Ultraschall bei Pfortaderhochdruck – Teil 2 – und EFSUMB-Empfehlungen zur Durchführung und Dokumentation von Ultraschalluntersuchungen bei Pfortaderhochdruck

Empfehlung 

Bei Patienten mit eindeutigen klinischen Befunden eines Pfortaderhochdrucks ist die Duplex-Doppler-Sonografie eine sehr treffsichere Methode zur Klärung der Ätiologie.

Insbesondere kann sowohl eine Pfortaderthrombose als auch eine Lebervenenthrombose mittels Duplex/Doppler-US diagnostiziert oder ausgeschlossen werden.

Wie in [Tab. 1], [2] genau beschrieben, können die zu untersuchenden und dokumentierenden Parameter, je nach Qualifikation der Einrichtung, zu der der Patient zur Erstuntersuchung überwiesen wurde, variieren. Wenn keine Diagnose gestellt werden kann oder der untersuchende Arzt keine ausreichenden Informationen für eine adäquate klinische Betreuung gewinnen kann, sollte der Patient in einer höher spezialisierten Ultraschall-Einrichtung oder mit anderen diagnostischen Techniken untersucht werden.

Empfehlungen 

Bei allen Patienten mit chronischen Lebererkrankungen sollte bei Erstdiagnose eine dopplersonografische Untersuchung durchgeführt werden, um das Vorliegen einer Zirrhose und eines Pfortaderhochdrucks zu erkennen, da die US-Befunde bei der Diagnose dieser Erkrankungen eine zufriedenstellende Sensitivität und hohe Spezifität besitzen.

Die unverzichtbaren Befunde, nach denen gesucht werden muss ([Tab. 2]), sind: Zeichen einer Zirrhose, Durchgängigkeit der Pfortader, deren Durchmesser und Richtung des Blutflusses, Durchmesser der Milz- und Mesenterialvenen mit Darstellung deren respiratorischen Differenzen und Flussrichtung, Milzgröße, Nachweis/Fehlen von portosystemischen abdominalen Kollateralen und Nachweis/Fehlen von Aszites.

Die meisten dopplersonografischen Befunde besitzen eine hohe Spezifität für die Diagnose eines klinisch signifikanten Pfortaderhochdrucks. Da die Doppler-Sonografie nicht invasiv und wiederholbar ist, wird, wie in [Tab. 1], [2] (Tab. 2 finden Sie online unter www.thieme-connect.de/ejournals). gezeigt, wird die Erhebung dieser speziellen Befunde in jeder Einrichtung unabhängig von deren Zentrumsstufe empfohlen.

Die dopplersonografische Untersuchung sollte bei Patienten mit Zirrhose jedes Mal bei Auftreten einer neuen klinischen Symptomatik wiederholt werden, um eine Pfortaderthrombose oder ein hepatozelluläres Karzinom auszuschließen, welche die häufigsten Ursachen für eine plötzliche Verschlechterung des Pfortaderhochdrucks und der klinischen Dekompensation sind.

Empfehlungen 

Bei Patienten mit Zirrhose und Pfortaderhochdruck bietet die Doppler-Sonografie keine exakten Informationen über das hämodynamische Ansprechen auf Betablocker, die zur Vermeidung von Varizenblutungen eingesetzt werden. Daher kann sie nicht eingesetzt werden, um zwischen Respondern und Non-Respondern der medikamentösen Therapie zu unterscheiden.

Die Doppler-Sonografie ist sinnvoll und wird daher zur nicht invasiven Nachuntersuchung von Patienten mit TIPS, postosystemischen chirurgischen Anastomosen und Meso-Rex-Bypass empfohlen.

Recommendation 

In patients with clear clinical signs of portal hypertension, duplex Doppler US is an accurate method to establish the cause.

Specifically, portal vein thrombosis and hepatic vein thrombosis can be identified or ruled out by duplex Doppler US.

The parameters to be investigated and reported may vary according to the level of expertise of the center to which the patient is referred for first examination, as detailed in [ Tables 1], [2] (Tab. 2, see online: www.thieme-connect.de/ejournals). If a diagnosis is not reached or the clinician in charge has not obtained enough information for adequate clinical management, the patient is to be assessed by US at a higher level of care or by other diagnostic techniques.

Recommendation 

All patients with chronic liver diseases should undergo a US Doppler examination at the time of first diagnosis to assess the presence of signs of cirrhosis and portal hypertension, since US signs provide satisfactory sensitivity and a high specificity for the diagnosis of these conditions.

The essential parameters to be described ([Table 2]) (Tab. 2, see online: www.thieme-connect.de/ejournals) are: signs of cirrhosis, portal vein patency, diameter and direction of flow, splenic vein and mesenteric vein diameters with respiratory variation and direction of flow, spleen size, presence/absence of porto-systemic abdominal collaterals and presence/absence of ascites.

Most US Doppler signs show high specificity for the diagnosis of clinically significant portal hypertension. Since US Doppler is noninvasive and repeatable, the search for these specific findings according to the level of care reported in [ Tables 1], [2] (Tab. 2, see online: www.thieme-connect.de/ejournals) is recommended.

US Doppler examination should be repeated in patients with cirrhosis every time a new clinical event occurs, to rule out portal vein thrombosis and hepatocellular carcinoma, which are frequent causes of rapid worsening of portal hypertension and clinical decompensation.

Recommendation 

Doppler US does not provide accurate information on the hemodynamic response to beta-blockers, utilized for the prevention of variceal bleeding, in patients with cirrhosis and portal hypertension. Thus, it cannot be utilized to discriminate responders from non-responders to drug treatment.

Doppler US is useful and recommended for the noninvasive follow-up of patients with TIPS, porto-systemic surgical shunts and meso-Rex bypass.

^* EFSUMB Education and Professional Standards Committee members: Jan Tuma (chairman); Radu Badea, Vito Cantisani, Christoph F. Dietrich, Hilde Berner Hammer, Gebhard Mathis, Dieter Nürnberg, Frantisek Zatura.

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