g oral contraceptives predispose to portal and hepatic venous
thrombosis. Examination: Abdominal wall veins are often prominent and rarely, they may form a caput rnedusae around the umbilicus. Murmurs- A venous hum may be heard over the collaterals (ruveilhier- !aumgarten syndrome". collaterals radiating occasionally to the precordium or over liver. A thrill may be felt at the site of maximum intensity. An arterial systolic murmur suggests primary liver cancer or alcoholic hepatitis. #he paraxiphoid umbilical veins indicate intrahepatic portal venous hypertension. $pleen- enlarges progressively, the edge is firm. Massive if presinusoidal portal obstruction, cirrhosis with hypersplenism, rarely tropical splenomegaly. %iver- &igh pressures are more often associated with a small, fibrotic liver. A soft liver suggests extrahepatic portal venous obstruction, a firm liver cirrhosis. Ascites- 'ortal hypertension raises capillary filtration pressure and increases (uantity of ascitic fluid. )nvestigations: *ltrasound- is the first imaging investigation. +ailure to demonstrate a normal confluence of hepatic veins at the ), and elicit a normal -oppler-flow signal are diagnostic. # scan- can demonstrate patchy hepatic parenchyma in the affected lobes, reflecting areas of venous infarction, oedema. fatty infiltration and compensatory caudate lobe enlargement. #echnetium- ..m isotope scanning- may illustrate classical pattern of preferential upta/e of colloid by the hypertrophied caudate lobe. &epatic venography- (a" ,enogram of ),- 0arrowing of upper ) , due to pressure of caudate lobe. (b" &epatic venous catheteri1ation- 2$pider web filling of collaterals. instead of flash filling of rapidly draining hepatic vein. (c" 'ressure measurements of ), are necessary if surgery is considered. Ascitic fluid- is mostly exudate from lea/ of protein-rich fluid from hepatic sinusoids, and lymph from the engorged liver. %iver biopsy- &epatic venous congestion with 3!2s in sinusoids in space of -isse beneath the hepatocyte basement membranes. !arium swallow- 'resence of varices. $plenoportography (,enography"- involves contrast study of the portal venous system via percutaneous splenic puncture. 4ith normal portal circulation. splenic and portal veins are filled and no other vessels are outlined. )ndications5 6. #o establish patency of portal vein e.g. in diagnosis of splenomegaly in childhood, and excluding hepatccellular carcinoma in patient with cirrhosis. 7. )nvestigation of cause of portal hypertension. 8. )nvestigation of splenomegaly of un/nown etiology. 9. !efore shunt surgery and postoperative demonstration of shunt. :. -iagnosisof chronic hepatic encephalopathy. Absence of large portal collateral circulation excludes the diagnosis. Abnormal venographic patterns- 6. 'resence of numerous collateral vessels and gross distortion of intrahepatic pattern (#ree in winter appearance" in cirrhosis. 7. 0umerous collateral vessels (gastro-oesophageal and spleno-portal" in- extra- hepatic, splenic or portal venous obstruction. 8. +illing defect in portal vein or liver from a space-occupying lesion. )ndirect angiography- by in;ection of contrast medium through catheter in coeliac axis. *tility- (6" )t reveals intrahepatic arterial patterns and allows space occupying lesions and hemangiomas to be identified. (7" A grossly enlarged hepatic artery in cirrhotic patient carries a favourable prognosis as opposed to reduction in both arterial and portal
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20"kicking motion. Keep legs straight and toespointed. Do not let legs touch the ground