A STUDY OF DOPPLER WAVEFORM PATTERN OF HEPATIC VEINS IN PATIENTS OF ACUTE VIRAL HEPATITIS IN COMPARISON WITH CONTROL POPULATION.
Objective: The objective of this study was to evaluate hepatic vein flow patterns in adults with acute viral hepatitis and to compare the findings with a control group of healthy people using Doppler ultrasound.
Study Design: Cross-sectional comparative study
Settings: Radiology Department Military Hospital and Combined Military Hospital Rawalpindi from 15 May 2007 to 15 November 2007.
Material and methods: Eighty patients who underwent doppler ultrasound at Military Hospital and Combined Military Hospital Rawalpindi during the study period were divided into two groups of 40 each. Cases were selected from the Out Patient Departments of Military Hospital and Combined Military Hospital Rawalpindi. Group I comprised patients with diagnosis of acute viral hepatitis based on clinical and laboratory findings. Group II included the control group comprising 40 healthy volunteers. Doppler ultrasound of hepatic veins was carried out in both the groups of patients.
Results: Abnormal wave pattern of hepatic veins on Doppler ultrasound was noted in 35 (87.5%) in group I and in 1(0.25%) of group II. One patient having abnormal Doppler wave pattern in group II subsequently developed acute viral hepatitis. Doppler ultrasound assessment of wave pattern in hepatic veins is an accurate method to differentiate a diseased liver from a normal one.
Conclusion: Doppler ultrasound of hepatic veins is a good technique to study disease status of liver.
The Doppler waveform of the hepatic vein in healthy subjects is normally triphasic (two negative waves and one positive wave) because of central venous pressure variations during the cardiac cycle. It has been established that the normal triphasic hepatic vein waveform is transformed into a biphasic or monophasic waveform in patients with acute viral hepatitis and cirrhosis. Moreover, a monophasic waveform has been shown to correlate with a high Child-Pugh score and a poor survival rate1.
Hepatic parenchymal disease such as acute viral hepatitis or liver transplant rejection has been associated with loss of this triphasic hepatic venous flow2. Influences of cardiac function, intraabdominal pressure, and intrathoracic pressure on hepatic vein flow pattern have also been reported. They affect not only the velocity of hepatic vein flow, but also the pulsatility3. Pulmonary venous hypertension and increased pressure in the right heart chambers will increase hepatic vein pulsatility, whereas increased thoracic pressure (Valsalva's maneuver) will slow down the venous return to the right heart and diminish the pulsatility of the hepatic veins4-6.
Patients and Methods
This "cross-sectional comparative study" was conducted at Radiology Department, Military Hospital Rawalpindi / Combined Military Hospital Rawalpindi from 15 May 2007 to 15 November 2007. A total number of 80 individuals were included and divided into two groups. Group I comprised 40 patients of acute viral hepatitis diagnosed on the basis of clinical and laboratory findings and group II comprised 40 healthy individuals which served as the control. All the individuals were selected on non probability convenience sampling technique. Following criteria were used,
Cases (Group I)
a. Patients in their 2nd to 6th decade of life.
b. Patients with diagnosed acute viral hepatitis based on clinical and laboratory findings.
c. Patients of both genders.
Controls (Group II)
All those individuals in second to sixth decade of life, not suffering from acute viral hepatitis or any other major illness consenting to be included in the study.
a. Patients with any major thoracic or abdominal surgery.
b. Known cases of any chronic liver or heart disease.
c. Patients not willing for Doppler ultrasonography.
After seeking permission from concerned authorities and 'Hospital Ethics Committee' study was commenced. All individuals were included in the study after informed consent and underwent Doppler ultrasound at Military Hospital / Combined Military Hospital Rawalpindi. The patients were subjected to Doppler ultrasound of hepatic veins. All the patients had Doppler ultrasound by the same consultant radiologist using Aloka Prosound SSD-5500 with 3.5 - 5 MHz transducer.
All the individuals were examined while lying supine on the examination couch. Liver was scanned in right upper quadrant of the abdomen both subcostally and through the intercostal spaces. The transducer was oriented horizontally or slightly oblique. The insonation angle was between 40 and 60 degrees. All measurements were performed preferably in inspiration.
Ultrasound diagnostic criteria
Wave forms formed on Doppler were entered as monophasic, biphasic or triphasic, with monophasic or biphasic taken as abnormal.
The patients diagnosed as having acute viral hepatitis had clinical presence of jaundice, raised bilirubin and disturbed liver function tests.
Data Analysis Procedure:
Collected data had been analyzed through SPSS version 12. Mean and standard deviation (SD) was calculated for age. Frequencies as percentages were presented for qualitative variables. Chi-square test was used to compare qualitative variable between both the groups. P- value less than 0.05 was considered statistically significant.
A total of eighty patients were included in this study divided into two groups I and II. Group I consisted of patients diagnosed with acute viral hepatitis whereas group II consisted of normal volunteers. Both groups underwent Doppler ultrasound.
Out of the eighty patients there were 57 males and 23 females. The age of patients in group I varied from 21 to 59 years with mean age of 36.7+-11.3 years while in group II age of patients varied from 20 to 58 years with mean age of 34.9+-10.8 years. The patient characteristics are shown in table 1.
Table-1: Group Wise Gender distribution of Patients
Group II (n=40)###30###10
The pattern of hepatic vein spectral Doppler in the two groups is expressed in table -2.
Table-2: Percentage of Types of Wave Pattern
Group II###0(0%)###1 (2.5%)###39(97.5%)
P less than 0.001
There was significant difference in wave pattern of both the groups (p less than 0.001).
