British Journal of Radiology (2005) 78, 242-244
© 2005 British Institute of Radiology
doi: 10.1259/bjr/15227254
Abnormal hepatic vein Doppler waveform in patients without liver disease
J F Pedersen, MD, PhD1,
A Z Dakhil, MD1,
D B Jensen, MD1,
B Søndergaard, MD2 and
P Bytzer, MD, PhD2
Departments of 1 Radiology and 2 Medical Gastroenterology, Glostrup University Hospital, Denmark
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Abstract
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In patients with liver cirrhosis Doppler ultrasound often detects absence of the retrograde (hepatopetal) flow phase in the hepatic vein, suggestive of an increased stiffness of the liver parenchyma around the vein. This is rarely or never reported in healthy control persons. We examined the frequency of absent retrograde flow in a consecutive series of 139 patients referred for abdominal ultrasound. We used state-of-the-art ultrasound scanners, and placed the Doppler gate so that in non-forced end-expiration it would sample the right hepatic vein 4–6 cm from the vena cava. There was no association between the hepatic vein flow pattern and age, sex or body mass index. 43 of 139 studied patients showed absent retrograde flow. Review of the case records revealed liver disease in 26 patients and no sign of liver disease in 17 patients. We suggest that absent retrograde flow in the hepatic veins may be seen not only in patients with overt liver disease but also in apparently liver-healthy patients.
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Introduction
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The hepatic vein Doppler waveform normally shows a triphasic pattern with two hepatofugal phases related to atrial and ventricular diastole, and a short phase of retrograde (hepatopetal) flow caused by the pressure increase in the right atrium at atrial systole [1]. Absence of this retrograde flow phase is seen in about half of patients with cirrhosis, and is believed to reflect an increased stiffness of the liver parenchyma around the liver veins [1, 2]. This pattern may also be seen in fibrosis, elevated aminotransferases, fatty liver, chronic hepatitis C and in metastatic liver disease [2–6]. However, we have seen an abnormal curve on occasion in patients without known liver disease and without any other ultrasound indication of liver disease.
It is not clear what action should be taken when an "abnormal" hepatic vein flow curve is unexpectedly revealed. In this study we therefore examine the frequency of abnormal Doppler curves in a sample of our patient population, and explore the possible explanations of the abnormal curves in apparently liver-healthy individuals.
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Material and methods
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During a 2 month period we registered all patients >18 years old without cardiac arrhythmia who had an abdominal ultrasound study, including the liver, performed by one of the authors (JFP, DBJ, AD). Only patients referred from a department in our hospital were included, to ensure that a case record would be available. Whenever the Doppler waveform showed absence of the retrograde flow phase the two remaining authors were informed (PB, BS). They would evaluate the case notes and decide whether there was evidence of liver disease.
The ultrasound examinations were performed with state-of-the art ultrasound units with convex abdominal probes (Elegra and Antares; Siemens, Issaquah, WA; HDI 5000 sonoCT; Philips Medical Systems, Bothell, WA). The Doppler gate was placed so that in non-forced end-expiration it would sample the right hepatic vein 4–6 cm from the vena cava. The Doppler tracing was documented on video print. The curve pattern was categorized into: triphasic; biphasic, without a retrograde flow phase; flat, monophasic (<10% fluctuation) [1] (Figure 1
). Triphasic curves were considered normal, biphasic and monophasic curves were considered abnormal. The patients body mass index (BMI) was calculated according to the formula BMI=weight/height2 (kg m–2).
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Figure 1. Hepatic vein Doppler waveforms. From top to bottom: normal triphasic waveform with two hepatofugal and one hepatopetal (retrograde) velocity peaks; biphasic waveform without retrograde flow phase; flat (monophasic) waveform.
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For the statistical analysis of quantitative data we used the two-sample rank sum test (Mann-Whitney) and for qualitative data we used Fisher's exact test. p<0.05 was considered significant.
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Results
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A total of 139 patients entered the study, 67 females and 72 males, mean age 56 years (range 19–91 years). The majority (84%) were referred from the surgical and medical gastroenterology departments. 96 patients (69%) had normal triphasic Doppler waveforms of the hepatic veins. There was no significant difference between patients with normal and with abnormal Doppler tracings concerning mean age, sex ratio and BMI (Table 1), and the fraction of abnormal curves was not higher in patients from the gastroenterology departments than in the remainder, 31% vs 32%.
