Imaging

Portal Vein Thrombosis

Preliminary Diagnosis: Portal Vein Thrombosis

I. What imaging technique is first-line for this diagnosis?

Gray scale, Color Doppler, and spectral waveform analysis of the portal veins.

II. Describe the advantages and disadvantages of this technique for diagnosing portal vein thrombosis.

Advantages

  • Relatively quick and highly portable imaging modality.

  • Does not expose patients to ionizing radiation.

  • Offers exquisite visualization of the hepatic vasculature, including directionality of flow and velocity.

  • May help guide percutaneous intervention, treatment, and therapy.

Disadvantages

  • Offers less visualization and evaluation of the surrounding soft tissues, osseous structures, and vascular structures than other imaging modalities.

III. What are the contraindications for the first-line imaging technique?

No specific contraindications to ultrasound exist.

IV. What alternative imaging techniques are available?

  • Triple phase CT imaging with contrast.

  • Triple phase MR imaging with contrast.

  • Catheter angiography.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosing portal vein thrombosis.

Triple phase CT imaging with contrast

Advantages

  • Highly sensitive and specific in detecting and detailing portal venous thrombosis and highly adept in detecting the extent of the thrombus.

  • May help guide percutaneous treatment and therapy.

  • Highly sensitive and specific in evaluating the surrounding soft tissues, osseous structures, and vasculature.

  • Highly adept in evaluating for any secondary complications.

Disadvantages

  • Exposes patients to ionizing radiation.

  • Less portable compared to sonographic imaging.

Triple phase MR imaging with contrast

Advantages

  • Offers exquisite visualization of the surrounding soft tissues.

  • Does not expose patients to ionizing radiation.

Disadvantages

  • Less adept in directing percutaneous treatment and therapy.

  • MR imaging with contrast is less specific in characterizing the vasculature.

  • Less specific in characterizing the degree of thrombosis and occlusion compared to sonographic imaging.

  • May be subject to motion and susceptibility weighted artifact, degrading image quality.

  • Gadolinium based contrast is contraindicated in patients with a GFR < 30.

  • Expensive.

  • Time consuming.

Catheter angiography

Advantages

  • Gold standard for diagnosing and treating portal venous thrombus.

  • Highly specific in detecting the degree of stenosis due to clot burden by measuring pressure gradients.

Disadvantages

  • Exposes patients to ionizing radiation.

  • Invasive procedure and exposes patients to greater morbidity and mortality.

  • Highly operator dependent.

VI. What are the contraindications for the alternative imaging techniques?

Triple phase CT imaging with contrast

May be contraindicated in pregnant patients.

Triple phase MR imaging with contrast

May be contraindicated in patients with non-MR compatible hardware.

Catheter angiography

May be contraindicated in patients in a severe hypocoaguable state.

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