摘要
研究背景
门静脉高压症（Portal Hypertension, PHT）是肝硬化严重的并发症，肝性脑病、腹水、食管静脉曲张（Esophageal Varices，EV）等等都与门静脉高压相关。尤其食管静脉曲张破裂出血（Esophageal Variceal Bleeding, EVB）是肝硬化门静脉高压最常见的致死性并发症，重度曲张静脉出血的年发生率高达15-30%，6周内的总死亡率高达20%-50%。尽管内镜检查、HVPG测定在诊断PHT、EV及预测EVB风险中发挥着重要作用，但作为PHT患者长期随访的检查手段，反复检查的耐受性、有创性以及对EVB风险预测的准确性方面依然有不尽如人意之处。寻找适合临床常规开展、患者易于接受、能够客观准确诊断门静脉高压、食管静脉曲张及预测EVB风险的检查方法或指标，依然是肝硬化患者长期随访过程中亟待解决的关键问题之一。
研究目的
1)探讨超声造影肝内循环时间参数（肝动脉肝静脉渡越时间，HV-HA；肝动脉门静脉间隔时间，PV-HA）评估门静脉压力可行性，对比分析超声造影肝内循环时间参数及肝脏血管多普勒超声参数（门静脉内径PVD，门静脉流速PVV，肝动脉阻力指数HARI，肝动脉搏动指数HAPI）评估门静脉高压的价值。
2)探讨超声造影肝内循环时间参数评估食管静脉曲张程度，对比分析ICT参数及肝脏血管多普勒超声参数在诊断食管静脉曲张中的应用价值。
3)探讨食管静息状态及吞咽状态对经腹超声食管下段曲张静脉彩色多普勒血流信号显示率的影响，以及食管下段曲张静脉多普勒血流信号半定量分级在EV评估中的应用。
资料与方法
本研究分别以游离门静脉压力（FPP）及胃镜下食管静脉曲张分级作为参照标准，通过超声造影测定造影剂肝内循环时间参数（HV-HA、PV-HA）及多普勒超声测量门静脉及肝动脉血流动力学参数（PVD、PVV、HARI、HAPI），分析两种超声成像模式下的超声造影参数及多普勒超声参数与游离门静脉压力及EV程度间的相关性。
采用自身前后对比分析的方法，研究食管静息及吞咽两种不同状态，对经腹超声食管下段曲张静脉彩色多普勒血流信号显示率的影响，并以胃镜食管静脉曲张分级为金标准，将经腹超声食管下段曲张静脉彩色多普勒血流信号半定量分级与胃镜EV分级做对照分析。
1)对31例乙型肝炎感染后患者行超声造影肝内循环时间及肝脏血管超声参数测定，并测定游离门静脉压力（Free portal pressure,FPP）。分析超声造影肝内循环时间及肝脏血管多普勒超声参数与门静脉压力间相关性。
2)对36例乙肝后肝硬化门静脉高压可疑食管静脉曲张患者行超声造影肝内循环时间及肝脏血管超声参数测定，并行胃镜检查对食管曲张静脉进行分级。分析超声造影肝内循环时间及肝脏血管多普勒超声参数与食管静脉曲张程度间相关性。
3)对34例EV患者行经腹超声食管下段及胃镜检查，对比分析食管静息状态及舒张状态对经腹超声食管下段曲张静脉血流显示率的影响，食管下段EV超声血流信号半定量分级与内镜EV分级相关性对照研究。
结果
1)超声造影肝内循环时间评估门静脉压力：超声造影剂肝内循环时间各参数在门静脉高压组及非门静脉高压组间差异有显著性意义。与非门静脉高压组相比较，门静脉高压组患者造影剂肝静脉到达时间（20.26±2.37vs26.33±1.63，P=0.001）及肝动脉肝静脉渡越时间（8.26±1.94vs13.83±1.17，P<.001）明显缩短，门静脉到达时间（25.13±2.37vs19.75±2.10，P<.001）及门静脉肝动脉间隔时间（13.13±2.25vs7.25±1.81，P<.001）明显延长。与肝脏血管多普勒超声参数相比较，肝动脉肝静脉渡越时间及肝动脉门静脉间隔时间与FPP间有更高相关性，其相关系数分别为r=-0.900，P<0.001，r=0.808，P<0.001。
2)超声造影对食管静脉曲张程度的诊断价值：HV-HA, PV-HA及HAPI在EV轻度、中度及重度各组间差异有显著性意义（P＜0.05），门静脉内径在重度与轻度或中度间差异有统计学意义（P＜0.05），而轻度组和中度组间差异无显著性意义，门静脉流速及肝动脉阻力指数在各组间差异无统计学意义。尤其超声造影HV-HA参数能够显著提高超声对重度EV诊断的准确性，ROC曲线AUC值达0.887，以8.63s为截断值，其诊断重度EV的敏感性及特异性分别为83%和76%。
3)吞咽状态对经腹超声评估食管静脉曲张的影响：食管静息状态下，EV组曲张静脉彩色多普勒血流信号显示率为67%，而食管吞咽状态下，能够显著提高该血流信号显示率，其显示率高达87%，同时能够提高血流信号丰富程度分级；随内镜下食管静脉曲张程度的增高，经腹超声食管下段曲张静脉彩色血流信号丰富程度增加，评分等级提高。以经腹超声食管下段曲张静脉彩色血流信号分级达2级以上为截断值，其诊断中重度EV的敏感性及特异性分别为82%和85%。
结论
1)以游离门静脉压作为参照标准，对比研究超声造影肝内循环时间参数及肝脏血管多普勒超声参数对门静脉高压的评估价值，结果显示，与多普勒超声参数相比，超声造影肝内循环时间参数与游离门静脉压力间有着更好的相关性。
2)以胃镜下食管静脉曲张分级作为评估EV的金标准，对比分析超声造影肝内循环时间参数及肝脏血管多普勒超声参数在诊断EV中的应用价值，结果显示，超声造影HV-HA参数能够显著提高超声对重度EV诊断的准确性，其诊断重度EV的敏感性及特异性分别为83%和76%。
3)将经腹超声食管下段曲张静脉彩色多普勒血流信号进行半定量分级，以胃镜食管静脉曲张分级为金标准，对比分析食管静息状态及吞咽状态下经腹超声对EV血流信号显示率。结果表明，吞咽状态下，经腹超声食管下段曲张静脉彩色多普勒血流信号显示率显著提高，食管下段血流信号分级有利于经腹超声对EV程度的半定量判断。
Introductions
