The National Ribat University Faculty of Graduate Studies and Scientific Research

Variations of the portal diameter in

Adult Sudanese Population , (ultrasonography Study ) .

A thesis submitted for Requirements of Partial Fulfillment of the Degree of M.Sc in Human and Clinical Anatomy.

By: Abdallah Greeballah Abdallah Mohammed .

Supervisor: Prof . TAHIR OSMAN ALI .

Acknowledgement

First of all, I would like to thank so much our almighty god for giving me strength, good health and knowledge in making this study.

I would like to give my sincere thanks to my supervisor:, Prof . TAHIR OSMAN ALI the dean of faculty of graduate studies and scientific research for his patience in guiding me throughout the research period.

I would also like to thank Dr.Kamal Eldin Elbadawi Babiker, dean of faculty of medicine for giving a hand and advice throughout the course.

Also, I would like to give special thanks to Dr. Yassier seddig for generous cooperation to facilitate my study.

I would like to acknowledge and thank The National Ribat University for giving me this chance of studying.

Dedication

I would like to dedicate this thesis and everything I do to my mother. to my father .. to my sisters Namarig ,Nusiba , Nuha and Emtethal . to my best friends Dr.Mohammed Basheir , Dr. Iman Elgaili ,

Abstract

Background: The hepatic portal vein, a short, wide vein, is formed by the superior mesenteric and splenic posterior to the neck of the pancreas. It ascends anterior to the IVC as part of the portal triad in the hepatoduodenal ligament . At or close to the porta hepatis, the hepatic and hepatic portal vein terminate by dividing into right and left branches; these primary branches supply the right and left livers, respectively

Material and methods: The study includes 65 sequential patients of both sexes and different age, 30 females and 35 males, who underwent abdominal ultrasound for various reasons, at Antalia diagnostic cener (Khartoum state), ultrasound was done investigating portal vein diameter .

Results: The results showed that the patients at the age of sixty years old, had stenosis in portal vein which are discovered accidently when they underwent abdominal ultrasound for various reasons. When comparing the study between men and women it was found that most abnormal variations are in men. Also it was found that the average diameter of portal vein 12.

Conclusion : The study revealed a normal mean portal vein diameter ranging below 12 mm with a normal respirophasic variation (above the cutoff point for portal hypertension).

مستخلص الدراسة

خلفية :

الوريد البابي الكبدي هو وريد قصير وعريض يتكون بإتحاد الوريد الطحالي والوريد المساريقي العلوي خلف البنكرياس. ويرتفع ألعلي أمام الوريد األجوف السفلي كجزء من بوابه ثالوث في الرباط الكبدي اإلثني عشر .

عند بوابة الكبد ينقسم البابي و الشريان الكبدي إلي تفرعات ليغذوا النصف األيمن والنصف االيسر من الكبد.

الﻤﻮاد وطرق الدراسة :

أجريت هذه الدراسة علي 56 مريضا من فئات عمرية مختلفة 03 من اإلناث و06 من الذكور

خضعوا لموجات صويتة للبطن ألسباب مختلفة تم الكشف فيها عن الوريد البابي الكبدي في مركز أنطاليا التشخيصي في والية الخرطوم و ذلك باستخدام الموجات فوق الصويته لتحديد قطره.

النتائج :

أظهرت النتائج أن المرضى الذين تزيد أعمارهم عن ستين سنه ظهر لديهم ضيق في الوريد البابي الكبدي الذي اكتشف عن طريق الصدفة عند فحصهم بالموجات الصوتية ألسباب طبية مختلفة عند مقارنة الدراسة بين الرجال والنساء وجد أن األكثر عرضه لهذا الضيق هم من الرجال .

كما أوجدت هذه الدراسة ان متوسط قطر الوريد البابي الكبدي 21 ملم.

.

