Evaluation of Changes Liver Hemodynamics with Color Doppler Ultrasound in the Cholestatic Patients

Research Article

Austin J Nutri Food Sci. 2014;2(3): 1017.

Evaluation of Changes Liver Hemodynamics with Color Doppler Ultrasound in the Cholestatic Patients

Safiye Kafadar1*, Hüseyin Kafadar2 and AY Erkin Ogur3

1Harput State Hospital, Elazig/Turkey

2Regional Center the Council of Forensic Medicine Elazig/Turkey

3Firat University Department of Radiology Elazig/Turkey

*Corresponding author: :Safiye Kafadar, Harput State Hospital, 23119 Elazig, Turkey

Received: February 19, 2014; Accepted: March 05, 2014; Published: March 13, 2014


Background⁄Aim: This study is aimed to determination of frontier findings warning physicians related to hemodymanic changes having development possibility in liver resulted from cholestasis by using such a method of color Doppler ultrasonography (RDUS) which is non invasive and reliable.

Patients and Methods: In this context; 42 patient groups having high hepatic enzyme level, 41 patient groups having elevated hepatic enzyme level and bilurubin, and 24 control groups constituted from healthy persons are examined with RDUS. In all cases congetion index (CI), fibrosis index (FI), hepatic vascular index (HVI), hepatic artery resistive index (HA–RI), hepatic artery pulsatility index (HA–PI), portal vein velocity (PVV), portal vein diameter (PVD) and spleen length are evaluated.

Results: According to these parameters, statistical difference among the control group, patient group of elevated hepatic enzyme level, and cholestasis patient group are evaluated. According to the FI, HVI, HA–PI parameters, between the patient group of high hepatic enzyme level and control group are determined significant difference (p<0,05). On the other hand, according to the CI, HA–RI, PV diameter, and spleen length parameters, these groups are not observed any significant difference (p>0,05). Between the patient group of high hepatic enzyme level and the cholestasis patient group, and between the control group and the cholestasis patient group are obtained significant difference as statistical in all parameters (p<0,05). According to the CI, FI, HA–RI, HAPI, PVV, and HVI parameters, these groups are determined high statistical significant difference (p<0,001). While CI, FI, HA–RI, HA–PI, PVD, and spleen length have increased in the cholestasis patient group; in turn, PVV and HVI have decreased.

Conclusion: Those results that RDUS have a utility and reliable modality on the changes happened in hepatic hemodynamy that might appeared by presence of biliary cirrhosis and its progression developed in the cholestatic patients.

Keywords: Cholestasis; Biliary Cirrhosis; Hepatic Artery; Portal Vein; Color Doppler Ultrasound.


Cholestasis is accumulation of the bile in the liver cells and bile ducts due to obstruction of bile flow into the small intestine. Decrease in bile passage into the intestine or absence of it results in accumulation of the substances in the blood that normally excreted through the bile. As a consequence, stasis in the liver ensues and this in turn leads to degeneration of hepatocytes, deterioration in the liver function tests, elongation of blood clotting time, increase in the risk of hemorrhagic diathesis, mental changes due to high bilirubin levels and tendency for infections. As pathology progresses, biliary cirrhosis can develop and septic shock and death associated with severe gastrointestinal bleedings due to secondary portal hypertension (PHT) can be seen. Despite current modern diagnostic and therapeutic approaches, biliary cirrhosis and its complications, arising in bile duct obstructions, are still serious causes of morbidity and mortality [1]. Ultrasound (US) is the primary radiologic imaging method used in diagnosis and follow up of cholestasis. Dilatation in the bile ducts, bile stones, bile duct tumors and findings of cirrhosis such as changes in the liver parenchyma echo can be detected with US. However pathology may not be detected with ultrasound in many cases. Therefore US can be inadequate in the evaluation of biliary cirrhosis and subsequent complications such as PHT [2]. Intra and extra hepatic bile ducts and level and cause of obstruction can be assessed with computerized (CT) and magnetic resonance imaging (MRI), endoscopic retrograde cholangiography ⁄ERCP) and magnetic resonance cholangiography (MRCP) [3]. Although of these radiologic modalities CT and MRI can visualize intraabdominal vessels, they have a limited significance in diagnosis and follow up of PHT because adequate information on direction and velocity of the flow cannot be obtained. Although angiography is considered as the gold standard in diagnosis of PHT, it is not a suitable imaging method for routine use in diagnosis and follows up because it is an invasive and expensive modality and it cannot detect blood flow rate and output. On the other hand, Doppler US is a preferable imaging method because it is noninvasive, inexpensive, and easily repeatable and it can display hemodynamic changes easily by assessing the blood flow rate and flow characteristics [4].

