CC BY-NC-ND 4.0 · Journal of Gastrointestinal and Abdominal Radiology 2021; 4(03): 177-193
DOI: 10.1055/s-0041-1728235
Review Article

Imaging of Portal Gastroduodenopathy

Rajesh V. Helavar
1   Department of Diagnostic and Interventional Radiology, Columbia Asia Radiology Group, Bengaluru, Karnataka, India
Vidyasagar Ramappa
2   Department of Gastroenterology and Hepatology, Columbia Asia Referral Hospital, Bengaluru, Karnataka, India
Praveen P. Wali
3   Department of Diagnostic Radiology, Columbia Asia Radiology Group, Bengaluru, Karnataka, India
› Author Affiliations


Portal hypertension is characterized by elevated pressure in portal venous system due to portal resistance due to various causes. The etiologies are either pre-hepatic, hepatic, or post-hepatic. Elevated portal pressure results in varices at various sites some of which are difficult to identify on endoscopy alone. Other manifestations of elevated portal pressure include portal gastropathy, enteropathy, colopathy, gastric antral vascular ectasia, and ascites. Imaging plays an essential role in diagnosis and imaging of various manifestations of portal hypertension by determining the locations of varices and plan the management for same. Endoscopy helps in visualizing mucosal varices but newer imaging modalities give a panoramic extent of the disease in the entire gastrointestinal tract with great specificity and sensitivity. Initially, Barium study was used to determine esophageal or gastric varices, computed tomography provides detailed anatomic information which can be used to plan management. Due to advancement in imaging and interventional techniques, treatment for varices has seen advent of multiple minimally invasive interventional radiological techniques. A brief outlook on anatomical aspect of varices and various recent advances in management of the same has been provided. Overall knowledge of the various imaging manifestations of portal hypertension can be helpful to evaluate prognosis and plan proper management.

