Abdominal Doppler 2013

Indicn. Of Abdominal Vas.
Studies
1.Liver Disorders: Cirrhosis, Diffuse malig.

infiltern.

2.Portal Hypertension(e.g.:Hepatic disorders,

Portal Vein thrombosis)

3.Hypertension due to renal disorders
Dr.Randhawa's Institute Of Ultrasound Training,New Delhi
4.Abdominal
aortic aneurysm Leriches syndr.

(Occlusion of Aorta at level of iliac bifurcation)

5.IVC outflow obstrucn. e.g :IVC thrombosis.
Cardiac ds: CHF ,Tricuspid regurgn.
Dr.Randhawa's Institute Of Ultrasound

Training,New Delhi
Identification of Vessels
Probe placed transversely just beneath
xiphoid. Aorta seen in T.S. & slight superior
angulation will show Celiac trunk arising from
Aorta and branching into common hepatic A.
(Which moves to rt.) and splenic artery (which
moves to lt.)

Training,New Delhi
Sup. Mesentric Artery
Identification:Slight tilting inferiorly from

celiac artery will show the SMA. Next ,probe
is moved longitudinally to see the SMA as
it moves almost parallel to aorta

Both celiac & SMA art. arise from ant. part of

aorta & at times may have common origin.

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SMA & AORTA

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Probe kept transversely with very light pressure

to locate left renal vein as it passes b/w aorta&
SMA .

From this position probe angulation done slight

superiorly & towards rt. to locate rt. Renal art.
Probe further rotated to trace the rt. Renal art.
as it passes post. to IVC.

Lt.Renal vein again brought into view in T.S.

& slight probe tilt to lt .will show the lt.renal artery.
Training,New Delhi
IDENTIFICATION OF VENOUS SYS.

IVC
Runs parallel to aorta on rt. Side

Superiorly
it recieves hepatic veins which have

hepatofugal flow

Near
umbilicus IVC divides into two common

iliac veins

Lt
.Common iliac v passes behind Rt. Common

iliac a.(Thus thrombosis of lt. iv more common
due to compression )
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Spectral Doppler Of IVC
IVC near heart shows waveform

having cardiac influence

Spectrum is complex with double

peak which may be followed by flow
reversal due to atrial systole.

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Sampling of IVC near Rt.atrium
Slight flow reversal due to atrial systole

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Spectral(Contd.)
IVC in mid & lower part has typical

venous waveform with phasic
variation due to resp.

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IVC can also be distended by lifting

the legs or by squeezing the thigh
muscles

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Cardiac
pathology effecting IVC flow
e.g. : CHF ,Tricuspid regurgitation lead

to decreased flow towards the heart &
there may be even flow reversal during
systole.

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IVC Obstruction due to thrombosis

IVC
may appear distended
Non
compressible
Thrombus
may be seen
Flow
may be absent or monophasic

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Absence of response to Valsalva

Normal response to valsalva----During

Valsalva Intrathoracic pressure
increases thus IVC distends. On
release of pressure IVC collapses due
to flow towards heart.

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HEPATIC VEINS
Three hepatic veins having flow

away from liver & towards IVC.

Waveform very much similar to IVC

because of cardiac influence.

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With
thrombosis:
Veins may distend

Normal
pulsatile waveform may be

replaced by monophasic flow or there
may be no flow .

Course
may be atypical with

thickening of venous walls.
Training,New Delhi
FLOW PATTERN OF HEPATIC VEIN
Antegrade flow (i.e. towards the rt.atrium) has two

components a larger systolic wave and a slightly
smaller diastolic wave.

Between these two antegrade flow patterns, at end

systole a small retrograde flow pattern may be seen.

Another retrograde flow pattern is seen during atrial

systole.

Training,New Delhi
Hepatic vein flow shows increased flow velocity

(systolic component) during inspiration and decreased
velocity during expiration.

Hepatic vein flow velocity will change with change of
Rt. atrial pressure. Diseases causing increased Rt.
Atrial pressure e.g: TR will reduce or replace antegrade
systolic flow with retrograde wave.

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Pulmonary hypertension will cause

prominent flow reversal during
atrial systole.

In atrial fibrillation velocity of

antegrade flow in systole and
retrograde flow of atrial systole is
reduced.

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Hepatic vein
Waveform very similar to that of IVC near heart

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Hepatic vein

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Monophasic due to cirrhosis

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Blunted due to fatty liver

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Blunted due to valsalva

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Variations of normal flow pattern

Alhough all 3 hepatic veins have similar flow pattern
in normal case but variations do occur.

Variations can be due to the phase in which
sampling is taken, inspiration,expiration or valsalva.

It can also be due to any focal fat infiltration or
malignant mass.

