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Case ID: 12864 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal Venous Thrombosis
	History	Abdominal Pain Diarrhea
	Findings	Early: - Acute right portal venous thrombosis - Peripheral hepatic septic emboli with infarction - Septic thrombophlebitis - Left retroperitoneal abscess Late: - Chronic right portal venous thrombosis with early cavernous transformation of the porta hepatis - Resolution of hepatic lesions and septic thrombophlebitis - Decrease in size of retroperitoneal abscess
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	John William Jaco :: National Capital Consortium -
	Reviewer	Marcia C. Javitt :: Walter Reed National Military Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 12450 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal Vein Embolization
	History	Patient with known HCC, is candidate for surgical resection but will need to increase the size of predicted remaining liver segments.
	Findings	CT images demonstrating patients HCC in the right lobe of the liver. Intraoperative venograms demonstrating embolization with no distal flow.
	Differential Dx	HCC Hemangiomas
	Discussion	... (continues ...)
	User Group
	Contributor	Amit Kumar Sanghi :: National Capital Consortium -
	Reviewer	Kenneth H Cho :: Walter Reed Army Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 11188 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Pneumatosis Intestinalis/portal Venous Gas
	History	76 yo man presents with 1.5 day history of increasing nausea, vomiting, and abdominal distention.
	Findings	Multiple linear and curvilinear lucencies are noted on the scout images throughout the liver, as well as multiple dilated air filled loops of small and large bowel. On the axial CT images, air was noted within the bowel wall completely surrounding the lumen throughout multiple loops of small bowel, as well as air within the mesenteric vasculature, and within the portal venous system peripherally to the edges of the liver.
	Differential Dx	• Mesenteric ischemia • Trauma • Small/Large Bowel obstruction • Infectious enterocolitis • Inflammatory enterocolitis • Post-operative • Medications, i.e. steroids, chemotherapy, immunosuppresants • Necrotizing enterocolitis (pediatric cases)
	Discussion	... (continues ...)
	User Group
	Contributor	Chuck A Kitley :: Madigan Army Medical Center -
	Reviewer	David T Nguyen, MD :: Madigan Army Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 10269 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Cavernous transformation of the portal vein
	History	57 yo female with several months of abdominal pain and bloating. Left tubo-ovarian torsion resected 3 months prior. Ultrasonography of the RUQ performed to assess mild elevation of transaminases.
	Findings	CT: Diffuse fatty infiltration of the liver is seen. Tortuosity and the development of additional vessels are present in the portal area. No portal vein thrombosis is seen. U/S: The liver is of increased diffuse echogenicity. Multiple dilated and tortuous tubular-appearing structures are seen in the portal area. No normal portal vein is seen. Color Doppler shows blood flow through these structures, consistent with periportal collateralization.
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	Daniel W Gabier :: Naval Medical Center Portsmouth -
	Reviewer	Stephanie A Bernard :: Penn State University - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 10087 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Hepatocellular carcinoma (hepatoma) with portal vein invasion and thrombosis
	History	62 y/o female with liver mass possibly hemangioma on CT scan for 3-phase CT scan of liver to evaluate. Pt with history of chronic Hepatitis B and is at risk for HCC (Hepatocellular Carcinoma).
	Findings	CT Findings Increased portal venous diameter (>13mm) portal vein thrombosis Ascites (not seen on these images) Enlarged splenic and mesenteric veins (>10mm, 10mm on these images) Porto-systemic collaterals
	Differential Dx	Differential for portal hypertension Prehepatic portal/Splenic Vein Occlusion Intraheptic Cirrhosis Metastatic Parasitic Posthepatic Cardiac (CHF, Tricuspid Insufficiency, Conststrictive Pericarditis) Hepatic Vein Occlusion (Budd-Chiari)
	Discussion	... (continues ...)
	User Group
	Contributor	Grant H Bonavia :: National Naval Medical Center Bethesda -
	Reviewer	Albert V Porambo :: Civilian Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 10034 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal Vein Thrombosis with cavernous transformation in metastatic pancreatic cancer
	History	51 year old Asian woman with right upper quadrant abdominal pain, nausea. 20 lb weightloss.
