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Ultrasound (Fall)
IVC & Porta Hepatis
141
Medical
09/25/2009

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Cards

Term
What are the major abdominal venous system?
Definition

1. IVC - from the common illiac veins to the diaphragm

2. IMV

3. Renal Vein

4. SMV

5. Splenic vein

6. Portal vein

7. Hepatic Vein

Term
How does the venous vessels look like in ultrasound?
Definition
The venous vessels will demonstrate tube like structures with well defined,  echogenic walls and an echofree lumen, but the wall of arteries and portal venous sturctures will be more echogenic than the thinner walled veins
Term
What are the great vessels of the ventral cavity?
Definition
Aorta and IVC
Term
What is the function of the IVC?
Definition
The IVC transports deoxygenated blood towards the heart
Term
What does the veins contain in them and how is it helpful?
Definition
The venous system contains valves, which prevent back flow of blood (called retrograde flow) during diastole
Term
In real time imaging arteries show 
Definition
pulsations of an artery
Term
The lumens in the veins open and close with ___________
Definition
respiration
Term
What produces a more variable response with respiration?
Definition
Valsalva maneuver
Term
What happens when a patient does valsalva maneuver?
Definition
The vessel distention may be greater when the patient holds his breath after a deep inspiration
Term
Why is arteries not influenced by respiration?
Definition
Arteries are not influenced by respiration since the arterial blood is under high pressure and the arterial walls are thick and strong which enables the vessel to withstand and alterations in intra-abdominal pressure caused by breathing
Term
How is the IVC formed?
Definition
The IVC is formed by the union of the two common iliac veins
Term
How are the common iliac veins formed?
Definition
The common iliac veins are formed by the union of the internal and external iliac veins
Term
Where does the IVC course?
Definition
IVC normally courses through the retroeritoneum, it lies to the right of the aorta and anerolateral to the vertebral processes
Term
The IVC lies _________ to the right kidney and _________ to the liver
Definition
medial / posterior
Term
What multiple tributaries does the IVC gives rise to which can be accessible with ultrasound through vascular exams?
Definition

Lumbar veins

Right suprarenal vein

Right gonadal vein

Term
Whats the only vessel posterior to the IVC?
Definition
Right renal artery
Term
What are the names of the 2 great vessels in the ventral cavity?
Definition
Aorta and IVC
Term
What is the purpose of the IVC?
Definition
To transport deoxygenated blood back to the heart and lungs to oxygenate it again
Term
What does the venous system contain within the lumen of the vessel that helps the blood more forward?
Definition
Valves
Term
If those valves are leaking or damaged, what do we call the flow of blood in those vessels when it goes in reverse or backwards?
Definition
Retrograde flow
Term

True or False

The venous system usually demonstrates pulsatile flow?

Definition

False

The venous system does not usually contain pulsatile flow unless close to the heart or in right sided CHF patients. Flow is in and out with the patients respiration

Term
What is the purpose of the Valsalva maneuver and are there any changes to the vessel itself with this maneuver is being performed?
Definition
The valsalva maneuver is where the patient will take in a deep breath, hold it and bear down as if having a bowel movement. Normally the venous system will distend or dilate
Term
What vessels form the common iliac veins?
Definition
Internal and external iliac vein union
Term
The IVC lies __________ to the right kidney and __________ to the liver
Definition
medial / posterior
Term
How does the IVC look in ultrasound?
Definition
The IVC is more elliptical than round with smaller AP measurement
Term
Where does the IVC begin to widen?
Definition
at the level of the renal veins
Term
What is rouleaux formation?
Definition
The normal IVC is usually anechoic, however, occasionally there are internal echoes. This is refered to as red cell aggregation or rouleaux formation
Term
When is rouleaux formation observed?
Definition
Rouleaux formation may be observed in any large vein as larger veins have slower flow. Slow flow is throught to enhance rouleaux formation
Term
What are the sections of IVC?
Definition

