Increasing pain in the right hypochondrium and disturbed breathing due to a mobile diaphragmatic compression of the vena cava and the liver veins with congestion of the liver and even the small bowel
A 57 years old lady presented with unbearable pain in the right upper abdomen below the rib cage at a constant level during daytime of 8/10 which could be only suppressed by amitriptyline at night to a level allowing sleep.
The medical history revealed a pleural effusion some years ago and pneumonia residuals in the thoracic CT scans.
Striae distensae on both breasts as well as an inverted nipple on the left breast were remarkable. The auscultation of the lungs and the abdominal palpation did not reveal any specifics. The constant upper abdominal pain which was radiating from the lateral hypochondrium towards the midline and then down to the umbilicus could not be by palpation.
The ultrasound examination revealed a localized flow acceleration at the mouth of the liver veins into the vena cava exactly at the height of the diaphragm. Deep inside the liver the flow velocity in the middle hepatic vein was at maximum 25 cm/s. It increased in midposition of the diaphragm to 98 cm/s at the confluence of the liver veins. In deep inspiration as well as in deep expiration the flow velocity increased at that location. In expiration at maximum 204 cm/s were achieved whereas in deep inspiration 125 cm/s was the maximum flow velocity.
The portal flow volume changed dramatically during respiration. In midposition of the diaphragm the flow volume within the portal vein was calculated with 2249 mL/min dropping to only 823 mL/min in deep expiration whereas in inspiration 1919 mL/min could be measured. The liver was not enlarged with a height of 12.5 cm in the right medioclavicular line.
For the first time a 4D- volume flow measurement of the superior mesenteric vein was done revealing a flow volume of 138 mL/min in midposition of the diaphragm whereas in deep expiration it dropped to 82 mL/min.
The best of my knowledge this is the first description of a diaphragmatic compression of the vena cava and the liver veins which produced a measurable effect onto the venous drainage of the bowel. The patient was constipated and was suffering from decreased peristalsis and lost 8 kg of body weight.
To my knowledge, this is the first sonographic proof of functional hepatic vein compression with congestion symptoms in the liver and intestine and the first ever use of color duplex sonographic 4D volume flow measurement of a vein.
Video of the 4D-dataset of the superior mesenteric vein – horizontal cut in the right lower corner
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