	Findings	CT: Cavernous transformation of the thrombosed portal vein occurs when small collateral veins adjacent to the portal vein expand and replace the obliterated portal vein. In this case, PV thrombosis is secondary to a pancreatic primary neoplasm with evidence of metastatic spread. The PV thrombus may be secondary to direct tumor extension or may be the sequelae of a paraneoplastic syndrome (hypercoagulable state). Peripheral hypodense liver lesions are likely metastases.
	Differential Dx	1. Tumor: Direct invasion of the PV, PV compression or paraneoplastic hypercoagulability 2. Cirrhosis 3. Infection (esp. in children) 4. Inflammation (pancreatitis) 5. Inherited coagulation disorders 6. Idiopathic
	Discussion	... (continues ...)
	User Group
	Contributor	Laura N Modzelewski :: National Naval Medical Center Bethesda -
	Reviewer	Elizabeth A. McGuigan :: National Naval Medical Center Bethesda - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 9933 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Mesenteric ischemia secondary to superior mesenteric vein thrombosis that extends into the portal vein.
	History	58 year old with metastatic pancreatic cancer and biliary stent placement with fever and RUQ pain.
	Findings	CT: Biliary stent in place. Heterogeneous pancreatic head mass. Liver demonstrates peripherally enhancing hypodense lesions compatible with metastatic disease. Intraluminal filling defect within the portal vein and superior mesenteric vein. Fat stranding of the mesentery with thickening of the intraluminal folds of small bowel.
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	Rick Riego de Dios :: National Capital Consortium -
	Reviewer	Albert V Porambo :: Civilian Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 9801 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Mesenteric and portal venous thrombosis
	History	50 y.o. man with new onset abdominal pain after recent Orthopedic surgery
	Findings	- There Is a Thrombus in the portal and Mesenteric Vein. - Engorgement of Mesenteric Vasculature. - Thickening and Enhancement Of Intestinal Wall. - Free Fluid in the Abdominal Cavity.
	Differential Dx	Differential diagnosis for dilated and thickened small bowel loops: - Vascular insuficiency. - Zollinger-Ellison syndrome. - Amyloidosis. - Lymphoma. - Abetalipoproteinemia
	Discussion	... (continues ...)
	User Group
	Contributor	ANA L MENDIZABAL :: Affiliation Unlisted - Please See Comments -
	Reviewer	Lynn Marie Bergren :: Naval Medical Center Portsmouth - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 8389 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal hypertension secondary to portal vein thrombosis
	History	50yo man with Hepatitis C who has developed increasing abdominal girth and early satiety.
	Findings	Intraluminal filling defect within the portal vein, which persisted on all phases of imaging. Large amount of free abdominal fluid (ascites). Lobular, shrunken liver - consistent with cirrhosis.
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	Joel McFarland :: National Naval Medical Center Bethesda -
	Reviewer	Albert V Porambo :: Civilian Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 8376 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	CT guided biopsy of liver revealed pt has cirrhosis with corresponding portal hypertension. The biopsy of the liver mass was consistent with focal fat deposit, but inconclusive, and will be re-biopsied for definitive diagnosis
	History	49 y/o white male with a history of heavy EtOH use (3-4 hard dinks per day over past 35 years) complains of persistent bruising after two recent falls in which he did not lose consciousness. Pt reports yellowing of his skin and eyes, and a bloated abdomen over past five days. He has had several no bleeds in the past two days, and two black and tarry foul smelling stools. No episodes of hemoptysis
	Findings	Ultrasound: Liver is echogenic with coarsened architecture and fatty infiltrate. There is a small mass in the left lobe. Triple phase contrast CT: Acites along the liver and pericolic gutter bilateral. Liver appears diffusely fatty. Evidence of portal hypertension such as cannulated umbilical artery, and esophageal varices. A hypoattenuated mass in the left lobe along the gallbladder fossa, which measures 6.1 x 4.5 cm. The region has decreased uptake, which is consistent with focal fat deposit.
	Differential Dx	With this patient’s history, clinical findings, and radiographic images, the differential is alcoholic hepatitis versus cirrhosis. Mass in the patient’s liver highly likely to be a hepatocellular carcinoma, but has a differential diagnosis of malignancy to include metastatic disease, and cholangiocarcinoma. A benign mass has the differential of a cyst, hemangioma, hepatic angioma, focal nodular hyperplasia, or an abcess.
	Discussion	... (continues ...)