Portal hypertension is a severe complication of chronic liver diseases andcirrhosis. Portal hypertension is a contributing factor for the development of ascitesand hepatic encephalopathy and a direct cause of esophageal variceal and of bleedingrelated death. Esophageal variceal bleeding occurs at a yearly rate of15%-30%inpatients with large varices. And it is associated with a mortality of at least20%at6weeks. Even if HVPG and endoscopy play important roles in evaluating portalpressure and esophageal variceal, both examinations are invasive, low tolerated, andare less favorable for the follow-up of cirrhosis patients. So satisfactory replacementsfor HVPG and endoscopy must be found to better evaluate portal pressure andesophageal variceal.
Objectives
1) To assess whether intrahepatic circulation time analysis can be used to predictportal venous pressure severity. To compare the values of the parameters ofCEUS and CDFI in the evaluation of the portal hypertension.
2) To assess whether intrahepatic circulation time analysis can be used toevaluate esophageal varices degree. To compare the values of the parametersof CEUS and CDFI in the evaluation of esophageal varices.
3) To assess the capability of transabdominal ultrasound in exploring theesophageal varices under different functional status of esophagus. To assess the values of the color doppler grades by transabdominal ultrasound indiagnosis of EV grades.
Methods
This study takes the free portal pressure (FPP) and endoscopy as gold standards.The CEUS and CDFI parameters of liver were measured in patients. The correlationsbetween ultrasound parameters and FPP or endoscopy were analysed. The esophagealvarices were evaluated by transabdominal ultrasound and endoscopy under differentfunctional status of esophagus. The correlations between ultrasound color Dopplergrades and endoscopic grades were analysed.
1) The CEUS and CDFI parameters of liver and free portal pressure weremeasured in31patients with hepatitis B virus–related liver disease. Pearsoncorrelation analysis was used to assess the correlation between the parametersof ultrasound and free portal pressure.
2) The CEUS and CDFI parameters of liver and endoscopy were measured in36patients with hepatitis B virus–related liver disease. The correlation wasanalyzed between the parameters of ultrasound and esophageal varices.
3) The esophageal varices were examined use transabdominal ultrasound andendoscopy in34patients with PHT under different functional status ofesophagus.The display rate of EV color Doppler signal under differentfunctional status of esophagus was analysed. Compared the relations betweencolor Doppler signal grades and the endoscopy grades of EV.