Training,New Delhi
Top hepatic vein shows dampaned pattern

Middle one shows nearly monophasic
Bottom one is normal triphasic

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Severe TR will cause reduction in S
wave velocity and later flow in systole

will stop

Much later S wave will reverse.

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TR-- S wave smaller than A

Grade 1
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S wave is absent
TR grade 2

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S wave reversal
TR grade 3

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Biphasic wave-- when A , S and V wave are all
retrograde , they may fuse and form a single wave

with flow in one direction.

D wave comprises flow in other direction leading to
biphasic wave.

Usually seen when significant TR is seen with rt
sided failure.

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Biphasic

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Biphasic

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Hepatic veinAbn. waveform
Spectral Doppler shows lack of normal

pulsatility due to partial obstruction
distal to this area.
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PORTAL VENOUS SYSTEM
Portal vein formed by confluence

of SMV and splenic v
Flow in portal v is
hepatopetal(towards the liver)
Hepatic a.runs alongside portal v.

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SCANNING
TECH.
3-3.5 mhz probe used

Lt.Portal vein scanned thru sub xiphoid

region as a smaller Doppler angle is obtd by
doing so.
Rt Portal vein scanned in its horizontal portion
thru intercostal spaces in lateral direction

App. Doppler angle essential in scanning rt.

Portal vein because at angles >60
No flow may be seen.
Training,New Delhi
PORTAL VEIN
Has a undulating waveform due to
effect of abdominal resp pressure.
With exp the flow increases & with
insp. It decreases.
On holding breath in expiration the
undulations decrease & thus this
manoever helps to see the
direction of the flow.

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Waveform---Portal Vein

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Portal vein Normal velocities

The maximum portal vein velocity varies from 15-30
cm/s.

The minimum velocity varies from 5-20 cm/s

The difference between maximum and minimum
velocity ranges from 5-15 cm/s. Difference will
increase with increase pulsatility.

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Reduced velocity,Increased pulsatility

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PATHOLOGY
Hepatic disorders or Portal vein thrombosis

Foll. Changes may be seen:

1.Flow may be away from liver

2.Flow may be monophasic having lost the resp.
variation.

3.It may be triphasic at times eg. CHF,TR

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4.Flow may be variable (sometimes towards &
sometimes away from liver)

5.No flow at times

6.With portal hypertension collaterals may be
seen

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Features of portal hypertension

Dilated Portal, splenic& sup.mesentric vein.

Portal vein diam. >13mm

Splenomegaly

Ascites

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Opening
of Collaterals

Dilated
hepatic & splenic arteries

Liver
size may be normal,decreased or

increased

Patent
paraumblical vein

Training,New Delhi
Determination of direction of blood flow in portal

vein helps in planning surgical tt options
Hepatofugal flow----portocaval or mesocaval shunt
Hepatopedal-----splenorenal shunt

Measurement of portal vein vel. Has prognostic

value in pts with portal hypertension
Low flow vel.---advanced disease.

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Portal vein----Abn. waveform
Waveform has marked variations of flow with

reversal(biphasic) due to congestive liver(a
sequel of CHF / TR resulting in increased res.
to flow)
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Prestenotic velocity is usually normal with

normal resistive pattern of the waveform.

However in marked stenosis (>50%) the res may

Lower when collaterals have dev.

In the absence of collaterals vascular res.

may in fact increase

In complete stenosis prestenotic vel may be very

low with little or no diastolic flow.(High res. Pattern)
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Portal vein stenosis
(A)At the site of stenosis (B)Distal to stenosis vel. is

lower & turbulence is seen
Peak vel. is very high
by flow above & below the
baseline
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Sites
for
collaterals
In the umbilical area supf. beneath the skin

At the splenic hilum

Along lesser sac

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Collaterals in S/C tissue(umb. Reg.)

----7.5 mhz

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Gastric varices----lesser sac

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Splenic varices----
Spectral waveform displayed above & below the baseline due to
turbulence seen in variceal flow
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CAVERNOUS TRANSFORMN- PORT. V

Seen in chronic venous obstruc.(more than 1 year).

Hence likely to be seen in pts with benign disease

Portal venous landmarks not visualized in their
normal positions.

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Extrahepatic
portal vein not seen

Fibrosis
produces high level echoes

Periportal
venous collaterals seen in the

region of porta hepatis as multiple tubular
struc having flow pattern similar to portal
vein.

Hepatic
artery shows increased size & flow.

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Caput medusae -- engorged veins of

abd wall

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SEV. SUP EPIGASTRIC VEIN
IEV INF EPIGASTRIC VEIN
SRV. SUP RECTAL VEIN
IRV. INF RECTAL VEIN
IMV. INF MESENTERIC VEIN
LGV. LT GASTRIC VEIN
SV. SPLENIC VEIN
PV. PORTAL VEIN
PUV. PARAUMBILICAL VEIN

Training,New Delhi
Dark tubular area within falciform ligament is seen in
healthy persons without any flow on color doppler.

