Full Description
The liver blood flow disorders are usually described under the term 'portal hypertension', which is a well known syndrome since it has been widely studied for years from a clinical, radiological and therapeutic point of view. In fact, portal hypertension is only the result of an obstacle to the portal flow, the clinical manifestations of which often occur at a late stage of the disease: bleeding esophageal varices, splenomegaly, ascites. In addition, it is well known that there is not always a precise relationship between the degree of the obstruction, i.e. the decrease of the portal inflow and the level of the portal hypertension. A severe obstruction to the portal flow may therefore sometimes remain clinically inconspicuous for a long time. For this reason improvement of our knowledge of portal hypertension mainly relies on angiographic investigations. Thus, splenoportography permits the discovery of prehepatic obstructions whereas hepa tic venography permitted the recognition of two different types of intrahepatic obstruction according to the pre-sinusoidal or post -sinusoidal site of the obstacle. More recently, arterial hepatic changes could be evidenced through arteriography. However, these angiographic investigations have not yet allowed for all the problems about portal hypertension to be clearly identified.
Contents
1. Normal Hepatic Circulation - Anatomy and Physiology.- I. The hepatic lobule and its three vascular axes.- II. Intrahepatic arterio-portal communications.- III. Normal hepatic circulation.- 2. Angiographic Methods.- I. Direct portal venous opacification.- II. Hepatic venous study.- III. Arterioportography.- IV. Computed tomography.- 3. The Main Arteriographic Signs of Portal Hypertension and their Hemodynamical Significance.- I. The mesenterico-portal axis opacification.- II. The spleen pattern.- 1. Angiographic signs.- 2. The four main angiographic patterns of the spleen.- III. Hepatic arterial changes.- 4. Presinusoidal Obstructions.- I. Proper angiographic signs.- 1. Arterial changes.- 2. Venous changes.- II. The main causes of prehepatic obstructions.- 1. Pancreatic diseases.- 2. Portal vein thrombosis.- 3. Other causes.- III. Intrahepatic presinusoidal obstructions.- 5. Diffuse Post-Sinusoidal Obstructions.- I. Proper arteriographic signs.- 1. The porto-systemic hepatofugal circulation.- 2. Reversal of the intrahepatic portal flow.- II. Evaluation of the intensity of the obstruction.- 1. Minimal obstructions.- 2. Moderate obstructions.- 3. Severe obstructions.- 4. Very severe obstructions.- III. Etiological diagnosis.- 1. Suprahepatic obstructions.- 2. Intrahepatic obstructions.- 6. Are There Portal Hypertensions Without Obstruction?.- I. Portal hypertension of splenic origin.- II. Portal hypertension and arteriovenous fistula.- 7. Contribution of Arterioportography to the Treatment of Portal Hypertension.- I. Checking of surgical porto-caval anastomosis by arterioportography.- 1. Standard shunts.- 2. Selective decompression shunts.- II. Treatment of portal hypertension according to hemodynamical changes.- 1. Portal hypertension with moderately decreased portal inflow.- 2. Portal hypertension with markedly reduced portal inflow.- 3. Portal hypertension with hepatofugal portal flow.- III. Interventional radiology and portal hypertension.- 1. Transhepatic obliteration of esophageal varices.- 2. Splenic artery embolization.- 3. Other non-surgical therapeutic methods.- 8. Segmental Intrahepatic Obstructions without Portal Hypertension.- I. Segmental reversal of the intrahepatic portal flow: angiographic pattern.- 1. Direct sign.- 2. Indirect signs.- II. Differential diagnosis of segmental reversal of intrahepatic portal flow: arterio-portal fistulae.- 1. Traumatic arterio-portal fistulae.- 2. Tumoral arterio-portal fistulae.- 3. Congenital arterio-portal fistulae.- 4. Arterio-portal fistula, cirrhosis and portal vein thrombosis.- 5. Arterio-portal fistula and cirrhosis.- III. Etiological diagnosis.- 1. Hepatic tumors.- 2. Extrahepatic masses.- 3. Liver trauma.- 4. Focal atrophy of the liver.- IV. Conclusions.- General conclusions.- References.