The contents

Title Page Chapter I Introduction 1.1. Introduction 1 1.2. Justification 2 1.3. Objectives 2 1.3.1. General objective 2 1.3.2. Specific objective 2 Chapter 2 Literature Review 2.1. Literature Review 3 Chapter 3 Materials and Methods 3.1. Study Design 9

3.2. Study Area 9

3.4. Study Population 9

3.4.1.Inclusion Criteria 9

3.4.2.Exclusion Criteria 9 3.5. Sampling 10

3.5.2. Sample size 10

3.6. Data collection 10

3.7. Data analysis 10

3.8. Ethical consideration 10 Chapter 4 Results 4.1. Results 11 Chapter 5 Discussion 5.1. Discussion 17 6.1. Conclusion 19 6.2. Recommendations 20 Chapter 7 References References 21 Appendix 23

Lists of tables Table Title Page

Table (4.1) Distribution of gender. 11

Table (4.2) Age group distribution among study 12 individuals.

Table (4.3) Portal vein diameter 13

Table (4.4) Crosstable between PVD and gender 26

Table (4.5) Crosstable between PVD and age 26

Table (4.6) Statistical parameter 25

List of figures 4.1 Gender distribution of study group 11 4.2 Age distribution 12 4.3 Portal vein diameter 13 1 Figure (1) 14 2 Figure (2) 14 3 Figure (3) 14

List of abbreviations

Abbreviations List

PV Portal vein

PVD Portal vein diameter

P HTN Portal hypertension

CLD Chronic liver disease

US Ultrasound

CT Computed tomography

Chapter one Introduction

Introduction: 1.1 Background :- Mean portal vein diameter is considered as the best indicator for portal hypertension. However, the cutoff point differs from study to study (above 10–15 mm) despite the existence of normal mean portal vein diameter between 10–15 mm in different settings. This implies the existence of limited evidence on normal portal vein diameter for all populations in all countries prior to setting the cutoff points. Therefore, the aim of this study was sonographic assessment of mean portal vein diameter among patients with liver problem referred to the Department of Radiology in Antalia Health Cente. (1) The normal portal vein diameter (PVD) can vary normally between 7 to 15 mm while normal portal venous pressure lies between 5 and 10 mmHg (14 cm of H2O). If portal venous pressure is more than 15 mmHg (30 cm of H2O), then it might indicate portal hypertension. A portal vein diameter greater than 13 mm is assumed to be the cutoff point for portal hypertension in the appropriate clinical setting. On the contrary, a portal vein diameter greater than 10 mm was also considered as portal hypertension . (2)

1.2. Justification :- Sudan is a one of the developing country and most of population work in rural area in farms and near to lakes .and they lack health awareness about protecting themselves . The most one that affect the portal vein is bilharzia and alcohol leading to portal hypertension and liver cirrhosis that lead to death ,so measurement of mean portal vein diameter in normal Sudanese population will provide to clinician best indicator for diagnosis and treatment of portal vein problems . .

1.3. Objectives

1.3.1. General objective: To estimate the Mean Portal Vein Diameter Using Sonography among patients Coming to Radiology Department of Antalia Health Center in 2017 . 1.3.2. Specific objectives: to :

 Identify the course of portal vein .  compare the diameter among gender.  Measure the diameter of portal vein .  Compare the variations with data from other studies.

Chapter Two Literature review

Literature review:

2.1. Gross anatomy: The hepatic portal vein, a short, wide vein, is formed by the superior mesenteric and splenic veins posterior to the neck of the pancreas. It ascends anterior to the IVC as part of the portal triad in the hepatoduodenal ligament (3). At or close to the porta hepatis, the hepatic artery and hepatic portal vein terminate by dividing into right and left branches; these primary branches supply the right and left lobes , respectively. Within the right and left livers, the simultaneous secondary branchings of the hepatic portal vein and hepatic artery supply the medial and lateral divisions of the right and left lobes , with three of the four secondary branches undergoing further (tertiary) branchings to supply independently seven of the eight hepatic segments.. (3)

