Seminar ( III )

Transplanted Liver
Doppler scan

Evaluation of the Hepatic Vessels in Sudanese Normal Liver

Transplants using Doppler ultrasonography
‫تقويم االوعية الدموية للكبد المزروع وسط السودانيين باستخدام الموجات فوق الصوتية‬

Seminar presented for the PhD degree requirement in Medical Ultrasound

BY: Ashraf Mustafa Mohammed Osman

supervisor: professor/ MOHAMMED AL FADIL
Co-supervisor: Dr /MONA AB SHANAB

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Ashraf Mustafa 09/11/2020 2
 Agenda to follow

Statement
Thesis
Introduction of the
overviews
problem

Case study
Methodology
objectives &
& results
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references
3
 Introduction
:

The liver is the largest internal organ in the body situated in the
right hypochondrium. Functionally, it is divided into right and left
lobes by the middle hepatic vein. The right lobe is larger and
contains
The liver
the caudate and quadrate lobes. The liver is further
subdivided into eight segments by divisions of the right, middle
and left hepatic veins. Each segment receives its own portal
pedicle, permitting individual segment resection at surgery.
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 Role of Doppler Ultrasound in Postoperative Evaluation

Vascular complications are the common causes of allograft failure after hepatic transplantation.
Early detection and treatment of vascular complications help reduce the incidence of graft failure.
Doppler ultrasound is a noninvasive test that allows real time dynamic evaluation of the allograft vasculature and is
extensively used in the postoperative evaluation of allografts.
Gray-scale ultrasound of the right upper quadrant precedes Doppler interrogation of the allograft vasculature. Along
with evaluation of the hepatic parenchyma, attention is paid to the presence of any perihepatic fluid collection.
Perihepatic fluid collections may represent postoperative hematomas, seromas or bilomas. Superinfection of any fluid
collection can cause abscess formation. Pneumobilia can be present in patients with bilioenteric anastomosis. Presence
of biliary dilation may indicate development of biliary stenosis.
Doppler
 examination of the liver transplant involves interrogation of the main
hepatic artery and its intrahepatic branches, main portal vein and its branches,
hepatic veins, and the IVC.

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 Normal liver transplant: color and spectral Doppler. Color and
spectral Doppler images of normal A,
hepatic artery; B, main portal vein; and C, right hepatic vein.
(From Crossin J, Muradali D, Wilson SR. Ultrasound of liver transplants: normal and abnormal.
Radiographics 2003;23:1093-1114.)

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 Thesis overviews
This study [ Hepatic Vessels in Sudanese Liver Transplants ] consists of
five chapters ( THE REPORT):
 Chapter one: contains introduction ,overview and objectives (general and
specific).And also it contains the statement of the problem & Reasons for
choosing this project.
 Chapter two : literature review in two parts; part one anatomy, physiology and
normal sonographic appearances of normal & transplanted livers ; and Part two
pathology of liver failure plus some surgical points.
 Chapter three : contains the materials and methods.
 Chapter four : contains the results presentation and analysis.
 Chapter five: contains the discussion, conclusion and recommendations. This plus
the bibliography & appendixes.

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 STATEMENT OF THE PROBLEM
& Reasons for choosing this project:
I. EARLY DETECTION OF HEPATIC REJECTION IS DIFFICULT.
II.NO NATIONAL FRAME PROTOCOL FOR LIVER TRANSPLANT ULTRASOUND FOLLOW UP.
III.RELATION TO CARDIAC SIGNS.
IV.HELP THE DOCTOERS AND THE PEOPLE IN THE MINISRY OF HEALTH TO CREATE A
CENTRE FOR LIVER TRANSPLANTATION IN SUDAN ( THE INFORMATION TO MAKE THE
DECISION). HELPING TO CREATE ACENTRE FOR TRANSPLANTAION AND FOLLOW UP AFTER.( clinical
Ultrasonography).
V.CAN HELP TO DETECT THE ETIOLOGICAL FACTORS AND CAUSES OF LIVER TRANSPLANT.
VI.LIVER FAILURE IS A KILLING DISEASE HOW WE CAN SOLVE THIS PROBLEM.
RELATION OF LIVER BLOOD FLOW TO HEPATIC ENCAPHALOPATHY ESPECIALLY WHEN
VII.
REJECTION OCCURS.

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 Project objectives:

1- GENERAL OBJECTIVES:
TO evaluate the hepatic vessels..

