in the splanchnic circulation
has also been reported.1
Percutaneous transhepatic portography pro-
vides information about the presence, type, and
distribution of portosystemic collateral vessels in
patients with portal hypertension.2 With this mo-
dality, hepatofugal collateral veins arising from
hilar splenic veins can be found in about 20% of
cirrhotic patients with portal hypertension. Two
thirds of these collaterals drain to the retroperi-
toneal venous system, and one third drain to the
renal veins (splenorenal shunt).2
Since the early 1980s, Doppler sonography has
been used to study the hemodynamics of the por-
tovenous system.3 Reversed flow in the main por-
tal vein or in its branches was soon identified as a
characteristic sonographic finding in portal hy-

C irrhosis and the resulting portal hyperten-

sion are known to affect the flow patterns of
the liver vasculature. In these conditions, Doppler
sonography can provide important information on
the hemodynamics of the portal venous system.
Signs of portal hypertension include a dilated por-
tal vein, reduced portal blood flow, and reversed
(hepatofugal) flow in the main portal vein and/or
its branches. Portosystemic collateral blood ves-
sels develop from pre-existing small portal vessels
Correspondence to: C. Görg
© 2001 John Wiley & Sons, Inc.
294
pertension.4 More recently, using color Doppler
sonography, Barakat et al5 reported for the first
time reversed intrasplenic venous blood flow in 4
patients with liver cirrhosis.
In this report, we describe 2 patients with sys-
temic hematologic diseases and splenomegaly in
whom we observed partially reversed intrasplenic
venous blood flow as a rare manifestation of por-
tosystemic shunting. The color Doppler ultra-
sound examinations were performed using a
128XP ultrasound scanner (Acuson, Mountain
View, CA) with a 3.5-MHz vector transducer. On
color Doppler sonography, the intrasplenic ves-
JOURNAL OF CLINICAL ULTRASOUND
 INTRASPLENIC VENOUS FLOW REVERSAL
FIGURE 1. Color Doppler sonogram demonstrates normal intrasplenic blood flow. Venous blood flow (V) is
directed toward the hilum and is coded in blue. Arterial flow (A) is directed toward the periphery of the spleen
and is coded in red. CR, cranial.
sels show a typical sonographic flow pattern simi-
lar to spokes converging on a hub (Figure 1). The
intrasplenic venous branches were traced by
aligning the transducer along their course using
several oblique planes. Spectral analysis was per-
formed in each case to confirm the venous flow
pattern.
CASE 1
A 60-year-old white man was admitted to our
clinic with fever, generalized lymphadenopathy,
and hepatosplenomegaly. Eighteen months ear-
lier, he had been diagnosed with advanced-stage
follicular lymphoma and bone marrow infiltra-
tion. He achieved a partial remission after 8
cycles of combination chemotherapy with cyclo-
phosphamide, doxorubicin (Adriamycin), vincris-
tine, and prednisolone.
Abdominal sonography was performed soon af-
ter admission and confirmed the presence of gen-
eralized abdominal lymphadenopathy, with ab-
dominal lymph nodes of up to 3 cm in diameter.
The liver was enlarged, with a craniocaudal di-
ameter of 18 cm, but had a normal, homogeneous
echotexture. The spleen was also enlarged, with a
size of 20 × 11 cm on longitudinal scans, but had
a normal, homogeneous echotexture. Color Dopp-
ler imaging demonstrated venous flow in the nor-
VOL. 29, NO. 5, JUNE 2001
mal direction in the dilated portal vein, in the
superior mesenteric vein, and in the main splenic
vein, particularly in the splenic hilar region (Fig-
ure 2A). At the periphery of the spleen, however,
reversed venous flow was observed (Figure 2B).
Spectral analysis confirmed the partially re-
versed intrasplenic venous flow (Figure 2C).
CASE 2
A 63-year-old white woman with known esopha-
geal varices was admitted to our clinic for esopha-
gogastroscopy. Six months earlier, she had been
diagnosed as having myeloproliferative syndrome
(by bone marrow biopsy) and thromboses of the
portal, splenic, and superior mesenteric veins.
Esophageal varices as well as sonographic signs
of splenic infarction were already present at the
time of initial admission 6 months earlier.
Endoscopy revealed grade II esophageal vari-
ces as well as varices of the cardia. Abdominal
sonography demonstrated an enlarged liver (17
cm craniocaudal diameter) with a normal, homo-
geneous echotexture. The spleen was also en-
larged (25 × 8 cm) on longitudinal scans, without
any focal lesions. Color Doppler imaging showed
the thromboses of the portal, superior mesenteric,
and splenic veins. Venous flow in the normal di-
rection was found in the central part of the spleen
295
 RESTREPO-SCHÄFER ET AL

