CLINICS 2012;67(6):609-614 DOI:10.6061/clinics/2012(06)11 CLINICAL SCIENCE The diameter of the originating vein determines esophageal and gastric fundic varices in portal hypertension secondary to posthepatitic cirrhosis Hai-ying Zhou, Tian-wu Chen, Xiao-ming Zhang, Li-ying Wang, Li Zhou, Guo-li Dong, Nan-lin Zeng, Hang Li, Xiao-li Chen, Rui Li Sichuan Key Laboratory of Medical Imaging, and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Sichuan/China. OBJECTIVE: The aim of this study was to determine whether and how the diameter of the vein that gives rise to the inflowing vein of the esophageal and gastric fundic varices secondary to posthepatitic cirrhosis, as measured with multidetector-row computed tomography, could predict the varices and their patterns. METHODS: A total of 106 patients with posthepatitic cirrhosis underwent multidetector-row computed tomography. Patients with and without esophageal and gastric fundic varices were enrolled in Group 1 and Group 2, respectively. Group 1 was composed of Subgroup A, consisting of patients with varices, and Subgroup B consisted of patients with varices in combination with portal vein-inferior vena cava shunts. The diameters of the originating veins of veins entering the varices were reviewed and statistically analyzed. RESULTS: The originating veins were the portal vein in 8% (6/75) of patients, the splenic vein in 65.3% (49/75) of patients, and both the portal and splenic veins in 26.7% (20/75) of patients. The splenic vein diameter in Group 1 was larger than that in Group 2, whereas no differences in portal vein diameters were found between groups. In Group 1, the splenic vein diameter in Subgroup A was larger than that in Subgroup B. A cut-off splenic vein diameter of 8.5 mm achieved a sensitivity of 83.3% and specificity of 58.1% for predicting the varices. For discrimination of the varices in combination with and without portal vein-inferior vena cava shunts, a cut-off diameter of 9.5 mm achieved a sensitivity of 66.7% and specificity of 60.0%. CONCLUSION: The diameter of the splenic vein can be used to predict esophageal and gastric fundic varices and their patterns. KEYWORDS: Portal Hypertension; Esophageal and Gastric Fundic Varices; Originating Vein; Computed Tomography. Zhou HY, Chen TW, Zhang XM, Wang LY, Zhou L, Dong GL, Zeng NL, et al. The diameter of the originating vein determines esophageal and gastric fundic varices in portal hypertension secondary to posthepatitic cirrhosis. Clinics. 2012;67(6):609-614. Received for publication on January 14, 2012; First review completed on February 7, 2012; Accepted for publication on February 28, 2012 E-mail: [email protected] Tel.: 86-817-2262216 INTRODUCTION inflowing veins of the collateral circulation for the determi- nation of appropriate treatments. Posthepatitic cirrhosis is common worldwide and results The originating vein is typically either the portal or in portal hypertension (PHT), due to an increase in splenic vein. Doppler ultrasound can not only detect the intrahepatic resistance combined with an increase in portal portal vein (PV) but also measure its diameter, flow and hepatic arterial blood flow. To decompress the portal direction, and flow velocity (7). However, this procedure venous system, portosystemic collateral vessels are formed has not been widely used in clinical settings, due to its lack in PHT (1-4). The collaterals are mainly composed of of reproducibility and poor accuracy resulting from intra- esophageal and gastric fundic varices, which contribute to and interobserver variation (8,9). Magnetic resonance massive hemorrhage of the upper alimentary tract (5,6). imaging is probably as accurate as angiography, but several Thus, it is crucial to evaluate the originating veins of of the rarest pathways (e.g., pleuropericardial or thoracic wall varices) may be missed at the time of MR imaging (10,11). The development of multidetector-row computed tomo- Copyright ß 2012 CLINICS – This is an Open Access article distributed under graphy (MDCT) has resulted in an improved spatial the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- resolution and the elimination of motion artifacts due to its commercial use, distribution, and reproduction in any medium, provided the ability to acquire images rapidly and continuously during a original work is properly cited. single held breath (12,13). The capacity for the postprocessing No potential conflict of interest was reported. of imaging data with a variety of three-dimensional (3D) 609 Esophageal and gastric fundic varices CLINICS 2012;67(6):609-614 Zhou HY et al. reformatting techniques (e.g., maximum intensity projec- (Aquilion, Toshiba Medical Systems, Tokyo, Japan). Prior tion (MIP), multiplanar reformation (MPR), and volume to CT image acquisition, a 21-gauge plastic cannula (B. rendering (VR)) can facilitate the identification of the Braun Melsungen AG, Melsungen, Germany) was placed originating veins and the distribution of portosystemic into an antecubital vein, and 400-600 