One patient in group II having abnormal wave pattern later on developed AVH and was treated accordingly.
This showed that the hepatic vein doppler flow pattern has a strong association with acute viral hepatitis and is significantly disturbed in such cases and thus can serve as a strong predictor of the diseased liver as well as can help in differentiating diseased individuals from normal ones.
Ultrasound is the initial examination performed in most patients with suspected hepatic abnormality7. Interrogation with ultrasound is best performed using a 5 MHz curvilinear probe but in large patients, a low frequency probe may be necessary. The liver is divided into right and left lobes by the middle hepatic vein. Further division into segmental anatomy is achieved by the course of the right and left hepatic veins and porta8.
The hepatic veins have a characteristic triphasic waveform, which reflects right atrial and inferior vena cava pressure8.
Hepatic vein flow patterns are under the effects of cardiac function and intrabdominal and intrathoracic pressure.
There is a low-velocity phase of retrograde flow during right atrial contraction (a wave). Two higher velocity phases of hepatofugal flow follow, the first during right ventricular systole after closure of the tricuspid valve, and the second during right ventricular diastole. This rise in atrial pressure interrupts the two periods of forward flow and may produce a short second period of hepatic venous flow reversal, even in healthy patients. V wave flow reversal is almost always smaller than the a wave flow reversal2,5,8.
A number of conditions can result in the alteration of Doppler hepatic venous flow pattern. Hepatic venous pulsatility may disappear during pregnancy and may remain abnormal even beyond 8 weeks postpartum. Hepatic venous waveforms in pregnant patients may be dampened or monophasic even before 20 weeks gestation, and most patients (80%) have flat waveforms in the final 10 weeks of pregnancy. The precise cause of these changes in pregnancy is unknown, although the altered cardiac output seen in pregnancy coupled with the pressure effects of the enlarged uterus may play a role9.
Abnormal flow may occur in the hepatic veins if there is abnormal communication between the hepatic veins and other hepatic vessels, right heart pressures are elevated, transmission of the right atrial pressure pattern is impeded because of venous outflow obstruction or infiltration and altered compliance of the hepatic parenchyma result in dampening of hepatic venous flow patterns. Examples of such pathological conditions include intrahepatic vascular shunts and vascular malformations10,11 right heart failure12, Budd Chiari syndrome13, other veno-occlusive hepatic diseases and Sinusoidal Obstruction syndromes14, Biliary tract disease and infiltrative tumours15 as well as benign masses16.
When the liver architecture becomes less pliant, as in cases of hepatic diseases e.g. acute viral hepatitis, obesity, cirrhosis, ascites, masses, and the presence of increased intraabdominal pressure, a depression occurs in the Doppler wave (biphasic flow pattern), or normal pulsations do not appear (monophasic flow pattern)17.
In this study we focused on the Doppler pattern of hepatic veins in patients with both clinical and laboratory based diagnosis of acute viral hepatitis. The results supported our hypothesis and showed that 87.5% patients with diagnosis of AVH had abnormal wave pattern in hepatic veins, while in the control group only one patient had abnormal wave pattern in hepatic veins; this patient subsequently had deranged liver function tests and had acute viral hepatitis. We compared the results with well documented international studies and the comparison is given as under.
Jequier18 et al in a prospective study on 100 healthy children, revealed no significant difference in hepatic wave pattern of normal and hungry children. But he demonstrated that age was a significant factor in most of the newborns where monophasic flow was present. Our study has clearly shown that wave pattern among diseased and control group is a reliable predictor of disease process.
Meyer19 et al showed that a triphasic pattern is seen in most of the healthy population and we have also demonstrated that the control group has shown a triphasic wave pattern in hepatic veins on Doppler ultrasound.
Arda20 et al in a double blind study done on 30 patients with early stage chronic liver parenchymal disease and 40 healthy patients using Doppler ultrasound, showed Triphasic wave forms in all of the healthy patients. Of the patients with liver disease, only 26.6% had a triphasic pattern, and the rest had biphasic or monophasic patterns. The results of this study validate the outcome of the research protocol used in our study.
Dietrich21 et al conducted a prospective study involving 135 patients of chronic hepatitis-C and 75 healthy individuals in which Doppler ultrasound was used to determine the wave pattern of blood flow in hepatic veins. In the diseased group 47% had triphasic, 36% had monophasic, and 17% had biphasic flow patterns; while in the healthy group, 75% had triphasic, 16% had monophasic, and 9% had biphasic flow patterns. These results are similar to the results of this study.
Szekely and Kupcsulik22 in their study arrived at a conclusion that biphasic wave pattern was seen in patients of acute liver disease and monophasic wave pattern was seen in patients of cirrhosis.
Thus our study has revealed that wave pattern seen in the hepatic veins does change, and serve as a reliable predictor of disease status in individuals of acute viral hepatitis.
The results of this study have shown that abnormal wave pattern in hepatic veins did accurately point out the disease process in patients. Colour Doppler ultrasound can thus also be used in routine screening of liver and help in separating diseased liver from the healthy ones. Although this study has included a small number of patients as study group yet the results are in favour of the use of Colour Doppler ultrasound as a screening test in detection of liver pathologies. However further research is required to find a still better method and to perfect this technique.
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|Author:||Siddiqui, Saeed Ahmed; Ali, Muhammad Zeeshan; Mirza, Tariq Mahmud; Asghar, Ali Zia|
|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Dec 31, 2011|
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