ALL IN HEALTHY AND

TRANSPLANTED LIVER.
(Normal versus transplanted).
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 2- SPECIFIC OBJECTIVES:
 TO measure the portal vein diameter (caliber) in healthy people as well as
in liver transplants.
 TO calculate the velocity of the portal vein in healthy liver as well as in
transplanted liver.
 TO find out the pulsatility index of the portal vein in transplanted liver.
 TO calculate the systolic and diastolic velocities of the hepatic artery in
liver transplant (PSV & EDV) plus the resistive index.
 TO calculate the sonic window of the hepatic artery in liver transplantation.
 TO measure the Doppler indices ( and evaluation of the waveform
character) of both the hepatic artery and the hepatic veins in the
transplanted liver.
 To measure the common bile duct diameter in the transplanted liver.
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In order to achieve all these
objectives, proper methods and tools
should be selected to pick up the
variables and to collect the data.
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Methodology & results

1-Materials:
Equipments:
* Data collection sheets. Pencil. Eraser .pen.
* Couch, pillow, bed sheet , pillow cover, cover, sterile gloves, acoustic gel.
* Two ultrasound machines of complete capabilities (ALOKA prosound SSD-
3500SX, and TOSHIBA US SYSTEM); with two probes (curvilinear = 3.5-7.0
MHz & linear = 7.5 -12 MHz).
2-Design :

the design used in this study, was the analytical case control study; the case here
is the transplanted liver vessels flow direction and velocity [45 cases, 4 of them
are of whole liver , 41 lobar transplantation) and the control was the expected
normal young ;university students; liver flow direction and velocity (300).
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Methodology & results

3-Population inclusion- exclusion

The data collected from 300 normal objects population; students of
faculty of medicine in Al Rabat University (ages between 16-22 yrs., 48
% M; 52% F); and only 45 out of only 65 patients in Sudan with
transplanted liver, 9 of them was children (ages between 1.5 - 65 yrs. ),
76 % M; 24 % F, has been tested and enter the study. Inclusion
criteria: Sudanese people that underwent liver transplantation, male or
a female, adult or a child. Exclusion criteria: very ill or rejected liver
transplantation.
4- Sample size & type:
The data of this study collected from the total of 345 objects, 300 of them
was young normal volunteers selected randomly. The other 45 objects was
those
Ashraf with liver transplantation.
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Methodology & results

5- Methods of data collection & technique:

Methods of data collection: using the data sheet to collect the data, we perform both transverse and
longitudinal ultrasound techniques plus coronal oblique; putting the transducer in four main points : 1- the
mid-line, 2- the mid clavicular line,3- the anterior and 4- the mid axillary lines all are intercostally line
that made a perpendicular imaginary line from the xiphisternum. In addition, sub costal scan is done in the
same points.

6- variables of data collection:

The data of this study collected using the following variables: the portal vein caliber, flow
direction and velocity in both normal and transplanted liver. The second variable was the liver
texture in both case and control objects as well as the hepatic artery peak systolic and end
diastolic velocities plus the resistive index in both normal livers and transplanted one.
The fifth variable was the liver size which then followed by the following variables: the
common bile duct, the splenic size and end with the hepatic veins and the inferior vena
caval spectral trace to know the waveform character.
The Doppler indices was added = RI, PI, S/D ratio, PSV, EDV, sonic window. This was done
to complete the picture of the data.
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Ashraf Mustafa
Methodology & results

7- methods of data analysis:

Using the suitable above mentioned techniques, these all variables collected to
create the data. Finally these data is tabulated, described, represented and
analyzed using SPSS version 20 ,putting in mind that the p value is 0.01 using the
chi square test as well as the t-tailed test [ p value is 0.05 , R2 < 1] to know the
significance . The results of this analysis put in a scientific frames and facts from
which the medical decision and recommendations is created in the discussion
chapter.

8- ethical approval:
Ethical approval has been granted from the hospital and the department of GIT
bleeding and liver disease. In addition, consent from the patients was signed and
oral agreement after they understand what will be done in the study. This did
not include or disclose any [ID] information concerning the patient.

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Main results :
 PV = normal native livers [hepatopetal; diameter less than 13
mm; velocity less than 20 cm/s . In transplanted livers
[hepatopetal ;diameter less than 20 mm; velocity range 20 -55
cm/s].
 HA = resistive index in both ( native & grafts) ranges between
0.55-0.75 with transplants near the upper limit.
 HVs = both are triphasic.
 CBD = less than 6 mm in native livers ; less than 4 mm in
transplants.
 The PV flow direction & velocity is the most important indicator
of healthy liver transplants.
 Liver span and texture plus splenic size and texture [ spleen
enlarged in trasnplants, the liver is normal ].
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 Example of tabulation of results

Liver variables Mean ± SD min max

Mean ± SD min max age 28.8±17.9 1.5 65
RI 0.7±0.1 0.55 0.78
Extra hepatic PV 13.62±1.3 Diameter 12.8±1.4 9 16
10 17
Velocity of PV
Velocity of PV 14.98±1.92 34.9±11.6 17 55
9.5 19 CBD_BD 3.5±1.2 2 7