Results
1) The relations between the parameters of CEUS and FPP:The hepatic vein-hepatic artery (HV-HA) interval times were significantly shorter in the portal hypertension (PHT) group compared with those in the non-PHT group(8.26±1.94s and13.83±1.17s, respectively; p<0.001). The portal vein-hepatic artery(PV-HA) interval times were significantly longer in the PHT group compared withthose in the non-PHT group (13.13±2.25s and7.25±1.81s, respectively; p<0.001).Considering the whole patient population, there were statistically significantcorrelations between FPP and HV-HA interval time, PV-HA interval time (r=-0.900,p<0.001; r=0.808, p<0.001; respectively). Compared with the parameters of CDFI,the HV-HA interval time has more significant correlations with FPP.
2) The diagnostic value of CEUS in assessing esophageal varices degree.
HV-HA interval time, PV-HA interval time, and HAPI showed significantdifference between each two group（sP＜0.05）.PVD has significant difference betweenserious group and moderate group or mild group（P＜0.05）, but there was no differencbetween moderate group and mild group. PVV and HARI have no difference betweeneach two groups.HV-HA has high accuracy rate in diagnosis of serious EV, which has asensitivity and specificity of83%,76%with the cutoff equal8.63s.
3) Transabdominal ultrasound evaluate EV in the state of swallowing.
Compared with the supine positions, the right side up obligue position can be easyexploring the esophageal varices. EV color Doppler signal was seen in67%patientsunder esophagus rest state, while the signal was seen in87%patients under esophagusswallowing state. The EV color Doppler signal grade was correlation with EV gradediagnosed by endoscopy.
Conclusions
1) ICT measurement is correlated with FPP, which has potential capability toevaluate portal pressure by non-invasive method in patients with HBV-related liver disease.
2) ICT measurement is correlated with EV degree, HV-HA has high accuracyrate in diagnosis of serious EV, which has a sensitivity and specificity of83%,76%with the cutoff equal8.63s.
3) Swallowing can significantly increase the display rate of esophageal varices.The EV color Doppler signal grade under esohpageal relaxation state haspotential role in non-invasive assess EV for PHT patients follow up.
引文
1. Merli M, Nicolini G, Angeloni S et al. Incidence and natural history of smallesophageal varices in cirrhotic patients. J Hepatol2003;38:266-72.
2. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liverand esophageal varices. A prospective multicenter study. N Engl J Med1988;319:983-9.
3. El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an11-year period in the Department of Veterans Affairs. Am J Gastroenterol2000;95:3566-73.
4. Carbonell N, Pauwels A, Serfaty L et al. Improved survival after varicealbleeding in patients with cirrhosis over the past two decades. Hepatology2004;40:652-9.
5. Groszmann RJ, Garcia-Tsao G, Bosch J et al. Beta-blockers to preventgastroesophageal varices in patients with cirrhosis. N Engl J Med2005;353:2254-61.
6. Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet2003;361:952-4.
7. Garcia-Tsao G, Groszmann RJ, Fisher RL et al. Portal pressure, presence ofgastroesophageal varices and variceal bleeding. Hepatology1985;5:419-24.
8. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradientreduction and prevention of variceal bleeding in cirrhosis: a systematic review.Gastroenterology2006;131:1611-24.
9. Goyal AK, Pokharna DS, Sharma SK. Ultrasonic measurements of portalvasculature in diagnosis of portal hypertension. A controversial subjectreviewed. J Ultrasound Med1990;9:45-8.
10. Wachsberg RH, Simmons MZ. Coronary vein diameter and flow direction inpatients with portal hypertension: evaluation with duplex sonography andcorrelation with variceal bleeding. AJR Am J Roentgenol1994;162:637-41.
11. Gibson RN, Gibson PR, Donlan JD, Clunie DA. Identification of a patentparaumbilical vein by using Doppler sonography: importance in the diagnosisof portal hypertension. AJR Am J Roentgenol1989;153:513-6.
12. von Herbay A, Frieling T, Haussinger D. Color Doppler sonographic evaluationof spontaneous portosystemic shunts and inversion of portal venous flow inpatients with cirrhosis. J Clin Ultrasound2000;28:332-9.
13. Gaiani S, Bolondi L, Li Bassi S et al. Prevalence of spontaneous hepatofugalportal flow in liver cirrhosis. Clinical and endoscopic correlation in228patients. Gastroenterology1991;100:160-7.
14. Haag K, Rossle M, Ochs A et al. Correlation of duplex sonography findings andportal pressure in375patients with portal hypertension. AJR Am J Roentgenol1999;172:631-5.
15. Baik SK, Kim JW, Kim HS et al. Recent variceal bleeding: Doppler US hepaticvein waveform in assessment of severity of portal hypertension and vasoactivedrug response. Radiology2006;240:574-80.
16. Kim MY, Baik SK, Park DH et al. Damping index of Doppler hepatic veinwaveform to assess the severity of portal hypertension and response topropranolol in liver cirrhosis: a prospective nonrandomized study. Liver Int2007;27:1103-10.