The portal venous system drains blood to the liver from the abdominal part of the alimentary canal (excluding the anus), the spleen, the pancreas and the gall-bladder and its ducts. The distal tributaries of this system correspond to, and accompany, the branches of the coeliac and the superior and inferior mesenteric enumerated above; only proximally does the arrangement differ. The inferior mesenteric vein ascends above the point of origin of its artery to enter the splenic vein behind the pancreas. The superior mesenteric vein joins the splenic vein behind the neck of the pancreas in the transpyloric plane to form the portal vein, which ascends behind the first part of the duodenum into the anterior wall of the foramen of Winslow and thence to the porta hepatis. Here the portal vein divides into right and left branches and breaks up into capillaries running between the lobules of the liver. These capillaries drain into the radicles of the hepatic vein through which they empty into the inferior vena cava. (4) The portal vein drains blood from the abdominal part of the gastrointestinal tract from the lower third of the esophagus to halfway down the anal canal; it also drains blood from the spleen, pancreas, and gallbladder. The portal vein enters the liver and breaks up into sinusoids, from which blood passes into the hepatic veins that join the inferior vena cava. The portal vein is about 2 in. (5 cm) long and is formed behind the neck of the pancreas by the union of the superior mesenteric and splenic veins . It ascends to the right, behind the first part of the duodenum, and enters the lesser omentum It then runs upward in front of the opening into the lesser sac to the porta hepatis, where it divides into right and left terminal branches. The portal circulation begins as a capillary plexus in the organs it drains and ends by emptying its blood into sinusoids within the liver. For the relations of the portal vein in the lesser omentum. Tributaries of the Portal Vein ,splenic vein, superior mesenteric vein, left gastric vein, right gastric vein, and cystic veins. Splenic vein leaves the hilum of the spleen and passes to the right in the splenicorenal ligament. It unites with the superior mesenteric vein behind the neck of the pancreas to form the portal vein It receives the short gastric, left gastroepiploic, inferior mesenteric, and . Inferior mesenteric vein ascends on the posterior abdominal wall and joins the splenic vein behind the body of the pancreas and receives the superior rectal veins, the sigmoid veins, and the . Superior mesenteric vein ascends in the root of the mesentery of the small intestine. It passes in front of the third part of the duodenum and joins the splenic vein behind the neck of the pancreas , it receives the jejunal, ileal, ileocolic, right colic, middle colic, inferior pancreaticoduodenal, and right gastroepiploic veins. Under normal conditions, the portal venous blood traverses the liver and drains into the inferior vena cava of the systemic venous circulation by way of the hepatic veins. This is the direct route. However, other, smaller communications exist between the portal and systemic systems, and they become important when the direct route becomes blocked . These communications are as follows: At the lower third of the esophagus, the esophageal branches of the left gastric vein (portal tributary) anastomose with the draining the middle third of the esophagus into the azygos veins (systemic tributary). Halfway down the anal canal, the superior rectal veins (portal tributary) draining the upper half of the anal canal anastomose with the middle and (systemic tributaries), which are tributaries of the internal iliac and , respectively. The paraumbilical veins connect the left branch of the portal vein with the superficial veins of the anterior abdominal wall (systemic tributaries). The paraumbilical veins travel in the falciform ligament and accompany the ligamentum teres. The veins of the ascending colon, descending colon, duodenum, pancreas, and liver (portal tributary) anastomose with the renal, lumbar, and phrenic veins (systemic tributaries). (5) Portal hypertension is a common clinical condition; thus, the list of portal– systemic anastomoses should be remembered. Enlargement of the portal– systemic connections is frequently accompanied by congestive enlargement of the spleen. Portacaval shunts for the treatment of portal hypertension may involve the anastomosis of the portal vein, because it lies within the lesser omentum, to the anterior wall of the inferior vena cava behind the entrance into the lesser sac. The splenic vein may be anastomosed to the left after removing the spleen.(6)

A study done in 2013 in Ethiopia by Gemechu Geleto, et al. Mean portal vein diameter using ultrasound A total of 195 patients who fulfilled the eligibility criterion and came to the Radiology Unit within the specified study period were consecutively included into the study. Howevere, resource was too limited to extend the number of participants. Data were collected from a total of 195 participants, among these, 121(62.1%) were males. The median age of the partcipants was 35 years. Near to twenty nine percent, 18.5% and 12.8% of the participants were in the age categories of 21–30, 51–60 and 11–20 years respectivly The normal mean portal vein diameter (±SD) was 10.6mm ±1.8 SD. The result showed an increment of mean portal vein diameter from the age less than 10 years up to 30 years. The mean portal vein diameter was 11.3 mm±1.6 in the age category of 41–50 years and 7.9 mm ±1.6 in less than 10 years children. The normal mean portal vein diameter in males was 10.9 mm ± 1.9 and 10.0 mm ±1.5 in females. Moreover, the normal mean portal vein diameter differed by age (F=8.20, P<0.001) and sex (t=3.60, P<0.001) significantly (7)