Spleen length
Portal vein caliber 9.76±2.09 13.7±1.5 11 17

3.3 13.8 Liver Span 13.5±2.2 9.6 19

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 statistics
As mentioned above, the data are tabulated,
described, represented and analyzed using
SPSS version 20, putting in mind that the p
value is 0.05 using the chi square test as
well as the t-student test [ p value is 0.05 ,
R2 < 1] to know the significance. The results
of this analysis put in a scientific frames and
facts from which the medical advice and
recommendations is created.
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 Example : analysis of results

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 60

50

40
velocity cm/s

f(x) = 1.42 x + 16.83

30

20

10

0
7 8 9 10 11 12 13 14 15 16 17
Caliber of portal vein (mm)

scatter plot chart shows the velocity versus the caliber of the PV; given by the relation [y = 1.4165x +16.834].

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 Discussion ( summary)
 The result analysis of normal livers reveals; which shows the PV velocity both inside
and outside the liver plus the internal caliber; it reveals that the mean intrahepatic
portal vein velocity is between (14.98±1.92) cm/s; and the diameter range is
(9.76±2.09). In frequency distribution of the extrahepatic portal vein velocity values,
the majority is in the range (14-15 cm/s) which is equal to the half of the tested objects.
 The result analysis of the transplanted livers reveals, the portal vein in either lobar or
cadaveric (completely) whole liver transplantation is of increased velocity because of
the anastomosing connections as well as a sudden change of the caliber from the Donor
to the Recipient. Our study shows that there is a significant increase in both diameter
and velocity of the intrahepatic PV
[ the mean values are [12.8±1.4 mm & 34.9 ± 11.6 cm/s respectively], in normal livers not
more than 13 mm & 25 cm/s respectively.

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 conclusion
 Hepatic artery resistance reflects graft rejection, therefore,
prevention of thrombosis or stenosis is a must to decrease the
risk.
 The portal vein flow direction & velocity is important in
transplanted livers = nutrient perfusion to the hepatocytes.
PV relation is created [ an equation] to help quick
diagnosis of stenosis or occlusion.
 Doppler imaging is important to exclude early hepatic veins
complications.
 Hepatic Doppler should be a routine follow up for liver
transplants.
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 conclusion
At the end, the study reveals that they are
three important indicators of transplanted
liver progressing to health. These are the
portal vein [ flow velocity and direction], the
splenic volume [ span], and the HA [flow
direction and the resistive index]. All of it
normally in liver transplant start high and
decrease with time.
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Recommendations

Duplex Ultrasonography is indeed a quick, cheep, and a very beneficial tool to follow up
the healthy liver transplants as well as to detect earlier the rejection, the advice for
the people in liver transplant follow up center to put this as a routine if possible
because it is very helpful.
For the researchers, in the future to know more about the liver Doppler in relation to
the length of the vessels (this research relate only the velocity to the diameter).
Liver Doppler should be a routine investigation and follow up; all readers of this reliable
research participate to distribute these facts especially to the decision makers.
As future study, continuous researches in this subject can yield in a delivery of a hepatic
follow up center, or even a center for liver transplantation in Sudan as well as liver
researches.
These recommendations directed to the gastroenterologist in both surgical & medical
departments, to the future researchers, and to the patients with or planned for liver
transplantation.
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 Relation to previous literature

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 Coincide with previous studies and
textbooks
1- books :

Severe acute hepatic transplant rejection (left) five days

after transplant. There is a hepatopetal flow in the portal
vein and hepatic artery (arrow). Seven days after transplant
(right): There is hepatofugal flow in the portal vein.
Increased slow flow sensitivity Doppler signal explains the
lighter color blue in both arteries and veins. Pathology
demonstrated severe rejection with centrilobular necrosis
and periportal inflammation.

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 Coincide with some previous studies and
textbooks
2- previous study :

Study ( 1 ) in our report writing ,

Sonographic Evaluation of Venous Obstruction in Liver Transplants
Done by: Wui K. Chong, Jason C. Beland and Susan M. Weeks
Citation: American Journal of Roentgenology. 2007;188: W515-W521.
10.2214/AJR.06.1262.Objectives. The purpose of the study was to identify specific Doppler criteria
for portal vein and outflow vein (hepatic veins and inferior vena cava) obstruction in liver
transplants.
Results. There were 16 cases of portal vein obstruction (11 stenosis, five occlusion) and 35 cases of
outflow vein obstruction (34 stenosis, one occlusion). Mean peak anastomotic velocity in normal
portal veins was 58 cm/s, whereas mean peak anastomotic velocity in stenosed veins was 155 cm/s
(p = 0.0007).
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 Coincide with previous studies and text
books
Postoperative Imaging in Liver Transplantation .
In this article, the authors depict the spectrum of findings seen at
ultrasonography (US), CT, MR imaging, cholangiography,
angiography, and scintigraphy in patients with post-transplantation
complications involving the hepatic artery, portal vein, IVC, and
hepatic vein, as well as biliary complications (biliary obstruction,
choledocholithiasis, bile duct stricture, bile duct leak) and other
complications. In addition, they provide a brief overview of
percutaneous interventional procedures that can be used in this
setting.