In biliary cirrhosis and cirrhosis resulting from other causes, occurrence of hemodynamic changes in the liver and the other organs are expected [5]. For example splenic circulation and splenorenal shunts detection is important in the severity of the portal hypertension (of any type) of liver cirrhosis. These collateral veins are well diagnosed by Doppler US [6]. Before changes in biochemical parameters develop and in cases that are evaluated as normal by radiologic imaging methods, hemodynamic changes could have been developed asymptomatically. Therefore detection of possible hemodynamic changes is crucial in early diagnosis of the disease and in monitoring the progression in patients who are already diagnosed. We investigated the detection of early and advanced phase changes in the liver hemodynamic in the cases with cholestasis by Doppler US and we studied the role of the Doppler US parameters in diagnosis and follow up of the disease progression.

Patients and Methods


Patients with cholestasis admitted subsequently in Firat University Department of Radio diagnostics between March and September 2007. Patient group that consisted of 42 patients with elevated enzyme levels, patient group that consisted of 41 cases with elevated bilirubin, patient group with cholestasis and control group that consisted of 24 healthy individuals were studied prospectively.


Cholestasis diagnosis was made on laboratory and clinical findings. Liver function tests were within normal limits in all control cases. Goal and structure of the study was described to all patients initially and their consent was obtained.

Cases with viral hepatitis and those with history of alcohol intake were not included in the study.

All cases were examined with RDUS by a single radiologist after 8 hours of fasting. Patients were examined in supine and⁄or lateral decubitus position. US examinations were done with LOGIQ 7 Doppler ultrasound equipment (General Electric, Yokogawa Medical and System Tokyo–Japan) and multifrequency 3.5 MHz convex transducer. PVD, PV flow velocity, HA–RI and HA–PI were measured in all cases. HVI values were calculated by proportionate PV flow velocity to HA–PI. CI was calculated with the ratio of PV area to PVH, and PI was calculated by multiplying ratio of HA–RI to portal velocity with 100. In all measurements, wall filter was kept at minimum to enable detecting slow flow signals in late diastole without allowing interferences in spectral analysis due to vessel wall vibrations. In order to minimize measurement faults, lowest possible PRF adjustments were chosen lest it lead to aliasing formation. Special attention was paid to have the angle between US beam and the vessel to be examined at possible minimum value and below 60 degrees all the time.

Statistical Evaluation

Percentage, average and standard deviation were used in statistical evaluation of enzyme elevation and characteristics of patients with cholestasis and control group. Relation between control and patient group in terms of all Doppler parameters was evaluated using Student’s t test. For evaluating the relations of Doppler parameters with each other, Pearson correlation analysis was used.


General characteristics of the cases

Age of the 43 patients with elevated enzyme (24 male, 18 female) who were evaluated with RDUS ranged between 23 and 68 (mean 44.9). Age of the 41 patients in cholestasis group (24 male, 17 female) ranged between 25–72 (mean 55.4). Control group consisted of 24 healthy individuals (13 male, 11 female) whose ages ranged between 21 and 74 (mean 43.9). In terms of age and gender, there was not any statistically significant difference between the groups (Table 1–5).