This is normal.
When flow is seen it is enlarged paraumbilical vein
seen in cases of portal hypertension.

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Patent para-umbilical vein

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Paraumbilical vein may drain into deeper systemic
veins like axillary and subclavian veins of upper

extremity via vascular connections like lateral
thoracic veins.

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Inferiorly paraumbilical vein may drain via superficial
vein , superficial epigastric vein , into femoral vein.

Via deeper inf. epigastric vein it may drain into
external iliac vein.

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When paraumbilical vein drains via superficial veins
like lateral thoracic veins or sup. epigastric vein,

caput medusae may be seen.

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Reason for preferential drainage through superficial
or deep route is unknown.

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Paraumbilical vein may prolapse into the
subcutaneous fat of abdominal wall causing

herniation.

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Hernia of paraumbilical v prolapsing

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Helical flow is spiral flow where there is

1---alternating red and blue color
Or
2-- both red and blue color in same part.

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Normal flow

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Normal laminar flow

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Spiral flow

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Spiral flow

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Normal persons, may be present but rare.

Normally after liver transplant and TIPS
insertion---- but it is transient.

If seen long after liver transplant and along with
it , portal v velocity is high, then it indicates
portal v stenosis.
Presence may suggest significant liver disease
with portosystemic shunts
Neoplastic invasion or displacement of portal
vein
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Helical flow

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ABDOMINAL AORTA
Flow above the celiac axis is of low res.

biphasic type since celiac artery & sup
mesentric art. supply visceral organs which
have low res.

Flow distal to SMA is triphasic since supplies

to pelvis & lower extremities (high res. Areas)

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WaveformLower Aorta
(Higher Res.)

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Waveform---Upper Aorta

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COELIAC
ARTERY
IT HAS COMMON HEPATIC A. AND SPLENIC A. AS

MAIN BR.

THEY SUPPLY LIVER AND SPLEEN RESP. WHICH
ARE LOW RES. ORGANS

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THUS FLOW IN THESE VS. IS LOW RES.(LIKE

INTERNAL CAROTID)

FORWARD FLOW IS SEEN BOTH PRE- MEAL AND
POST MEAL

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Coeliac Artery(low res.)

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Coeliac artery---branches

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COELIAC ARTERY-Branches

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SUPERIOR MESENTERIC A
IT
SUPPLIES INTESTINE ,STOMACH AND

COLON WHICH ARE OF HIGHER RES.

THUS
FLOW IN SMA UNLIKE COELIAC AND

ITS BR. IS OF HIGH RES(eg.ext.carotid)

HOWEVER
AFTER MEAL RES. DECREASES

AND FLOW IS CONSTANTLY FORWARD

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WaveformSMA(High res.)

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Blood flow change with meal
Before meal SMA shows high res. Pattern

diastolic flow is very low.

After meal res. to flow decreases thus diastolic

flow increases

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Preprandial flow
Post Prandial flow

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Bowel ischemia
Clinically presents as post meal pain & unexp.

wt. loss.

Stenosis of SMA may be the reason behind

As usual stenotic area causes inc of PSV
and post stenotic turbulence

Hemodynimacally stenosis usually has PSV

greater than 275 cm /s in SMA and greater
than 200 cm/s in Coeliac a and its br
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THROMBUS
Acute-(less
than 10 days ) has foll. Features
1-hypoechoic

2-smooth
margins

3-poorly
attached

4-vein
is dilated

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CHRONIC THROMBUS
Features

1-hyperechoic

2-irregular borders

3-well attached

4-contracted vein

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VEINS
TECHNIQUE OF PROPER VISUALIZATION OF

ABDOMINAL VEINS

----ELEVATE PT. HEAD AND KEEP FEET BELOW
HEART LEVEL

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THROMBOSIS
Flow void in color duplex image

Acute venous thrombosis(less than 10 days) vein
distended to twice the size of acc. Artery

Inability to compress the venous lumen
completely

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Valsalva increases intra-abd pressure and thus

post valsalva flow in lower limb increases

Upper ext. Flow inc. On inspiration

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RENAL VEIN
NORMAL
WAVEFORM SHOWS RESPIRATORY

PHASCITY TYPICAL OF PERIPHERAL VEIN

OBSTRUCTED VEIN MAY SHOW
1 NON PHASIC FLOW
2 DILATION OF VEIN
3ECHOGENIC THROMBUS IN LUMEN
4 POOR OR NO RESPONSE TO VALSALVA

Training,New Delhi
Visualization of renal vein is important in
suspected cases of renal carcinoma to see for

any invasion.