1. Hepatic

2. Pre-renal

3. Renal

4. Post-renal

Term
Which is the Hepatic section?
Definition
Hepatic section is where the hepatic veins empty into the IVC
Term
Which is the pre-renal section?
Definition
Pre-renal section is inferior to the hepatic veins, but superior to the renal veins
Term
Which is the renal section?
Definition
Where the renal veins and the multiple tributaries are
Term
Which is the post renal section?
Definition
post renal section extends just inferior to the renal veins until the bifurcation
Term
Why do we look at the IVC?
Definition
The IVC is primarily evaluated to detect intraluminal thrombus or tumor invasion
Term
The tumor invasion most commonly occurs in the _______ _______ and extends into the _______
Definition
renal veins / IVC
Term
What is the most common tumor to involve the IVC?
Definition
renal cell carcinoma
Term
What are some normal variants of the IVC?
Definition
There may be some normal variants of the IVC like a double IVC or a left positioned IVC or a portion of the vessel may be absent, but these variants are not common
Term
Where does the Hepatic veins originate and where does it empty into?
Definition
Originates in the liver and empties into the IVC
Term
The Hepatic veins are located ________ to the renal veins
Definition
superior
Term
What are the 3 major hepatic veins?
Definition

Right

Middle

Left

Term
Which vein is responsible for draining all the venous blood out of the liver?
Definition
Hepatic vein
Term
which lobe does the right, left and the middle hepatic vein empty?
Definition
right lobe, left lobe and the caudate lobe
Term
The hepatic vein ________ in diameter as they approach the IVC
Definition
increases
Term
What causes the playboy bunny or a moose head sign?
Definition
Transversely the hepatic veins look like anechoic linear structures that empty into the IVC causing a playboy bunny or a moose head sign
Term
The hepatic veins exhibit ______, which is a reflection of _________ and _______ activity
Definition
pulsatility, cardiac and respiratory
Term
The flow direction away from the organ is called
Definition
Hepatafugal
Term
There are small veins that drain directly into the IVC which are these veins?
Definition
Caudate lobe veins. Occasionally normal caudate veins are seen with ultrasound
Term
Suprarenal veins are also called as
Definition

adrenal veins

not normally seen with ultrasound

Term
From where does the renal vein return blood and where does it empty?
Definition
kidney / IVC
Term
Renal vein lies _________ to the level of the renal arteries
Definition
superior
Term
Left renal vein is ___________ than the right renal vein
Definition
longer
Term
Which other veins does the left renal vein receive?
Definition
Left renal vein receives the left gonadal vein and the left suprarenal vein
Term
The left renal vein passes posterior to the ________ vein and __________ ______ & ______ prior to entering the IVC
Definition
splenic vein, pancreas body & tail
Term
The LRV courses anterior to the _______ and lies between the _________ _______ and the ______
Definition
aorta / aortic wall and the SMA
Term
Why does the left renal vein engorge?
Definition
due to the compression by the SMA and aorta
Term
Where does the LRV appear dilated?
Definition
Prior to the crossing between the SMA and aorta
Term
Which renal vein is shorter?
Definition
Right renal vein
Term
Where does the right gonadal vein come off?
Definition
the IVC
Term
The right renal vein may also receive the _______ ________ ________
Definition
right suprarenal vein
Term
Representing the gender the gonadal veins are also known as
Definition
testicular and ovarian veins
Term
Where does the left and right gonadal veins drain into?
Definition
the left gonadal vein opens into the left renal vein and the right gonadal vein drains directly into the IVC just inferior to the right renal vein
Term
What does the azygos and hemi azygos vein provide?
Definition
The azygos and hemi azygos veins provide an alternate pathway for venous retun in the case of IVC obstruction
Term
Where is the azygos vein located?
Definition
right
Term
Where is the hemi azygos located?
Definition
left
Term
What can be mistaken for the right crus? How must this mistake be checked?
Definition
The right crus can be mistaken for either the right renal artery or vein if care is not taken to follow vessels to see if they arise from the aorta or empty into the IVC
Term
Why won't the left and right veins be symmetrical?
Definition
Veins open and close so the left and right veins may not be symmetrical
Term
Why would the veins appear as large as the IVC
Definition
Since veins change in their diameter, especially prior to entering the IVC or conversely
Term
Why would the renal veins and artry be confusing and what must be done to be sure?
Definition
Renal veins are generally anterior to he renal arteries, however, crossing over frequently happens. If the anatomy is confusing, using pulsed wave or color doppler would be helpful
Term
What are the reasons for the IVC to get displaced? Why does it get displaced?
Definition

The reasons for IVC to be displaced is

1. a liver mass

2. right renal artery aneurysm

3. lymphadenopathy

4. a tortuous aorta

5. a right renal or adrenal mass

The reason the IVC can be so easily displaced is because it is not anchored strongly 

 