ml of water was collateral vessels in patients with liver cirrhosis; therefore, immediately used as negative oral gastric contrast material. MDCT is probably the optimal imaging technique in this A breath-hold thoracoabdominal plain scan was obtained. setting (14-16). Almost all of the reported studies have Subsequently, a 1.5-ml/kg bolus of iopamidol (Ultravist 300, sought to illustrate the anatomical distributions of porto- Iopamidol, Schering, Germany) was injected with an systemic collaterals. To our knowledge, there have been no automated pump injector (MEORAD-Stellant, MEORAD reports focusing on how to predict esophageal and gastric Company, Pittsburg, Germany) at a rate of 3.0 ml/s through fundic varices and their patterns with the diameters of the the 21-gauge cannula into the antecubital vein. Triphasic originating vein of the inflowing vessels, as measured with enhancement CT scans were subsequently commenced 25, MDCT. Therefore, the aim of this study was to determine 45, and 65 s after the start of the injection. The first enhanced how to use the diameter of the originating vein to predict acquisitions were used to acquire hepatic arterial phase the varices and their patterns to develop a better under- images, and the third acquisitions were used to acquire standing of and to prevent massive hemorrhage of the portal venous phase images. The following parameters were upper alimentary tract. used for the second and third sets of enhanced images: peak voltage of 120 kVp, tube current of 120-380 mA, collimation MATERIALS AND METHODS of 7 mm, pitch of 1.3, matrix of 5126512 mm, and a reconstructed section thickness of 1 mm. The second or Ethics statement third sets of enhanced images were obtained during This study was approved by the institutional ethics suspended respiration for 10-15 s, and the thoracoabdom- review board of our university hospital, and written inal scanning coverage along the z-axis ranged from 60- informed consent was obtained from all participants prior 75 cm. The parameters used for non-enhanced images and to initiation of the study. the first set of enhanced images were similar to those used for the second and third sets of images with the exception of Patient population the 5-mm reconstructed section thickness. Patients were enrolled in this study according to the following inclusion criteria: (1) PHT secondary to post- Image data analysis hepatitic cirrhosis resulting from hepatitis B, as confirmed by clinical data and laboratory examinations and imaging The data derived from the third enhanced acquisition studies performed according to the American Association were transferred to an image processing workstation for the Study of Liver Diseases (AASLD) practice guidelines (Aquilion Multislice CT, Toshiba, Tokyo, Japan) for recon- on chronic hepatitis B (2007) (17); (2) lack of prior treatment struction. The display parameters, including width, level, for esophageal and gastric fundic varices caused by the opacity, and brightness, were chosen subjectively to absence of upper gastrointestinal bleeding; (3) absence of visualize these portosystemic collaterals most effectively. portal vein emboli, hepatic artery-portal vein fistula, and For MPR, a slab of 7-10 mm was applied to avoid the hepatic carcinoma; and (4) available thoracicoabdominal interference of the vertebral bodies. The images were triple-phase enhanced CT scans. reviewed by two radiologists working in consensus, Between January 2010 and July 2011, 106 consecutive including an experienced radiology professor (the corre- patients (74 men and 32 women; mean age, 53.5 years; age sponding author, who has 13 years of experience in range, 16 - 78 years) who met the inclusion criteria and thoracoabdominal radiology) and an experienced radiolo- agreed to take part in the study were recruited. The gist (the first author, who has six years of experience in common clinical manifestations included a feeble state, radiology), with emphasis on the patterns of esophageal and abdominal distension, dyspepsia and dull pain in the liver. gastric fundic varices, the inflowing vessels and their According to the Child-Pugh classification, the cohort was originating veins. The patterns of the varices were evaluated composed of 45 patients classified as Child-Pugh A, 35 as in some cases with PV-IVC. The inflowing vessels were the Child-Pugh B, and 26 as Child-Pugh C. left gastric vein and the posterior and short gastric veins. The cohort was divided into two groups based on Because there was a degree of difficulty in differentiating whether they had esophageal and gastric fundic varices, the posterior gastric and short gastric veins, we regarded as confirmed by enhanced MDCT. The group with varices these as the posterior/short gastric vein. The originating was subdivided into two subgroups according to whether veins were the PV and splenic vein (SV). the varices were or were not associated with portal vein- The PV and SV diameters were measured on axial CT inferior vena cava (PV-IVC) shunts.