17. Zhang L, Duan YY, Li JM, Yin JK. Hemodynamic features of Dopplerultrasonography in patients with portal hypertension: intraoperative directmeasurement of portal pressure in the portal venous system. J Ultrasound Med2007;26:1689-96.
18.梁红梅,李艳玲,刘莉蓉,齐志国.彩色多普勒超声相关指数与门脉高压病例门脉压力相关性的实验研究.实用医学影像杂志2010;11:185-8.
19. Vizzutti F, Arena U, Rega L et al. Performance of Doppler ultrasound in theprediction of severe portal hypertension in hepatitis C virus-related chronicliver disease. Liver Int2007;27:1379-88.
20. Chiu KC, Sheu BS, Chuang CH. Portal venous flow pattern as a useful tool forpredicting esophageal varix bleeding in cirrhotic patients. Dig Dis Sci2005;50:1170-4.
21. Nelson RC, Sherbourne GM, Spencer HB, Chezmar JL. Splenic venous flowexceeding portal venous flow at Doppler sonography: relationship toportosystemic varices. AJR Am J Roentgenol1993;161:563-7.
22. Yin XY, Lu MD, Huang JF et al. Color Doppler velocity profile assessment ofportal hemodynamics in cirrhotic patients with portal hypertension: correlationwith esophageal variceal bleeding. J Clin Ultrasound2001;29:7-13.
23.罗蓉,赵健雄.彩超对肝硬化门、脾静脉血流量检测与电子胃镜食管胃底静脉曲张相关性的观察.重庆医学2011;40.
24. Agha A, Abdulhadi MM, Marenco S et al. Use of the platelet count/spleendiameter ratio for the noninvasive diagnosis of esophageal varices in patientswith schistosomiasis. Saudi J Gastroenterol2011;17:307-10.
25. Sarangapani A, Shanmugam C, Kalyanasundaram M et al. Noninvasiveprediction of large esophageal varices in chronic liver disease patients. Saudi JGastroenterol2010;16:38-42.
26. Barikbin R, Hekmatnia A, Omidifar N et al. Prediction severity of esophagealvarices: a new cutoff point for Platelet count/spleen diameter ratio. MinervaGastroenterol Dietol2010;56:1-6.
27. Li X, Wu K, Fan D. Insulin resistance and platelet count/spleen diameter ratio:two simple, easy-to-get tests for predicting esophageal varices in cirrhosis.Hepatology2009;49:1394; author reply-5.
28.黎强,周良,张煜成et al.二维及能量多普勒超声在食管腹段静脉曲张诊断的探讨.影像诊断与介入放射学2008;17:3.
29.李瑞珍,周平,等.经腹彩色多普勒超声与内镜检查诊断食管静脉曲张的对比研究.中华超声影像学杂志2002:286-8.
30. Tamano M, Yoneda M, Kojima K et al. Evaluation of esophageal varices usingcontrast-enhanced coded harmonic ultrasonography. J Gastroenterol Hepatol2004;19:572-5.
31.孙英,王传英,李秀清.超声造影诊断食管胃底静脉曲张.中国医学影像技术2010;26:712-4.
32. Albrecht T, Blomley MJ, Cosgrove DO et al. Non-invasive diagnosis of hepaticcirrhosis by transit-time analysis of an ultrasound contrast agent. Lancet1999;353:1579-83.
33. Hirota M, Kaneko T, Sugimoto H et al. Intrahepatic circulatory time analysis ofan ultrasound contrast agent in liver cirrhosis. Liver Int2005;25:337-42.
34. Lim AK, Taylor-Robinson SD, Patel N et al. Hepatic vein transit times using amicrobubble agent can predict disease severity non-invasively in patients withhepatitis C. Gut2005;54:128-33.
35. Kaneko T, Teshigawara O, Sugimoto H et al. Signal intensity of the liverparenchyma in microbubble contrast agent in the late liver phase reflectsadvanced fibrosis of the liver. Liver Int2005;25:288-93.
36. Lin LW, Duan XJ, Wang XY et al. Color Doppler velocity profile andcontrast-enhanced ultrasonography in assessment of liver cirrhosis.Hepatobiliary Pancreat Dis Int2008;7:34-9.
37. Maruyama H, Ishibashi H, Takahashi M et al. Effect of signal intensity from theaccumulated microbubbles in the liver for differentiation of idiopathic portalhypertension from liver cirrhosis. Radiology2009;252:587-94.