Another study in 2015, in USA by Stamm determined mean main portal vein diameter in healthy patients evaluated with CT, compared this value to the "upper limit of normal" reported previously, and evaluated effects of age, sex, height, and BMI on portal vein diameter . healthy patients underwent abdominal CT as potential renal donors. They excluded patients with evidence of liver or severe cardiac disease. They recorded patients' age, sex, height, weight, and BMI. Patients' main portal vein diameters were measured by fellowship-trained abdominal imagers on non-contrast and post-contrast images in axial and coronal projections at a defined location. A general linear mixed model was used for analysis.

191 patients with 679 main portal vein measurements were included in the analysis. Mean main portal vein diameter was 15.5 ± 1.9 mm; this value was significantly different from the upper limit of normal of 13 mm commonly referenced in the literature (95% CI: 2.22-2.69 mm higher, p < 0.0001). Portal vein diameter does not vary significantly when measured on axial vs. coronal images. On average, post-contrast main portal veins were 0.56 mm larger compared to non-contrast, (95% CI: 0.40- 0.71 mm, p < 0.0071). Patient height and BMI are positively correlated with MPV diameter. (8)

A study was done in 2016 in Nepal by Bhattarai. et al ,to determine that the Upper Gastro-intestinal endoscopy is considered the best screening tool for varices in cirrhotic patients. It is still an expensive, invasive tool, has poor compliance and not routinely available in every hospitals in Nepal. This study was undertaken to establish the role of portal vein diameter and spleen size by ultrasonography in predicting gastro- esophageal varices , One hundred and fifty patients with clinical features, laboratory and sonological findings suggestive of cirrhosis of liver and endoscopic evidence of portal hypertension were included in the study. Ultrasonography assessments of portal vein diameter and spleen size alongside endoscopy for detection of varices were done.

Average portal vein diameter of patients without gastro-esophageal varices was 10.800 ± 1.1402 mm, while it was 13.731 ± 1.061mm in patients with varices(p<0.001, There was 92.72 % sensitivity and 90 % specificity for prediction for presence of esophageal varices when the cutoff value for portal vein diameter was 12.25 mm (9)

A study done in Caribe, by Geofery Luntsi,et al in northen Nigeria and study carried out among apparently healthy adult subjects in Abubakar Tafawa Balewa University Teaching Hospital (ATBUTH), An ultrasound machine ALOKA SSD-1000, (IP-1233EV, SN-57324, Japan) with curvilinear transducer with a frequency of 3.5MHz was used. A total of 201 apparently healthy adults were enrolled for the study. The study constitutes 72 (35.82%) males and 129 (64.18%) females. The subjects were between the ages of 18–80 years, with mean age of 32.5±11.3 years. Participants within the age group of 25–29 years had the highest frequency of 15(7.46%), while those within the age group of 45–49 years had the lowest frequency of 3 (1.49%) .(10)

Chapter Three Materials and methods

Materials and methods

3.1. Study design: This is an observational descriptive. All individuals who went to do ultrasonography in Antalia medical diagnostic center due to abdominal pain or urine retention .

3.2. Study area: The study will be conducted at Antalia Medical diagnostic center in Khartoum, Sudan.

3.3. Study population: The study populations will be individuals booking to do abdominal ultrasound for various reasons such as abdominal pain , urine retention in Khartoum state in Antalia medical diagnostic center.

3.3.1. Inclusion Criteria: All individuals underwent study in Antalia Medical Center with normal portal vein . 3.3.2. Exclusion Criteria : All patients with history of portal hypertension or patient with past history of liver problem .

3.4. Sampling

. 3.4.1 Sample Criteria: The sample group of this study was selected randomly among Sudanese peoples of both sexes within ages more than 18 year 3.4.2 . Sample size: The number of the frame sample population is (100 ), the degree of perception is (0.004), and the confidence level is 95% thus from above inputs and by using the formula: {n=N/1+N(D2)} where n= sample size, D= degree of perception (0.004%) , and N= the no. of the frame sample population .

