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Non-Invasive Diagnosis Ofportal Vein Occlusion by Radionuclide Angiography 1673

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Non-Invasive Diagnosis Ofportal Vein Occlusion by Radionuclide Angiography 1673 Gut 1992; 33: 1671-1674 1671 Non-invasive diagnosis of portal vein occlusion by radionuclide angiography Gut: first published as 10.1136/gut.33.12.1671 on 1 December 1992. Downloaded from P MacMathuna, M K O'Connor, D G Weir, P W N Keeling Abstract TABLE I Clinical details ofthe three patient groups The accuracy of non-invasive radionuclide angiography in detecting portal vein occlusion PVO Cirrhosis Control* was assessed in 61 patients - 10 with portal vein No 10 25 26 Mean age (years) 47 52 4 occlusion confirmed by conventional porto- Male/female 5/5 10/15 14/12 graphy, 25 with chronic liver disease and a Liver disease 3/10 25/25 0/26 patent portal vein (mild=12, severe=13), and PVO=portal vein occlusion. 26 with normal liver function, who served as *Controls=.patients undergoing bone, cardiac, or cerebral controls. The median percentage portal scanning. venous flow for the portal vein occlusion group was 8% (range 1-30) (consistent with negligible and in post-transplant graft dysfunction.4 flow) compared with 78% (52-87) for control At present, the accurate diagnosis of PVO subjects (p<0.005) and 68% (61-80) and 49% requires either arterial portography or spleno- (23-59) respectively for patients with mild and portography, both of which are invasive severe liver disease (p<0.001 and p<0.005). radiological proceedures that may have compli- At a portal venous inflow of <20%, the cations, particularly in patients with a coagulo- proceedure had a specificity of 100% and pathy.56 A reliable non-invasive diagnostic sensitivity of 90% in diagnosing portal vein technique would represent a considerable occlusion. Non-invasive radionuclide angio- advance. Recent reports have advocated either graphy provides a safe and accurate screening ultrasonography78 or computer tomography.9 method for evaluating portal vein patency or The application of radionuclide angiography in occlusion in the investigation of portal hyper- assessing portal vein patency or occlusion has tension or before liver transplantation. received limited attention. We have previously (Gut 1992; 33: 1671-1674) described a new non-invasive dynamic hepatic scintigraphic technique to define the portal venous and hepatic arterial contributions to total http://gut.bmj.com/ Complete or partial occlusion ofthe portal vein is liver perfusion.'0 More 'recent in vivo animal a common cause of portal hypertension in child- studies provide experimental evidence to hood.'2 In adults, portal vein occlusion (PVO) validate this technique." Preliminary use of this may complicate chronic liver disease but more method in a small number of patients success- frequently results from intra-abdominal sepsis, fully detected PVO.'° The present study aimed neoplasia, or a thrombotic disorder.3 In many to assess the accuracy of this technique in the cases, however, no aetiological factor is found. diagnosis of PVO in a larger cohort of patients. on September 25, 2021 by guest. Protected copyright. Departments ofClinical Gastrointestinal haemorrhage is the commonest Medicine and Nuclear Medicine, Trinity clinical presentation, while the presence of College Medical School, ascites and encephalopathy usually indicate Patients and methods St James' Hospital, associated liver dysfunction. Early recognition of Dublin P MacMathuna the condition is important since management PATIENTS M K O'Connor may differ from that of cirrhosis, particularly if Three groups of patients were included in this D G Weir portacaval surgery is considered.3 PVO is a investigation (Table I). P W N Keeling contraindication to liver transplantation and Correspondence to: Dr Padraic MacMathuna, after transplantation, thrombosis of the portal Gastrointestinal Unit, Mater vein (or hepatic artery) is a recognised cause of Group 1: patients with PVO (Table II) Misericordiae Hospital, Dublin 7, Ireland. graft dysfunction.4 Consequently, defining the Ten patients (5 men and 5 women) with a mean venous Accepted for publication patency or occlusion of the portal system age of 47 years (range 21-72) were assessed. The 20 May 1992 is equally important in pretransplant assessment diagnosis of PVO was confirmed in each case by TABLE II Individual clinical and radiological details concerning the 10 patients with portal vein occlusion Patient Age Cavernous no (years) Aetiology Cirrhosis Clinicalfeatures Diagnostic method transformation 1 54 Idiopathic No Oesophageal varices Angiography No 2 21 Idiopathic No Oesophageal varices Angiography No 3 55 Pancreatitis No Oesophageal varices Angiographv No 4 35 Idiopathic/? trauma Yes Oesophageal varices/hepatic Angiography No encephalopathy 5 63 Cirrhosis Yes Oesophageal varices/hepatic Angiographv No encephalopathy 6 40 Polycylhaemia rubra vera No Oesophageal varices/ascites Angiographv No 7 69 Idiopathic No Oesophageal sarices Angiographx No 8 38 Idiopathic No Asymptomatic Laparotomy +angiographv Yes 9 72 Cirrhosis/hepatocellular Yes Oesophageal varices Angio+post mortem Yes carcinoma? 