Publication History

Article published online:
09 August 2021

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  • References

  • 1 Widrich WC, Srinivasan M, Semine MC, Robbins AH. Collateral pathways of the left gastric vein in portal hypertension. AJR Am J Roentgenol 1984; 142 (02) 177-193
  • 2 Sharma M, Rameshbabu CS. Collateral pathways in portal hypertension. J ClinExpHepatol 2012; 2 (04) 338-352
  • 3 da Silva A, Navarro T, Oliveira S, Faion A, Ferreira L. Posterior gastric vein, portal hypertension. Rev Col Bras Cir 1999;XXVI(5)
  • 4 Johns TN, Evans BB. Collateral pathways in portal hypertension. Ann Surg 1962; 155: 838-845
  • 5 Moubarak E, Bouvier A, Boursier J. et al Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review. Abdom Imaging 2012; 37 (05) 746-766
  • 6 Sharma M, Babu CS, Dhiman RK, Chawla Y. Induced hypotension in the management of acute hemobilia during therapeutic ERCP in a patient with portal biliopathy (with videos). Gastrointest Endosc 2010; 72 (06) 1317-1319
  • 7 D’Amico G, De Franchis R. Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology 2003; 38 (03) 599-612
  • 8 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
  • 9 Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16 (06) 1343-1349
  • 10 Watanabe N, Toyonaga A, Kojima S. et al Current status of ectopic varices in Japan: results of a survey by the Japan Society for Portal Hypertension. Hepatol Res 2010; 40 (08) 763-776
  • 11 Eisenberg R. Gastrointestinal Radiology. Philadelphia, PA: Lippincott Williams and Wilkins;2003:125–130
  • 12 Farber E, Fischer D, Eliakim R. et al Esophageal varices: evaluation with esophagography with barium versus endoscopic gastroduodenoscopy in patients with compensated cirrhosis–blinded prospective study. Radiology 2005; 237 (02) 535-540
  • 13 Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: evaluation with CT. Radiographics 1995; 15 (03) 609-622
  • 14 Kiyosue H, Ibukuro K, Maruno M, Tanoue S, Hongo N, Mori H. Multidetector CT anatomy of drainage routes of gastric varices: a pictorial review. Radiographics 2013; 33 (01) 87-100
  • 15 Saad WE. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol 2013; 16 (02) 60-100
  • 16 Laleman W, Simon-Talero M, Maleux G. et al EASL-CLIF-Consortium. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology 2013; 57 (06) 2448-2457
  • 17 Uflacker R, Silva AdeO, d’Albuquerque LA, Piske RL, Mourão GS. Chronic portosystemic encephalopathy: embolization of portosystemic shunts. Radiology 1987; 165 (03) 721-725
  • 18 Payen JL, Calès P, Voigt JJ. et al Severe portal hypertensive gastropathy and antral vascular ectasia are distinct entities in patients with cirrhosis. Gastroenterology 1995; 108 (01) 138-144
  • 19 McCormack TT, Sims J, Eyre-Brook I. et al Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy?. Gut 1985; 26 (11) 1226-1232
  • 20 Kodama M, Uto H, Numata M. et al Endoscopic characterization of the small bowel in patients with portal hypertension evaluated by double balloon endoscopy. J Gastroenterol 2008; 43 (08) 589-596
  • 21 Bini EJ, Lascarides CE, Micale PL, Weinshel EH. Mucosal abnormalities of the colon in patients with portal hypertension: an endoscopic study. GastrointestEndosc 2000; 52 (04) 511-516
  • 22 Kim TU, Kim S, Woo SK. et al Dynamic CT of portal hypertensive gastropathy: significance of transient gastric perfusion defect sign. Clin Radiol 2008; 63 (07) 783-790
  • 23 Ishihara K, Ishida R, Saito T, Teramoto K, Hosomura Y, Shibuya H. Computed tomography features of portal hypertensive gastropathy. J Comput Assist Tomogr 2004; 28 (06) 832-835
  • 24 Walker L, Kumari D, Bochnakova T, Davidson J, Patel I, Tavri S. Left sided portal hypertension in the presence or absence of splenic vein thrombosis: a single tertiary center experience):. J Vasc Interv Radiol 2018; 29 (04) 231-233
  • 25 Koklu S, Coban S, Yuksel O, Arhan M. Left-sided portal hypertension. Dig Dis Sci 2007; 52 (05) 1141-1149
  • 26 Pereira P, Peixoto A. Left-Sided Portal Hypertension: A Clinical Challenge. GE Port J Gastroenterol 2015; 22 (06) 231-233
  • 27 de Franchis R. Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53 (04) 762-768
  • 28 Sebastian B, Singhal S, Madhurkar R, Alex A, Uthappa M. Role of splenic artery embolization in gastric variceal hemorrhage due to sinistral portal hypertension. Journal of Clinical Interventional Radiology 2019; 3: 27-36
  • 29 Patidar KR, Sydnor M, Sanyal AJ. Transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2014; 18 (04) 853-876
  • 30 Keller FS, Farsad K, Rosch J. The transjugular intrahepatic portosystemic shunt: technique and instruments. Tech Vasc Interv Radiol 2016; 19 (01) 2-9
  • 31 Shah RP, Sze DY. Complications duringtransjugular intrahepatic portosystemic shunt creation. Tech Vasc Interv Radiol 2016; 19 (01) 61-73
  • 32 Suhocki PV, Lungren MP, Kapoor B, Kim CY. Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Intervent Radiol 2015; 32 (02) 123-132
  • 33 Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol 2013; 16 (02) 101-151
  • 34 Park JK, Saab S, Kee ST. et al Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-analysis. Dig Dis Sci 2015; 60 (06) 1543-1553
  • 35 Kim YH, Kim YH, Kim CS, Kang UR, Kim SH, Kim JH. Comparison of balloon-occluded retrograde transvenous obliteration (BRTO) using ethanolamine oleate (EO), BRTO using sodium tetradecyl sulfate (STS) foam and vascular plug-assisted retrograde transvenous obliteration (PARTO). Cardiovasc Intervent Radiol 2016; 39 (06) 840-846
  • 36 Kim DJ, Darcy MD, Mani NB. et al Modified balloon-occluded retrograde transvenous obliteration (BRTO) techniques for the treatment of gastric varices: vascular plug-assisted retrograde transvenous obliteration (PARTO)/coil-assisted retrograde transvenous obliteration (CARTO)/balloon-occluded antegradetransvenous obliteration (BATO). Cardiovasc Intervent Radiol 2018; 41 (06) 835-847
  • 37 Wang ZW, Liu JC, Zhao F. et al Comparison of the effects of TIPS versus BRTO on bleeding gastric varices: a meta-analysis. Can J Gastroenterol Hepatol 2020; 2020: 5143013
  • 38 Saad WE, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol 2011; 28 (03) 339-349
  • 39 Al-Osaimi AM, Sabri SS, Caldwell SH. Balloon-occluded retrograde transvenous obliteration (BRTO): preprocedural evaluation and imaging. SeminInterventRadiol 2011; 28 (03) 288-295
  • 40 Sauer BG, Sabri SS, Shami VM, Al-Osaimi AM. Balloon-occluded retrograde transvenous obliteration (BRTO): follow-up and postprocedural imaging. Semin Intervent Radiol 2011; 28 (03) 325-332