3.6. Data collection: The data will be obtained after taken permission of radiological technologist . The ultrasound machine is Toshiba (2006) coloured digital . All samples will be revised by dr. Alatia the manager of Antalia Diagnostic Center to diagnose and comment on details.

3.7. Data analysis: Data will be analyzed by SPSS (social package for statically science) version 21 .

3.8. Ethical clearance: All the samples will be collected after Permission taken from the individuals under study. Also Ethical clearance from the National Ribat University .

Chapter Four

Results

Results 4.1 distribution of gender A total of 65 individuals who underwent ultrasound , were examined, Twenty- six of them were males (53,8%) and nineteen (46.2%) were females.

Table (4.1) and fig (4.1).

Table (4.1): Distribution of gender.

Gender Frequency Percent

Male 35 53.8%

Female 30 46.2%

Total 45 100%

figure (4.1): Distribution of gender distribution

Female Male

46% 54%

Figure(4-1) show the gender distribution .male represent approximately (54%) and females represent near (46%)

4.2 Age group distribution :- . The age of subjects were arranged into four groups ranging from

(20-65 < ) years, shown in table (4.2) and fig (4.2).

Table (4.2): Age group distribution among individuals.

Age group/years Frequency Percentage Less than 20 5 7.7 % 21-40 34 52.3 % 41-65 21 32.3 % More than 65 5 7.7 % Total 65 100 %

Fig (4.2): Represents age distribution.

Frequency Percent

52.3

32.3

34 7.7 21 7.7 5 5 < 20 21-40 41-65 > 65

Figure(4-2) show the age group was represented in bar chart and the group age (21-40) is presented approximately 52.3 %

Portal vein diameter :

The PVD of subjects were arranged into two groups normal( range from 10 to 15 ) and abnormal( less than 10 ) , shown in table (4.4) and fig (4.4).

Table (4.3) represent portal vein diameter

PVD diameter Frequency Percentage

Normal 59 90.7

abnormal 6 9.3

figure (4.3) represent portal vein diameter

Normal abnormal

9%

91%

Figure(4-3) shows normal portal vein diameter found in most of subject (90,7%) and abnormal result were found in (9,3%).

Figure (1) shows ultrasound presentation of portal vein

Figure (2) shows diameter of portal vein

Figure (3) presents stenotic portal vein

Table (4.4) PVD diameter Gender PVD diameter Total Crosstabulation between the gender Abnorma Normal and PVD l

Female 2 28 30 This table represents

the crosstabulation Male 4 31 35 between the gender Total 6 59 65 and portal vein diameter

Table (4.5) Age * PVD diameter Crosstabulation

Age PVD diameter Total

Abnormal Normal

< 20 0 5 5

21-40 0 34 34

41-65 3 18 21

> 65 3 2 5

Total 6 59 65

This table represent the crosstabulation between the portal vein diameter and age of subject

Table( 4.6)

Statistical parameters

Mean Median STD Min Max

PVD 9.95 10 0.838 7 11.3

Chapter Five

Discussion

5.1 Discussion:

This study was aimed at assessing the normal mean portal vein diameter and its distribution by age and sex using Sonography. The study revealed a normal mean portal vein diameter of 9.95 mm ±,838 SD with a respirophasic variation of 25.6%. In addition, the normal mean portal vein diameter seemed to have varied by age and sex.

The normal mean portal vein diameter in our setting was 10.6 mm ±1.8 SD which is in agreement with other studies done in USA (11 mm±2 SD) (5), Nigeria (11.45 mm±1.49 SD) (2), and Kolkata (11.54 mm) (6). However, our finding is inconsistent with the finding of a study done in Addis Ababa, Ethiopia (7.9 mm±2 SD) (7).. On top of this, mean portal vein diameter was significantly greater in males than in females in this study. Male participants were higher in this study (62%) than study done in Addis Ababa (38%). Hence, the variation could be due to the participants' sex.

The respirophasic variation of mean portal vein diameter was 25.6%, which shows that normal mean portal vein diameter increase during inspiration that is above the cutoff point (20%). Subject below 20% in respirophasic variation of mean PVD are suspected to have portal hypertension (4, 7). However, the finding of this study was slightly higher than a study done in Addis Ababa, Ethiopia (21.5%) (7).