	User Group
	Contributor	Russell A. Patterson :: Uniformed Services University -
	Reviewer	Julian Paul Kassner :: National Naval Medical Center Bethesda - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 7868 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Hepatocellular Carcinoma, with portal hypertension, portal vein thrombosis, esophageal varices, "caput medusa", ascites
	History	44 year-old male with known history of hepatocellular carcinoma with new onset of ascites.
	Findings	1.Heterogeneously enhancing tumor involving the entire right lobe of the liver and shrunken nodular appeareance of the liver 2.Marked ascites 3.Non-enhancement of the portal vein 4.Enlarged collateral esophageal varices 5.Superficial soft tissue swelling
	Differential Dx	Metastasis Hepatic Adenoma Focal Nodular Hyperplasia Cavernous Hemangioma
	Discussion	... (continues ...)
	User Group
	Contributor	Eduardo Escobar :: Walter Reed Army Medical Center -
	Reviewer	William R Carter, M.D. :: National Naval Medical Center Bethesda - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 6745 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal Vein Thrombosis
	History	71 year-old male three months post radio frequency ablation of liver malignancy.
	Findings	Near occlusive thrombosis is seen in the main portal vein with complete occlusion of the right portal vein, but trace contrast to the left portal vein. There is no evidence of enhancement within the thrombus. These findings suggest a bland thrombus.
	Differential Dx	Idiopathic, portal vein invasion or compression by tumor, post operative (splenectomy, transplant), blood dyscrasias, coagulopathies, sepsis, pylephlebitis, pancreatitis, cholangitis, suppurative lymphadenitis, cirrhosis, and portal hypertention.
	Discussion	... (continues ...)
	User Group
	Contributor	Christian LaCelle Carlson :: Brooke Army Medical Center -
	Reviewer	Neal C Dalrymple :: Wilford Hall USAF Medical Center - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 4835 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal venous thrombosis
	History	Clinical History: 40 yo male with abdominal pain.
	Findings	Findings: Filling defect and loss of normal contrast enhancement is seen in the portal vein, parts of the splenic and superior mesenteric vein. On certain images, a “train track” appearance is seen with contrast seen around the hypoattenuated clot. The patient also has ascites. Older study shows thickened loop of bowel consistent with ischemia.
	Differential Dx	Differential and Discussion: The etiology of portal venous thrombosis is varied. Extrinsic compression of the vessel by a mass, infection, trauma, pancreatitis, hepatic venous obstruction and hypercoagulable states are common causes. This patient had a history of pulmonary embolism and is being worked up for hypercoagulable states.
	Discussion	... (continues ...)
	User Group
	Contributor	Chun W Chen :: National Capital Consortium -
	Reviewer	James G. Smirniotopoulos, M.D. :: Uniformed Services University - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 4479 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Splenic Laceration => Right portal vein thrombosis => Transient hepatic attenuation difference (THAD)
	History	16-year-old with abdominal pain after blunt abdominal trauma during football practice two weeks earlier.
	Findings	• increased enhancement of the right hepatic lobe • decreased attenuation of the left hepatic lobe • right portal vein thrombosis • grossly heterogeneous spleen
	Differential Dx	• portal vein thrombosis • Hepatic hypoperfusion • Splenic infarcts
	Discussion	... (continues ...)
	User Group
	Contributor	John J. Combs :: National Capital Consortium -
	Reviewer	:: - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 4377 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal Hypertension with Gastroesophageal varices
	History	33 y.o. male with severe idiopathic granulomatous hepatitis.
	Findings	The liver is diffusely nodular and cirrhotic. There is a small amount of peri-capsular ascites. The spleen is enlarged. Numerous smooth tubular structures are present at the location of gastroesophageal vessels. The spleen is enlarged and splenorenal varices is present.
	Differential Dx	Lymphadenopathy * Neoplastic * Infecions Varices * portal Hypertension * IVC Obstruction ('uphill varicies') * SVC Obstruction ('downhill varices') Neurofibromas in NF-1
	Discussion	... (continues ...)
	User Group
	Contributor	Kevin F. McCarthy :: Civilian Medical Center -
	Reviewer	:: - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 3925 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal vein thrombosis and portal hypertension associated with alcoholic liver disease.
	History	A 43-year-old woman with alcoholic hepatitis and new-onset ascites, for which paracentesis was performed. Ultrasound (unavailable) demonstrated portal vein thrombosis. MR was obtained some time later, in the course of evaluation for transplantation.