10 51 Idiopathic No Oesophageal varices Angiographv Yes 1672 MacMathuna, O'Connor, Weir, Keeling , Lung score`2 into two groups: mild disease with a Tc99 Child-Pugh score of <8 (n= 12) and severe Gut: first published as 10.1136/gut.33.12.1671 on 1 December 1992. Downloaded from ROI disease with a score of >8 (n= 13). Group 3: normal control subjects There were 26 control subjects (14 men and 12 I women) with a mean age of 54 years (range 25- 78) none ofwhom had any clinical, biochemical, or radiological evidence of liver disease or extra- hepatic portal hypertension. These patients were undergoing cardiac, bone, or cerebral isotope scanning and dynamic liver scintigraphy could be incorporated without unnecessary additional exposure to radionuclides. Written informed consent was obtained from each patient before the study. METHODS The technique of dynamic hepatic radionuclide angiography has been described previously in detail.'0 In brief, fasting patients were positioned supine beneath a large field of view gamma camera (General Electric, Maxi II). After a 5 minute resting period, in patients with PVO or liver disease, 370 MBq (10 mCi) of 99mTc Figure 1: Schematic outline illustrating thefield ofview pertechnetate were administered by bolus peri- ofthe gamma camera conventional arterial portography or spleno- pheral intravenous injection followed rapidly by including regions ofinterest portography with additional conclusive evidence a 30 ml saline flush to ensure rapid transit of the (ROIs) over the liver, spleen, lung, and left kidney. from laparotomy and post mortem examination radionuclide into the heart. In control subjects, in two cases (see Table II). In three patients there 555-740 MBq (15-20 mCi) of 99mTc labelled was coexisting liver disease and in one of these human albumin, methylene diphosphonate, or patients (patient 9), the PVO was associated with glucoheptonate were administered in a similar the development of hepatocellular carcinoma. manner. Computer image acquisition began at Pancreatitis (patient 3) and polycythaemia rubra the onset of the injection. Images were acquired http://gut.bmj.com/ vera (PRV) (patient 6), accounted for two other onto a 64x64 word matrix at a rate of 0 5 cases while no cause was evident in the remaining seconds/image for 100 seconds and stored on an five patients (idiopathic). A2 computer system for subsequent analysis (Medical Data Systems, Ann Arbor, MI, USA). The procedure takes approximately 3 minutes to Group 2: patients with chronic liver disease without complete. PVO Preliminary data analysis involved a summa- on September 25, 2021 by guest. Protected copyright. This group comprised 25 patients (12 men and tion of the initial 30 images to form a composite 13 women) with a mean age of 51 years (range image outlining the arterial phase of tracer 30-74), all of whom had documented chronic transit through the hepatobiliary system. liver disease (clinical, biochemical, and histo- Regions of interest (ROIs) were drawn over the logical criteria) with patent portal vein as shown liver, spleen, lungs, and left kidney ensuring that radiologically. The aetiological factors for the the liver ROI excluded the descending aorta and liver disease included alcohol (n=19), chronic right kidney (Fig 1). The ROIs were then used to active hepatitis (n=3), Wilson's disease (n=2), generate time-activity curves (TACs). Because of and haemochromatosis (n=l). Twenty of the interference from the right lung into the liver patients had portal hypertension, shown by the ROI, a correction factor was applied to take presence of endoscopically proved oesophageal account of this 'cross-talk', resulting in a varices, with or without splenomegaly. The corrected liver TAC (Fig 1). Deconvolution patients were classified according to the severity analysis of the TACs was used to improve of liver disease using the modified Child's-Pugh separation of the arterial and portal venous 3.Or 10.0r A 60 Figure 2: Left: corrected liver and spleen curves. x 50 Centre: curves following 30 deconvolution analysis. Modified cJ 1*0 Right: magnitude ofthe 0 spleen modified so that the spleen upslope matches that ofthe liver curve. AS and AL 0 0 0 represent the areas under the 50 100 so 100 50 100 spleen and liver curves respectively. Time (sec) Non-invasive diagnosis ofportal vein occlusion by radionuclide angiography 1673 phases of total liver blood flow. In addition, this TABLE IH Individual results ofthe hepatic arterial (% HA) for the 10 patients with portal method takes account of tracer recirculation and and portal
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