title: Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations.
abstract: OBJECTIVE
  To explore portal hypertension and portosystemic shunts and to stage chronic liver disease (CLD) based on the pathophysiology of portal hemodynamics.
  
  
  METHODS
  Per-rectal portal scintigraphy (PRPS) was performed on 312 patients with CLD and liver angioscintigraphy (LAS) on 231 of them. The control group included 25 healthy subjects. We developed a new model of PRPS interpretation by introducing two new parameters, the liver transit time (LTT) and the circulation time between right heart and liver (RHLT). LTT for each lobe was used to evaluate the early portal hypertension. RHLT is useful in cirrhosis to detect liver areas missing portal inflow. We calculated the classical per-rectal portal shunt index (PRSI) at PRPS and the hepatic perfusion index (HPI) at LAS.
  
  
  RESULTS
  The normal LTT value was 24 +/- 1 s. Abnormal LTT had PPV = 100% for CLD. 27 non-cirrhotic patients had LTT increased up to 35 s (median 27 s). RHLT (42 +/- 1 s) was not related to liver disease. Cirrhosis could be excluded in all patients with PRSI < 5% (P < 0.01). PRSI > 30% had PPV = 100% for cirrhosis. Based on PRPS and LAS we propose the classification of CLD in 5 hemodynamic stages. Stage 0 is normal (LTT = 24 s, PRSI < 5%). In stage 1, LTT is increased, while PRSI remains normal. In stage 2, LTT is decreased between 16 s and 23 s, whereas PRSI is increased between 5% and 10%. In stage 3, PRSI is increased to 10%-30%, and LTT becomes undetectable by PRPS due to the portosystemic shunts. Stage 4 includes the patients with PRSI > 30%. RHLT and HPI were used to subtype stage 4. In our study stage 0 had NPV = 100% for CLD, stage 1 had PPV = 100% for non-cirrhotic CLD, stages 2 and 3 represented the transition from chronic hepatitis to cirrhosis, stage 4 had PPV = 100% for cirrhosis.
  
  
  CONCLUSIONS
  LTT allows the detection of early portal hypertension and of opening of transhepatic shunts. PRSI is useful in CLD with extrahepatic portosystemic shunts. Our hemodynamic model stages the evolution of portal hypertension and portosystemic shunts. It may be of use in the selection of patients for interferon therapy.
authors.affiliation: Department of Nuclear Medicine, Clinical Emergency Hospital, Prof Dr Octavian Fodor, Cluj-Napoca, Romania. dragoteanu@yahoo.co.uk
authors.forename: Mircea
authors.initials: M
authors.lastname: Dragoteanu
authors.forename: Ioan-A
authors.initials: IA
authors.lastname: Balea
authors.forename: Liliana-A
authors.initials: LA
authors.lastname: Dina
authors.forename: Cecilia-D
authors.initials: CD
authors.lastname: Piglesan
authors.forename: Ioana
authors.initials: I
authors.lastname: Grigorescu
authors.forename: Stefan
authors.initials: S
authors.lastname: Tamas
authors.forename: Sabin-O
authors.initials: SO
authors.lastname: Cotul
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D002908:Chronic Disease; D005260:Female; D006801:Humans; D006975:Hypertension, Portal / Q000000981:diagnostic imaging / Q000503:physiopathology*; D008099:Liver / Q000098:blood supply / Q000503:physiopathology; D008107:Liver Diseases / Q000000981:diagnostic imaging / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D009683:Nuclear Medicine / Q000379:methods*; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D011877:Radionuclide Imaging; D012039:Regional Blood Flow; D012720:Severity of Illness Index