FIGURE 2. Case 1: a 60-year-old man with follicular lymphoma and splenomegaly. (Left) Color Doppler sono-
gram of the spleen shows venous blood flow directed toward the hilum of the spleen (in blue, short arrow) and
also flow directed toward the periphery of the spleen (in red, long arrows). (Middle) Color Doppler sonogram
shows venous flow (V) directed toward the periphery of the spleen. (Right) Spectral analysis confirms the flow
reversal. V, vein.

(Figure 3A), but reversed flow was seen at the
periphery (Figure 3B). Spectral analysis con-
firmed the partially reversed venous flow (Figure
3C).
DISCUSSION
Barakat et al5 systematically studied the splenic
venous blood flow using color Doppler “mapping”
of the spleen in 176 patients with intrahepatic
portal hypertension due to chronic liver disease
and with proven esophageal varices. Normal
splenic venous flow was maintained in all but 4
patients (2%), who had either reversed or dual
splenic venous drainage patterns resulting in
transsplenic portosystemic shunts. Three of these
4 patients also had reversed flow in the hilar
splenic veins, whereas only 1 patient had a blood
flow pattern similar to that in our 2 patients: nor-
mal venous flow in the hilar part of the spleen but
reversed flow in the peripheral regions of the
spleen. The clinical significance of this dual flow
pattern is unclear. According to Barakat et al,5
abnormal flow patterns in intrasplenic veins may
be associated with a higher risk of esophageal
variceal bleeding. They recommended that the in-
trasplenic venous flow pattern be assessed before
surgical intervention in patients with portal hy-
pertension.
However, in contrast to the patients in Barakat

FIGURE 3. Case 2: a 63-year-old woman with myeloproliferative syndrome and splenomegaly. (Left) Color
Doppler sonogram of the spleen shows a combination of venous blood flow directed toward the hilum of the
spleen (in blue, bottom arrows) and reversed flow (in red, top arrow) in veins draining toward the periphery.
(Middle) Color Doppler sonogram shows several peripheral intrasplenic veins (V) with reversed flow (in red).
CR, cranial; S, spleen. (Right) Spectral analysis confirms the reversed venous blood flow (arrow) in 1 of the
peripheral veins.

296 JOURNAL OF CLINICAL ULTRASOUND

 INTRASPLENIC VENOUS FLOW REVERSAL
et al’s study,5 who all had liver cirrhosis, our pa-
tients had hematologic disorders that resulted in
transsplenic portosystemic shunting. In hemato-
logic diseases such as lymphoproliferative and
myeloproliferative syndromes, complications
such as splenic infarctions6 and nontraumatic in-
trasplenic bleeding due to spontaneous splenic
rupture7 are common; nontraumatic splenic pseu-
doaneurysms8 are also seen. Reversed intra-
splenic venous flow, however, is rare. One might
speculate that changes in splenic venous flow rep-
resent a potential risk factor for splenic complica-
tions.
Routine measurement of intrasplenic blood
flow in all patients with portal hypertension
should help to clarify the frequency as well as the
clinical significance of the reversal of intrasplenic
venous flow.
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VOL. 29, NO. 5, JUNE 2001
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