Term
What would be a reason to ultrasound the IVC?
Definition
to detect intraluminal thrombus or tumor invasion
Term
What is rouleaux flow?
Definition
Red cell aggregation, red cells stack together in a similar fashion to a roll of coins. This may be observed in any large veins as larger veins have slower flow. Slow flow is throught to enhance rouleaxu formation
Term
What are the 4 sections of the IVC?
Definition

1. Hepatic

2. Pre-renal

3. Renal

4. Post renal

Term
If a tumor is seen in the renal veins, what other vessel would one interrogate and why?
Definition
Tumors in the renal veins will most likely invade the IVC. Therefore a sonographer shoud also look at the IVC for tumor extension
Term
Where do the Hepatic veins originate, where do they end and what are their names?
Definition

The hepatic veins originate in the liver and end at the IVC. There are 2 Hepatic veins -

Right, Middle and left Hepatic veins

Term
What vessels drain all of the venous blood out of the liver?
Definition
Hepatic veins
Term
The RHV empties the RLL and the LHV empties he LLL. What does the MHV empty?
Definition
The caudate lobe
Term

True or False:

The hepatic veins decrease in diameter as they approach the IVC

Definition

False

The Hepatic veins increase in diameter as they approach the IVC

Term
What is the name of the flow of blood if it is flowing away from the liver?
Definition
Hepatofugal
Term
What is the opposite of Hepatofugal blood flow?
Definition
Hepatopetal - going towards the liver
Term
What 2 veins enter the left renal vein instead of the IVC?
Definition
Left Gonadal Veins and Left suprarenal veins
Term
Where does the right gonadal vein drain into?
Definition
directly into the IVC
Term
The _________ _______ system does not enter the IVC
Definition
portal venous
Term
What is the function of the portal venous system?
Definition
The function of this system is to deliver blood from the spleen and gastrointestinal tract to the liver for metabolism and detoxification. This system is much different from the arterial and venous blood supply to the liver
Term

What is the portal venous system made up of?

Definition

1. portosplenic confluence

2. Main portal vein

3. Right poral vein with branches

4. left portal vein with branches

Term
Which vein is the largest vein?
Definition
Splenic vein
Term

True or False

Splenic vein is less tortuous than the splenic artery.

Definition
True
Term
Where does the splenic vein begin?
Definition
Splenic vein begins at the hilum of the spleen
Term
The splenic vein passes transversely to the ______ across the posterior abdominal wall _______ to the splenic artery and _________ to the body and tail of the pancreas
Definition
right / inferior / posterior
Term
What does the splenic vein drain?
Definition
Splenic Vein drains part of the pancreas and stomach and the spleen
Term
what is used as a landmark for locating the pancreas?
Definition
splenic artery and vein
Term
The splenic vein is located ________ to the pancreatic body and tail
Definition
posterior
Term
The splenic artery is tortuous but usually follows the ________ border of the pancreatic body and tail
Definition
superior
Term
What vessels form the portosplenic confluence?
Definition
SMV, IMV and splenic vein
Term
What vessel joins the splenic vein to form the portospleniv confluence?
Definition
IMV
Term
What organs does the IMV drain?
Definition
The IMV drains the inferior part of the large intestines, primarily the area along the rectum, sigmoid area and the descending colon
Term
From its origin, the IMV courses _______
Definition
superiorly
Term
When is the IMV seen with ultrasound?
Definition
When IMV dilates with Portal HTN then it can be visible with ultrasound
Term
Where does the SMV originate?
Definition
SMV originates at the ileocecal valve where the ileum and small intesting join the cecum of the large intestine
Term
Where does the SMV course?
Definition
SMV courses superiorly towards the midline
Term
Prior to the confluence which 3 veins were separate entities? Once they join what is it called? and when continued laterally it is known as the _______ _______ _______.
Definition

SMV, IMV & splenic vein

porto splenic confluence

main portal vein

Term
The main portal vein ascends obliquely to the _____ passing posterior to the superior portion of _________, _______, ________ and ________ and anterior to the ______
Definition
right, duodenum, common bile duct, proper hepatic artery and GDA, IVC
Term
How much blood does the main portal vein supply to the liver?
Definition
80%
Term
How much blood does the Hepatic artery supply to the liver?
Definition
20%
Term
How long is the main portal vein and where does it begin?
Definition
The main portal vein is 8 cm long and begins posterior to the neck of the pancreas
Term
What landmark is used for the pancreatic neck?
Definition
main portal vein
Term
The MPV courses _________ and _______ about ________ before it enters the liver
Definition
superiorly, laterally, 5-6 cm
Term
Where does the MPV enter the liver?
Definition
Porta Hepatis
Term
After the MPV enters the liver it divides into the ______ and ______ _______ ________
Definition
right and left portal veins
Term
What vessels make up the porta hepatis?
Definition