1. Ripoll C, Groszmann R, Garcia-Tsao G, Grace N, Burroughs A, Planas R, et al.Hepatic venous pressure gradient predicts clinical decompensation in patientswith compensated cirrhosis. Gastroenterology.2007;133(2):481-8.
2. Moller S, Bendtsen F.[Portal pressure should be measured on suspicion ofportal hypertension]. Ugeskr Laeger.2010;172(49):3411-3.
3. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management ofgastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology.2007;46(3):922-38.
4. Burroughs AK. The natural history of varices. J Hepatol.1993;17Suppl2:S10-3.
5. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, etal. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis.N Engl J Med.2005;353(21):2254-61.
6. Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet.2003;361(9361):952-4.
7. Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, GlickmanM. Portal pressure, presence of gastroesophageal varices and variceal bleeding.Hepatology.1985;5(3):419-24.
8. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradientreduction and prevention of variceal bleeding in cirrhosis: a systematic review.Gastroenterology.2006;131(5):1611-24.
9. Vorobioff J, Bredfeldt JE, Groszmann RJ. Increased blood flow through theportal system in cirrhotic rats. Gastroenterology.1984;87(5):1120-6.
10. Benoit JN, Womack WA, Hernandez L, Granger DN."Forward" and"backward" flow mechanisms of portal hypertension. Relative contributions inthe rat model of portal vein stenosis. Gastroenterology.1985;89(5):1092-6.
11. Goyal AK, Pokharna DS, Sharma SK. Ultrasonic measurements of portalvasculature in diagnosis of portal hypertension. A controversial subjectreviewed. J Ultrasound Med.1990;9(1):45-8.
12. Haag K, Rossle M, Ochs A, Huber M, Siegerstetter V, Olschewski M, et al.Correlation of duplex sonography findings and portal pressure in375patientswith portal hypertension. AJR Am J Roentgenol.1999;172(3):631-5.
13. Wachsberg RH, Simmons MZ. Coronary vein diameter and flow direction inpatients with portal hypertension: evaluation with duplex sonography andcorrelation with variceal bleeding. AJR Am J Roentgenol.1994;162(3):637-41.
14. Gibson RN, Gibson PR, Donlan JD, Clunie DA. Identification of a patentparaumbilical vein by using Doppler sonography: importance in the diagnosisof portal hypertension. AJR Am J Roentgenol.1989;153(3):513-6.
15. von Herbay A, Frieling T, Haussinger D. Color Doppler sonographic evaluationof spontaneous portosystemic shunts and inversion of portal venous flow inpatients with cirrhosis. J Clin Ultrasound.2000;28(7):332-9.
16. Gaiani S, Bolondi L, Li Bassi S, Zironi G, Siringo S, Barbara L. Prevalence ofspontaneous hepatofugal portal flow in liver cirrhosis. Clinical and endoscopiccorrelation in228patients. Gastroenterology.1991;100(1):160-7.
17. Baik SK, Kim JW, Kim HS, Kwon SO, Kim YJ, Park JW, et al. Recent varicealbleeding: Doppler US hepatic vein waveform in assessment of severity ofportal hypertension and vasoactive drug response. Radiology.2006;240(2):574-80.
18. Kim MY, Baik SK, Park DH, Lim DW, Kim JW, Kim HS, et al. Damping indexof Doppler hepatic vein waveform to assess the severity of portal hypertensionand response to propranolol in liver cirrhosis: a prospective nonrandomizedstudy. Liver Int.2007;27(8):1103-10.
19. Zhang L, Duan YY, Li JM, Yin JK. Hemodynamic features of Dopplerultrasonography in patients with portal hypertension: intraoperative directmeasurement of portal pressure in the portal venous system. J Ultrasound Med.2007;26(12):1689-96.
20.梁红梅,李艳玲,刘莉蓉,齐志国.彩色多普勒超声相关指数与门脉高压病例门脉压力相关性的实验研究.实用医学影像杂志.2010;11(03):185-8.
21. Vizzutti F, Arena U, Rega L, Romanelli RG, Colagrande S, Cuofano S, et al.Performance of Doppler ultrasound in the prediction of severe portalhypertension in hepatitis C virus-related chronic liver disease. Liver Int.2007;27(10):1379-88.
22. Albrecht T, Blomley MJ, Cosgrove DO, Taylor-Robinson SD, Jayaram V,Eckersley R, et al. Non-invasive diagnosis of hepatic cirrhosis by transit-timeanalysis of an ultrasound contrast agent. Lancet.1999;353(9164):1579-83.
23. Hirota M, Kaneko T, Sugimoto H, Kure S, Inoue S, Takeda S, et al. Intrahepaticcirculatory time analysis of an ultrasound contrast agent in liver cirrhosis. LiverInt.2005;25(2):337-42.
