Portal Vein Pulsatility

The normal flow in the portal venous system is typically continuously hepatopetal, with minimal if any pulsatility in rhythm with the cardiac cycle. Marked portal venous pulsatility can be classified as continuous pulsatile or reversed pulsatile flow.

The continuous pulsatile pattern is continuously hepatopetal, but with marked pulsatility. This pattern can be seen in patients with congestive heart failure, but can also be seen as a normal finding in thin subjects, where there is an inverse correlation of pulsatility to body mass.

The second pattern, reversed pulsatile flow is characterized by marked pulsatility and reversal of flow direction related to the cardiac cycle. There is a strong correlation of reversed pulsatile flow to high (> 20 mmHg) right atrial pressures in patients with chronic heart failure. However, reversed pulsatile flow can also be seen with tricuspid insufficiency, liver disease (cirrhosis, Budd–Chiari syndrome, hepatic outflow obstruction (constrictive pericarditis, mediastinal hematoma, pericardial mass or effusion), and shunts (portal vein–hepatic vein fistula, portocaval shunt). High abdominal pressures during deep inspiration can also cause transient reversal of flow. This is more commonly seen in patients with severe right heart failure or liver disease, but can also be seen in patients without these conditions.

Therefore, pulsatile portal venous flow by itself should not be construed as a sign of cardiac abnormality, especially if there is no reversal of the portal venous flow. The image above, however, shows a reversed pulsatile flow pattern and is from a patient with congestive heart failure.

Special thanks to Dr. Hansel Otero for the case.

References

• Gallix BP, Taourel P, Dauzat M, Bruel JM, Lafortune M. Flow pulsatility in the portal venous system: a study of Doppler sonography in healthy adults. AJR Am J Roentgenol. 1997 Jul;169(1):141-4.
• Görg C, Riera-Knorrenschild J, Dietrich J. Pictorial review: Colour Doppler ultrasound flow patterns in the portal venous system. Br J Radiol. 2002 Nov;75(899):919-29.
• Görg C, Wollenberg B, Beyer J. Reversed portal vein pulsatility on Doppler ultrasound secondary to an iatrogenic mediastinal haematoma. Br J Radiol. 2001 Oct;74(886):962-4.