	Findings	Axial and coronal gadolinium enhanced GRE images of the liver demonstrate massive hepatomegaly and a moderate amount of ascites. The right portal vein does not fill with contrast. There is contrast in the umbilical vein within the falciform ligament. No other venous collaterals are identified. The spleen is not grossly enlarged.
	Differential Dx	1. portal hypertension a. Cirrhosis is the most common cause in the West; b. Schistosomiasis is the most common cause world wide 2. Malignancy a. Primary or secondary hepatic malignancy b. Gastric carcinoma c. Pancreatic carcinoma d. Cholangiocarcinoma 3. portal or mesenteric pyelophlebitis, associated with appendicitis or diverticulitis 4. Hypercoaguable states 5. Iatrogenic causes a. Upper abdominal surgery b. Endoscopic sclerotherapy c. Hepatic transplantation 6. Inflammatory disorders a. Crohn's disease b. Ulcerative colitis c. Pancreatitis REFERENCE: Gore and Levine, Textbook of Gastrointestinal Radiology, pp. 1590-98, 1608-30, 1650-54.
	Discussion	... (continues ...)
	User Group
	Contributor	Christopher J Bennett :: National Capital Consortium -
	Reviewer	:: - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 3393 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Gallbladder wall thickening, secondary to portal venous hypertension from hepatic venocclusive disease (after bone marrow transplant)
	History	This is a 39-year-old female five and six days after bone marrow transplant for aplastic anemia. She had received chemotherapy and total lymphoid radiation prior to the transplant. Right upper quadrant pain and tenderness have been increasing for several days. Two ultrasound examinations are performed, the initial one at 5 days (Film 1) and the follow-up at 6 days (Films 2 and 3).
	Findings	In Film 1 the gallbladder (GB) wall is markedly thickened (1.7 cm), with a lamellated or striated appearance. Ascites is present. portal venous flow (not shown) is hepatopetal, normal in direction. One day later (Film 2), the GB wall thickening has increased to the point (2.3 cm) that the lumen is now obliterated. portal venous flow (Film 3) has reversed and is now hepatofugal.
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	Ultrasound Learning File - © ACR :: ACR Learning File® -
	Reviewer	James G. Smirniotopoulos, M.D. :: Uniformed Services University - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 3000 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	Biliary tree air from previous surgery (Film 1). portal venous air (Film 2).
	History	You are given two abdominal films to review (Films .1 and .2). One of the patients is in extremis and expired shortly after the film was obtained. The other patient complained of minimal abdominal discomfort. Can you tell which patient will soon be dead and why?
	Findings	There are tubular branched lucencies in the right upper quadrant of both patients. In Film .1 the air is centrally located over the liver (Film .1Z). There are surgical clips present. There is more small intestinal gas present than is usually seen but there is no dilatation to suggest an obstruction. In Film .2 the branching lucencies extend almost to the periphery of the liver (Film .3(zoom of Film .2)). There is extensive dilatation throughout the small bowel, and both linear and bubbly gas shadows representing infarcted bowel can be seen in the left abdomen (Film .4(zoom of Film .2)). Did you notice the left lower lobe air space process and malpositioned nasogastric tube in Film .2? Film .1 represents an example of air within the biliary tree in a patient who had a choledochojejunostomy. Film .2 represents air in the portal venous system from infarcted bowel. This patient expired and an autopsy showed extensive small bowel necrosis.
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	Gastrointestinal Learning File - © ACR :: ACR Learning File® -
	Reviewer	James G. Smirniotopoulos, M.D. :: Uniformed Services University - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

Case ID: 2834 Sample Image Click to View	:: - TF Case :: - Thumbnails :: - Topic ::


	Diagnosis	portal Vein Thrombosis
	History	The patient c/o intermittent epigastric pain for 3 weeks. The intensity of the pain is maximal 2 hours postprandially. He has also experienced nausea and vomiting. He denies any other symptoms.
	Findings	There is a hypodensity present in the porta hepatis. This finding is consistent with portal vein thrombosis. There are also collateral vessels visible.
	Differential Dx
	Discussion	... (continues ...)
	User Group
	Contributor	Anonymous Resident :: National Capital Consortium -
	Reviewer	:: - Case Accepted: 2009-07-08 12:27:33-04 :: Revised: :: Submitted:

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