24. Lim AK, Taylor-Robinson SD, Patel N, Eckersley RJ, Goldin RD, Hamilton G,et al. Hepatic vein transit times using a microbubble agent can predict diseaseseverity non-invasively in patients with hepatitis C. Gut.2005;54(1):128-33.
25. Kaneko T, Teshigawara O, Sugimoto H, Hirota M, Inoue S, Takeda S, et al.Signal intensity of the liver parenchyma in microbubble contrast agent in thelate liver phase reflects advanced fibrosis of the liver. Liver Int.2005;25(2):288-93.
26. Lin LW, Duan XJ, Wang XY, Xue ES, He YM, Gao SD, et al. Color Dopplervelocity profile and contrast-enhanced ultrasonography in assessment of livercirrhosis. Hepatobiliary Pancreat Dis Int.2008;7(1):34-9.
27. Maruyama H, Ishibashi H, Takahashi M, Imazeki F, Yokosuka O. Effect ofsignal intensity from the accumulated microbubbles in the liver fordifferentiation of idiopathic portal hypertension from liver cirrhosis. Radiology.2009;252(2):587-94.
28. Groszmann R, Vorobioff JD, Gao H. Measurement of portal pressure: when,how, and why to do it. Clin Liver Dis.2006;10(3):499-512.
29. Vizzutti F, Arena U, Rega L, Pinzani M. Non invasive diagnosis of portalhypertension in cirrhotic patients. Gastroenterol Clin Biol.2008;32(6Suppl1):80-7.
30. Lee TH.[Recent advances in diagnosis of portal hypertension]. Korean JGastroenterol.2010;56(3):135-43.
31. Berzigotti A, Rossi V, Tiani C, Pierpaoli L, Zappoli P, Riili A, et al. Prognosticvalue of a single HVPG measurement and Doppler-ultrasound evaluation inpatients with cirrhosis and portal hypertension. J Gastroenterol.2011.
32. Ferreira FG, Ribeiro MA, de Fatima Santos M, Assef JC, Szutan LA. Dopplerultrasound could predict varices progression and rebleeding after portalhypertension surgery: lessons from146EGDS and10years of follow-up.World J Surg.2009;33(10):2136-43.
33.蒋莹,邵堂雷,郝燕,杨伟平,诸葛琦.肝硬化门脉高压患者入肝血流的超声评价.中国医学影像技术.2005;21(10):3.
34.谭友文,於学军,等.肝硬化门静脉高压门脉血流动力学检测及其临床意义.中华超声影像学杂志.2001(3):151-3.
35. Ditchfield MR, Gibson RN, Donlan JD, Gibson PR. Duplex Doppler ultrasoundsigns of portal hypertension: relative diagnostic value of examination ofparaumbilical vein, portal vein and spleen. Australas Radiol.1992;36(2):102-5.
36. Perisic M, Ilic-Mostic T, Stojkovic M, Culafic D, Sarenac R. Dopplerhemodynamic study in portal hypertension and hepatic encephalopathy.Hepatogastroenterology.2005;52(61):156-60.
37. Iwao T, Toyonaga A, Oho K, Tayama C, Masumoto H, Sakai T, et al. Value ofDoppler ultrasound parameters of portal vein and hepatic artery in the diagnosisof cirrhosis and portal hypertension. Am J Gastroenterol.1997;92(6):1012-7.
38. de Bem RS, Lora FL, de Souza RC, Trippia MA, Amarante HM, Carmes ER.[Correlation of Doppler ultrasound of the portal system with endoscopicchanges caused by portal hypertension in cirrhotic patients]. Arq Gastroenterol.2006;43(3):178-83.
39. Choi YJ, Baik SK, Park DH, Kim MY, Kim HS, Lee DK, et al. Comparison ofDoppler ultrasonography and the hepatic venous pressure gradient in assessingportal hypertension in liver cirrhosis. J Gastroenterol Hepatol.2003;18(4):424-9.
40. Jeong PH, Baik SK, Choi YJ, Park DH, Kim MY, Kim HS, et al.[Comparisonof Doppler ultrasonography and hepatic venous pressure gradient in assessingportal hypertension in liver cirrhosis]. Taehan Kan Hakhoe Chi.2002;8(3):264-70.
41. Merkel C, Sacerdoti D, Bolognesi M, Bombonato G, Gatta A. Dopplersonography and hepatic vein catheterization in portal hypertension: assessmentof agreement in evaluating severity and response to treatment. J Hepatol.1998;28(4):622-30.