Main Portal Vein

Proper Hepatic artery

Common Hepatic duct

Term
why is the porta hepatis called the mickey mouse sign?
Definition
In an oblique scanning plane, the 3 vessels look like the head and ears of the mickey mouse and therefore it is called the micky mouse sign
Term
Which portal vein is longer and has a smaller diameter?
Definition
The left portal vein is longer and has smaller diameter than the RPV
Term
Before entering the left lobe of the liver the left portal vein gives branches to which lobe?
Definition
caudate lobe
Term
what is the origin of the LPV and where does it course?
Definition
The origin of the LPV is the MPV and it courses medially
Term
The LPV branches into the ______ and _______ segment
Definition
medial and lateral
Term
What does the LPV and its medial and lateral branches look like in a transverse scanning plane? Hence what is it called?
Definition
The LPV and its medial and lateral branches looks like horns of a steer hence it is called steer head sign
Term
What portal vein is shorter and larger?
Definition
The right portal vein is shorter and larger in diameter than the LPV
Term
Which vein originates from the RPV? what does it do before entering the right lobe of the liver?
Definition
The cystic vein originates from the RPV and gives a branch to the caudate lobe before entering the right lobe of the liver
Term
The RPV courses _________ _________ and then divides into branches called the __________ and __________ segments
Definition
right, laterally / anterior and posterior segments
Term
How can the portal vein be distinguished from other structures, especially the hepatic vein?
Definition
It has highly echogenic walls
Term
Why does the portal vein get an echognic walls around them?
Definition
The portal vein gets this echogenicity due to the high collagen content in the walls
Term
Why are the portal veins evaluated?
Definition
Portal veins are evaluated for thrombosis and tumor invasion and for portal HTN
Term
How must the portal vein be evaluated?
Definition
The portal vein is evaluated with color doppler and duplex doppler and should show blood flowing into the liver or "hepatopetal" flow
Term
Where does the common hepatic artery arise from? what does it bifurcate into?
Definition
Common Hepatic Artery arises from the celiac axis and bifurcates into the GDA and proper hepatic artery
Term
Just prior to the bifucation the CHA passes _______ to the MPV
Definition
anterior
Term
Where does the proper hepatic artery begin? Where does it ascend to?
Definition
Proper hepatic artery begins at the bifurcation and ascends to the porta hepatis of the liver within the folds of the hepatoduodenal ligament.
Term
What does the proper hepatic artery divide into?
Definition
It divides within the porta hepatis into the right and left hepatic arteries.
Term
What does the right hepatic arery give rise to? What does it supply?
Definition
The right hepatic artery gives rise to the cystic artery. The cystic artery supplies the GB, hepatic ducts and part of the CBD
Term

True or false

The portal venous system enters the IVC

Definition
False
Term
What is the function of the portal venous system?
Definition
The function of this system is to deliver blood from the spleen and gastrointestinal tract to the liver for metabolism and detoxification
Term
Name the 4 components or segments of the portal venous system
Definition

portosplenic confluence

Main portal vein

right portal vein with branches

left portal vein with branches

Term
What vessel is a definite landmard for the locating the pancreas?
Definition
The splenic vein, which cradles the posterior aspect of the pancreas
Term
What is the name of the ligament that crosses over the celiac axis?
Definition
median arcuate ligament
Term
What 3 veins make up the porto splenic confluence?
Definition
SMV, IMV and the splenic vein
Term
What vessel supplies the liver with 80% of its blood supply and originates behind the pancreas neck?
Definition
MPV
Term
What is the porta hepatis?
Definition

An area in the liver hilum that is made up of 3 vessels

1. MPV

2. CHD

3. PHA

Term
What is the steerhead sign?
Definition
The medial and lateral branches of the left portal vein
Term
What is the mickey mouse sign?
Definition
The portal triad oblique
Term
What segments do the right portal vein branch into?
Definition
Anterior and posterior
Term
What does the proper hepatic artery divide into?
Definition
right and left hepatic artery
Term
What vessel does the right hepatic artery give rise to?
Definition
cystic artery which feeds the gall bladder
Term
Where does the cystic vein originate and what does a branch of that vessel feed?
Definition
It comes off the right portal vein and the branch of the cystic vein feeds the caudate lobe