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 Coincide with previous studies and text
books
Postoperative Imaging in Liver Transplantation .

General discussion & conclusion. Multiple complications can be observed after liver
US is the main initial imaging modality for the
transplantation.
evaluation of liver transplant dysfunction due to its easy availability
and high sensitivity in the detection of vascular as well as biliary
complications. CT is complementary to US and is often used as a problem-solving
modality, being reserved for second-line investigation when US findings are indeterminate or
inconclusive. Cholescintigraphy remains the most sensitive noninvasive modality for the
detection of bile leak. MR cholangiopancreatography is very useful in the evaluation of bile
duct dilatation and obstruction. Imaging is useful for the detection of early and late
complications, as well as for long-term follow-up to assess transplant viability. An
understanding of potential posttransplantation complications and of the strengths and
weaknesses of each imaging modality will aid in early diagnosis and promote timely therapy.
Values :
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 The appendix

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‫لا‪AA‬بحث‪Some important names‬‬ ‫مع‪A‬رفة ا‪A‬ماجد أ‪A‬ثناء‬

‫‪.‬ب‪/‬محمد لا‪AA‬فاضل ‪1-‬‬

‫‪.‬دكتورة منى ا‪A‬بو ش‪A‬نب‪2-‬‬
‫‪ .‬دكتور عبد لا‪AA‬منعم‪ A‬أ‪A‬خصائي لا‪AA‬جرا‪A‬حة و رئيس ج‪A‬معية لا‪AA‬كبد لا‪AA‬سودا‪A‬نية ‪3-‬‬
‫‪.‬دكتور عبد ال‪A‬رحيم‪ A‬دبورة أ‪A‬خصائي لا‪AA‬جرا‪A‬حة ونائبرئيس ج‪A‬معية لا‪AA‬كبد ‪4-‬‬
‫‪.‬دكتور ( أ‪/‬م ) أ‪A‬حمد مصطفى أ‪A‬بو ك‪A‬نة عميد ك‪A‬لية علوم‪ A‬ا‪A‬ألشع‪A‬ة (ج لا‪AA‬سودا‪A‬ن) ‪5-‬‬
‫‪.‬ب‪ /‬عبد لا‪AA‬منعم‪ A‬ادم‪5- A‬‬
‫‪.‬دكتور ب‪AA‬ابكر عبد ال‪A‬وهاب‪6-‬‬
‫‪.‬دكتورة أ‪A‬سماء ا‪A‬برا‪A‬هيم‪7- A‬‬
‫ب‪ /‬ك‪A‬ارولينإدوارد ‪8-‬‬
‫‪.‬ب ‪ /‬لا‪AA‬صاف‪A‬ي أ‪A‬حمد عبد هللا‪9- AA‬‬
‫‪Ashraf Mustafa‬‬ ‫‪.‬دكتور لا‪AA‬سر علي س‪A‬عيد ‪10-‬‬
‫‪09/11/2020‬‬ ‫‪31‬‬
 ‫المريض ‪:‬مهندس‪ /‬نادر مصطفى احد الزارعين والمؤسسين لجمعية زارعي الكبد‬
‫السودانية‬

‫‪Ashraf Mustafa‬‬ ‫‪09/11/2020‬‬ ‫‪32‬‬

 Left : Portal vein waveform ; right: HA + SA = seagull sign

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 Normal portal vein; color flow &
spectral Doppler

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 Normal : Portal vein ,CBD & HVs

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 Sudanese Child underwent liver transplantation
her name :Ensaf omer

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 Unlike renal transplantation , the liver should be removed
first.

Some images of Sudanese Removed livers

before transplantations

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 Us results of Zain Al abdeen Mohammed post-
transplantation in India , age : 1yr 3month

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 Short Case study

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 Us results ,date :18/11/2017;one of the research objects
in Sahiroon specialized hospitals

 Name : zain al abdeen age : 2 yrs

 Tranplant type : lobar.
 Liver span = 96.5 mm.
 PV caliber = 12.1 cm.
 PV Velocity = 17.9 cm/s.
 PV : monophasic + Hepatopetal flow.
 HA : biphasic + Hepatopetal flow + RI = 0.7.
 HVs: triphasic + Hepatofugal flow.
 CBD = 4.0 mm.
 Spleen length = 11.8 cm.
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End
 The

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 ‫شكرا لالستماع و المتابعة‬

‫‪Ashraf Mustafa‬‬ ‫‪09/11/2020‬‬ ‫‪43‬‬