42. Fernandez M, Chesta J, Jiron MI, Manquez P, Brahm J.[Liver cirrhosis andportal hypertension: non-invasive measurement of blood flow in the portal veinwith Doppler-duplex]. Rev Med Chil.1991;119(5):524-9.
43.郭梦安,廖锦堂.肝硬化肝功能分级的超声造影定量分析.中国医学影像技术.2009;25(10):1824-26.
44.谭小蕖,钱林学,张晓丽,马棣,胡向东,张庆, et al.超声造影诊断早期肝硬化的初步探讨.中华超声影像学杂志.2008;17(12):1048-52.
45. Laleman W. Role of vasoactive substances and cellular effectors in thepathophysiology of cirrhotic portal hypertension: the past, the present and thefuture--Georges Brohee Lecture. Acta Gastroenterol Belg.2009;72(1):9-16.
46. Treiber G, Csepregi A, Malfertheiner P. The pathophysiology of portalhypertension. Dig Dis.2005;23(1):6-10.
47. Pinzani M, Gentilini P. Biology of hepatic stellate cells and their possiblerelevance in the pathogenesis of portal hypertension in cirrhosis. Semin LiverDis.1999;19(4):397-410.
48. Garini G, Delsante M, Iannuzzella F.[Pathophysiology of portal hypertensionand mechanisms of sodium and water retention in cirrhosis]. Recenti Prog Med.2011;102(3):134-40.
49. Kim MY, Baik SK.[Pathophysiology of portal hypertension, what's new?].Korean J Gastroenterol.2010;56(3):129-34.
1. Merli M, Nicolini G, Angeloni S et al. Incidence and natural history of smallesophageal varices in cirrhotic patients. J Hepatol2003;38:266-72.
2. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liverand esophageal varices. A prospective multicenter study. N Engl J Med1988;319:983-9.
3. El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an11-year period in the Department of Veterans Affairs. Am J Gastroenterol2000;95:3566-73.
4. Carbonell N, Pauwels A, Serfaty L et al. Improved survival after varicealbleeding in patients with cirrhosis over the past two decades. Hepatology2004;40:652-9.
5. Groszmann RJ, Garcia-Tsao G, Bosch J et al. Beta-blockers to preventgastroesophageal varices in patients with cirrhosis. N Engl J Med2005;353:2254-61.
6. Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet2003;361:952-4.
7. Garcia-Tsao G, Groszmann RJ, Fisher RL et al. Portal pressure, presence ofgastroesophageal varices and variceal bleeding. Hepatology1985;5:419-24.
8. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradientreduction and prevention of variceal bleeding in cirrhosis: a systematic review.Gastroenterology2006;131:1611-24.
9. Gulzar GM, Zargar SA, Jalal S et al. Correlation of hepatic venous pressuregradient with variceal bleeding, size of esophageal varices, etiology, ascites anddegree of liver dysfunction in cirrhosis of liver. Indian J Gastroenterol2009;28:59-61.
10. Tarzamni MK, Somi MH, Farhang S, Jalilvand M. Portal hemodynamics aspredictors of high risk esophageal varices in cirrhotic patients. World JGastroenterol2008;14:1898-902.
11. Hong WD, Zhu QH, Huang ZM et al. Predictors of esophageal varices inpatients with HBV-related cirrhosis: a retrospective study. BMC Gastroenterol2009;9:11.
12. Sarangapani A, Shanmugam C, Kalyanasundaram M et al. Noninvasiveprediction of large esophageal varices in chronic liver disease patients. Saudi JGastroenterol2010;16:38-42.
13. Medhat A, Iber FL, Dunne M, Baum R. Ultrasonographic findings withbleeding and nonbleeding esophageal varices. Am J Gastroenterol1988;83:58-63.
14. Chiu KC, Sheu BS, Chuang CH. Portal venous flow pattern as a useful tool forpredicting esophageal varix bleeding in cirrhotic patients. Dig Dis Sci2005;50:1170-4.
15. Wachsberg RH, Simmons MZ. Coronary vein diameter and flow direction inpatients with portal hypertension: evaluation with duplex sonography andcorrelation with variceal bleeding. AJR Am J Roentgenol1994;162:637-41.
16. Adithan S, Venkatesan B, Sundarajan E et al. Color Doppler evaluation of leftgastric vein hemodynamics in cirrhosis with portal hypertension and itscorrelation with esophageal varices and variceal bleed. Indian J Radiol Imaging2010;20:289-93.
17. Nelson RC, Sherbourne GM, Spencer HB, Chezmar JL. Splenic venous flowexceeding portal venous flow at Doppler sonography: relationship toportosystemic varices. AJR Am J Roentgenol1993;161:563-7.