Training,New Delhi
Role of color doppler in liver pathologies

Hepatocellular ca, approx 80% show
vascularity.
This feature may help in differentiating
nodules of cirrhosis, which are
avascular from malignant nodules of
hepatocellular ca.

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Metastases are poorly vascular
and only 30% show flow.

Hemangiomas also are similar and
only 30% are vascular.

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Hepatocellular CA

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Focal nodular hyperplasia has flow in
form of radiating pattern or multiple

tubular strands.

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A-Gray scale image shows a subtle

isoechoic mass
B-Doppler shows star like arterial
pattern suggesting FNH

C-Lesion appearing like focal sparing in
fatty liver
D-Doppler shows hypervascular mass
with star like appearance.Classic
finding of FNH

E-Subtle mass in rt.lobe of liver
F-Doppler shows it to be hypervascular
with vascular pattern typical of FNH

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Spared area of liver may be differentiated from
any mass by the fact that normal hepatic vessels

are seen to run through spared area.

Mass will displace normal vessels.

Neovascularity may however be seen in mass if it
is vascular.

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Focal Spared Area

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Budd Chiari Syndrome

Color Doppler may show areas of absence of
color flow in hepatic veins.

Collaterals may be seen within the liver.

Spectral doppler of any flow in hepatic vein may
show dampening.

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IVC Thrombus

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Dampened waveform in hepatic vein

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IVC waveform proximal to thrombus

showing dampening

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Increased pulsatility of portal vein

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Reduced velocity

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Intra hepatic collaterals

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Pseudoaneurysm with spectrum

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Pseudoaneurysm

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Appendicitis

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Volvulus

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Intrastenotic
PW Doppler image of the right ICA shows spectral

broadening (turbulence) with an elevated PSV. These results
may be due to a high degree of stenosis immediately
proximal to the point of sampling; therefore, further
investigation with another imaging modality is required.
Training,New Delhi
Post stenotic
PW Doppler image of the proximal right ICA shows a tardusparvus waveform(a prolonged systolic acceleration time
with low PSV) A severe proximal stenosis behind the
shadowing plaque is suspected; therefore, evaluation with
another imaging modality is required.
Training,New Delhi
E-FAR DISTAL THE VELOCITIES ARE LOWER

AND WAVES ARE SPACED FAR APART

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Abdominal Doppler 2013

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Indicn. Of Abdominal Vas.

1.Liver Disorders: Cirrhosis, Diffuse malig.

2.Portal Hypertension(e.g.:Hepatic disorders,

3.Hypertension due to renal disorders

Dr.Randhawa's Institute Of Ultrasound Training,New Delhi

aortic aneurysm Leriches syndr.

Dr.Randhawa's Institute Of Ultrasound

Dr.Randhawa's Institute Of Ultrasound

Sup. Mesentric Artery

Identification:Slight tilting inferiorly from

Both celiac & SMA art. arise from ant. part of

Dr.Randhawa's Institute Of Ultrasound

SMA & AORTA

Dr.Randhawa's Institute Of Ultrasound

Probe kept transversely with very light pressure

From this position probe angulation done slight

Lt.Renal vein again brought into view in T.S.

IDENTIFICATION OF VENOUS SYS.

Runs parallel to aorta on rt. Side

it recieves hepatic veins which have

umbilicus IVC divides into two common

.Common iliac v passes behind Rt. Common

Spectral Doppler Of IVC

IVC near heart shows waveform

Spectrum is complex with double

Dr.Randhawa's Institute Of Ultrasound

Sampling of IVC near Rt.atrium

Slight flow reversal due to atrial systole

IVC in mid & lower part has typical

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IVC can also be distended by lifting

Dr.Randhawa's Institute Of Ultrasound

e.g. : CHF ,Tricuspid regurgitation lead

Dr.Randhawa's Institute Of Ultrasound

IVC Obstruction due to thrombosis

may appear distended

may be absent or monophasic

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Absence of response to Valsalva

Normal response to valsalva----During

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Three hepatic veins having flow

Waveform very much similar to IVC

Dr.Randhawa's Institute Of Ultrasound

Veins may distend

pulsatile waveform may be

may be atypical with

FLOW PATTERN OF HEPATIC VEIN

Antegrade flow (i.e. towards the rt.atrium) has two

Between these two antegrade flow patterns, at end

Another retrograde flow pattern is seen during atrial

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Hepatic vein flow shows increased flow velocity

Dr.Randhawa's Institute Of Ultrasound

Pulmonary hypertension will cause

In atrial fibrillation velocity of

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Waveform very similar to that of IVC near heart

Dr.Randhawa's Institute Of Ultrasound

Monophasic due to cirrhosis

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Blunted due to fatty liver

Dr.Randhawa's Institute Of Ultrasound

Blunted due to valsalva