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Table 1. Comparison of 96 patients with a normal (triphasic) hepatic vein Doppler curve and 43 patients with abnormal (biphasic and monophasic) curves. Patients with abnormal curves are divided according to evidence of liver disease
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Among the 43 patients with abnormal tracings the ultrasound study suggested liver disease in 23. Review of the case notes revealed liver disease in 20 patients, whereas three patients with ultrasound signs of steatosis and one with MR-verified hepatic haemangiomata lacked biochemical signs of liver disease. Furthermore, two patients without ultrasound signs of liver disease were diagnosed with alcohol related liver disease and CMV hepatitis, respectively. Thus, hepatic disease was diagnosed in 26 patients with abnormal liver vein tracings (cirrhosis, 3; alcohol related liver disease, 14; non-alcoholic steatohepatitis, 3; hepatitis, 1; metastases, 4; haemangiomata, 1). No liver disease could be suggested in 17 patients – ultrasound showed gall bladder calculi in three of them, 1–3 1 cm hepatic cysts in two (considered trivial), and normal liver and gallbladder in 12 patients. Among the patients with abnormal Doppler curves there was no statistical difference between patients with and without liver disease concerning age, sex ratio and BMI (Table 1
).
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Discussion
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Assessment of the hepatic vein Doppler waveform extends the examination time only marginally. Furthermore, application of colour Doppler imaging will make it extremely fast and simple to ensure that there is a retrograde flow phase in the hepatic veins. A short flash of colour shift in the hepatic veins will prove flow reversal, so that recording of a spectral curve can be reserved for examinations with no colour shift.
We found no association between the hepatic vein flow pattern and age, sex or BMI, leaving the relation between waveform and hepatic pathology to be examined. In their first report on Doppler waveforms of the hepatic veins Bolondi and co-workers observed no abnormal curves in 65 healthy volunteers [1]. Similarly, in subsequent studies no abnormal tracings were obtained from 50 [3], 36 [6], 30 [7] and 25 [8] healthy volunteers, and a recent study reported normal liver vein Doppler curves in 48 of 49 healthy volunteers [5]. Taken together these studies suggest that healthy individuals almost always have normal triphasic liver vein Doppler curves. It therefore appears likely that an abnormal Doppler tracing detected in an apparently liver-healthy patient may still indicate some degree of liver abnormality.
Our study deals with a group of 139 adult patients referred for an abdominal ultrasound examination. The patients were unselected, but predominantly referred from the gastroenterology departments. In 43 patients we found an abnormal hepatic vein Doppler curve, which in 26 of them could be explained by liver disease. In the remaining 17 patients (12% of the examinations) the case records gave no indication of liver disease.
The study thus confirms both that abnormal hepatic vein flow curves may be seen in a spectrum of hepatic disorders, and also, more interestingly, that an abnormal hepatic vein waveform is quite common in apparently liver healthy patients, which to our knowledge has not been reported by others. We suggest that an abnormal hepatic vein Doppler curve, believed to reflect an increased stiffness of the liver parenchyma around the hepatic veins, may be a non-specific indicator of liver abnormality, also in individuals with normal liver biochemistry.
Our study was not designed to answer the natural next question, if and to which extent further diagnostic work-up should be considered, but with the present knowledge we find it justified to ignore an abnormal hepatic vein Doppler curve in a patient with no clinical sign of liver disease. We plan further studies to reveal whether an abnormal hepatic vein waveform may be transient, or whether in some patients it may mark a step towards future development of overt liver disease.
Received for publication July 23, 2004.
Revision received October 1, 2004.
Accepted for publication November 15, 2004.
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References
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- Bolondi L, Bassi SL, Gaiani S, et al. Liver cirrhosis: changes of Doppler waveform of hepatic veins. Radiology 1991;178:513–6.[Abstract/Free Full Text]
- Colli A, Fraquelli M, Andreoletti M, Marino B, Zuccoli E, Conte D. Severe liver fibrosis or cirrhosis: Accuracy of US for detection - analysis of 300 cases. Radiology 2003;227:89–94.[Abstract/Free Full Text]
- Colli A, Cocciolo M, Riva C, et al. Abnormalities of Doppler waveform of the hepatic veins in patients with chronic liver disease: correlation with histologic findings. AJR Am J Roentgenol 1994;162:833–7.[Abstract/Free Full Text]
- Dietrich C, Lee J-H, Gottschalk R, et al. Hepatic and portal vein flow pattern in correlation with intrahepatic fat deposition and liver histology in patients with chronic hepatitis C. AJR Am J Roentgenol 1998;171:437–43.[Abstract/Free Full Text]
- O'Donohue J, Ng C, Catnach S, Farrant P, Williams R. Diagnostic value of Doppler assessment of the hepatic and portal vessels and ultrasound of the spleen in liver disease. Eur J Gastroenterol Hepatol 2004;16:147–55.[CrossRef][Medline]
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- Arda K, Ofelli M, Calikoglu U, Olcer T, Cumhur T. Hepatic vein Doppler waveform changes in early stage (Child-Pugh A) chronic parenchymal liver disease. J Clin Ultrasound 1997;25:15–9.[CrossRef][Medline]
- Teichgräber UKM, Gebel M, Benter T, Manns MP. Characterisation of hepatic venous flow via duplex Doppler sonography. Ultraschall Med 1997;18:267–71.[Medline]
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Abstract
Introduction