The implications of mean portal vein diameter and respirophasic variation in this study seem contradictory with the findings in Addis Ababa, Ethiopia. This might be due to the loose indication of average portal vein diameter for portal hypertension as compared to increase in portal vein diameter during deep inspiration (8). In addition, the mean portal vein diameter seemed to have varied significantly with age (F=8.20, P<0.001) and sex (t=3.60, P<0.001). There was a consistent finding with respect to mean portal vein diameter variation by age in previous studies done in India (12), USA (5), Nigeria (2) and Addis Ababa, Ethiopia (7). Previous studies done in West Bengal (6), India (12) and Addis Ababa, Ethiopia (7) identified that mean PVD did not vary by sex although no statistical tests were done.

This study could have its own limitation in that, the role of confounding factors in determining the mean portal vein diameter variation by age and sex was not controlled. Hence, interpretation and utilization of the findings should be made with care.

In conclusion, the study revealed a normal mean portal vein diameter ranging below 12 mm with a normal respirophasic variation (above the cutoff point for portal hypertension). In addition, the normal mean portal vein diameter seemed varied by age and sex. Hence, decisions made in clinical settings should base on these findings. Besides there is a need for large scale study to determine mean portal vein diameter variation by age and sex, controlling other confounders

Chapter Six

Conclusion and recommendations

Conclusion and Recommendations

6.1. Conclusion

The study revealed a normal mean portal vein diameter ranging below 12 mm with a normal respirophasic variation (above the cutoff point for portal hypertension).

In addition, the normal mean portal vein diameter seemed varied by age and sex. Hence, decisions made in clinical settings should base on this result .

The portal vein diameter was found to be with in normal range in fifty nine subjects (91%),and in six subject (9%) it was below the normal range .

There is gender variation in a mean portal vein diameter .

.

6.2. Recommendations:

Ultrasonography is best method to evaluate a mean portal vain diameter and it is used in most of clinical cases to investigate patient with any symptom or sign of portal hypertension and it is safe and cheap .

The present study gives the diameter of portal vein and its difference according to side and sex.

In view of this, the diameters which has been presented in this study may provide reference values which are specific to ultrsonography and it may be of value in studies to investigate other pathologic features of the portal vein system .

Chapter Seven References

REFERENCES

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2- McMinn R.M.H . abdomen . In: R.M.H. McMinn, editor. Last’s Anatomy Regional and Applied. 9th Edn. UK: Churchill Livingstone, Robert Stevenson House; 1994. p. 600-601.

3- Ljiljana V, Milena T, Ivan J . Types and Subtypes of the portal vein

4- Afifi, Adel K, Bergman Ronald A. portal vein . In: Afifi, Adel K, Bergman Ronald A, editors. Functional Neuroanatomy. 2nd Edn. Iowa: McGrawHill; 2005. p. 350

5- Dodevski1 Ace, Tosovska Dobrila Lazarova1, Nadica Mitreska, Vjolca Aliji, Elizabeta Stojovska Jovanovska portal vein –variation in the origin and clinical significance(435) .Med.Sci. 1,2014.

6- Uchino1 Akira ,Saito1 Naoko ,Takahashi1 Masahirom, Nanami

Okano1. Variations of the portal vein diagnosed by ultrasound at 3 tesla. Published online: 9 November 2015 .

7-Hsin-Wen , Chen Pao-Sheng, Yen Chau-Chine Lee . Magnetic Resonance Angiographic Evaluation of portal vein in General

Population: A Morphologic Study in 507 Cases. Chin J Radiol 2004; 29: 223.

8- R Wilson, T Veras, W Gary . Variation Of The portal vein And Its

Embryological Explanation. Wilson Veras on 22 March 2017

9-Al-Hussain, S.M.; Shoter, A.M. & Bataina, Z.M. (2001). Portal vein in Adults. Saudi Medical Journal, Vol.22, No.10, (October 2001), pp. 895-898, ISSN 0379-5284.

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Annex The National Ribat University Faculty of Graduate Studies Variations of the portal vein diameter in Adult Sudanese Population , (ultrasonography Study ) .

1-Index number:

2- Gender: Male: Female:

3-Age : Less than 20 21-40 21-40 More than 65

4-Diameter of PCA: Normal: Abnormal:

Notes…………………………………………………………… ………………