18. Yin XY, Lu MD, Huang JF et al. Color Doppler velocity profile assessment ofportal hemodynamics in cirrhotic patients with portal hypertension: correlationwith esophageal variceal bleeding. J Clin Ultrasound2001;29:7-13.
19.罗蓉,赵健雄.彩超对肝硬化门、脾静脉血流量检测与电子胃镜食管胃底静脉曲张相关性的观察.重庆医学2011;40.
20. Berzigotti A, Zappoli P, Magalotti D et al. Spleen enlargement on follow-upevaluation: a noninvasive predictor of complications of portal hypertension incirrhosis. Clin Gastroenterol Hepatol2008;6:1129-34.
21. Agha A, Abdulhadi MM, Marenco S et al. Use of the platelet count/spleendiameter ratio for the noninvasive diagnosis of esophageal varices in patientswith schistosomiasis. Saudi J Gastroenterol2011;17:307-10.
22. Barikbin R, Hekmatnia A, Omidifar N et al. Prediction severity of esophagealvarices: a new cutoff point for Platelet count/spleen diameter ratio. MinervaGastroenterol Dietol2010;56:1-6.
23. Li X, Wu K, Fan D. Insulin resistance and platelet count/spleen diameter ratio:two simple, easy-to-get tests for predicting esophageal varices in cirrhosis.Hepatology2009;49:1394; author reply-5.
24.黎强,周良,张煜成et al.二维及能量多普勒超声在食管腹段静脉曲张诊断的探讨.影像诊断与介入放射学2008;17:3.
25.李瑞珍,周平,等.经腹彩色多普勒超声与内镜检查诊断食管静脉曲张的对比研究.中华超声影像学杂志2002:286-8.
26.杨舒萍,王康健,沈浩霖.超声造影对食管胃底静脉曲张的诊断价值.中华医学超声杂志（电子版）2010;07:1497-502.
27.孙英,王传英,李秀清.超声造影诊断食管胃底静脉曲张.中国医学影像技术2010;26:712-4.
28. Tamano M, Yoneda M, Kojima K et al. Evaluation of esophageal varices usingcontrast-enhanced coded harmonic ultrasonography. J Gastroenterol Hepatol2004;19:572-5.
29. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management ofgastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology2007;46:922-38.
30. de Franchis R. Revising consensus in portal hypertension: report of the BavenoV consensus workshop on methodology of diagnosis and therapy in portalhypertension. J Hepatol2010;53:762-8.
31. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management ofgastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology2007;46:922-38.
32. Madhotra R, Mulcahy HE, Willner I, Reuben A. Prediction of esophagealvarices in patients with cirrhosis. J Clin Gastroenterol2002;34:81-5.
33. Schepis F, Camma C, Niceforo D et al. Which patients with cirrhosis shouldundergo endoscopic screening for esophageal varices detection? Hepatology2001;33:333-8.
34. Thomopoulos KC, Labropoulou-Karatza C, Mimidis KP et al. Non-invasivepredictors of the presence of large oesophageal varices in patients with cirrhosis.Dig Liver Dis2003;35:473-8.
35. Burton JR, Jr., Liangpunsakul S, Lapidus J et al. Validation of a multivariatemodel predicting presence and size of varices. J Clin Gastroenterol2007;41:609-15.
36. Staub F, Tournoux-Facon C, Roumy J et al. Liver fibrosis staging withcontrast-enhanced ultrasonography: prospective multicenter study comparedwith METAVIR scoring. Eur Radiol2009;19:1991-7.
37.郭梦安,廖锦堂.肝硬化肝功能分级的超声造影定量分析.中国医学影像技术2009;25:1824-26.
38.杨舒萍,王康健,沈浩霖.超声造影对食管胃底静脉曲张的诊断价值.中华医学超声杂志（电子版）2010;7:1497-702.
1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management ofgastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology2007;46:922-38.
2. Burroughs AK. The natural history of varices. J Hepatol1993;17Suppl2:S10-3.
3.黎强,周良,张煜成et al.二维及能量多普勒超声在食管腹段静脉曲张诊断的探讨.影像诊断与介入放射学2008;17:3.
4.李瑞珍,周平,等.经腹彩色多普勒超声与内镜检查诊断食管静脉曲张的对比研究.中华超声影像学杂志2002:286-8.
5. Tamano M, Yoneda M, Kojima K et al. Evaluation of esophageal varices usingcontrast-enhanced coded harmonic ultrasonography. J Gastroenterol Hepatol2004;19:572-5.
6.孙英,王传英,李秀清.超声造影诊断食管胃底静脉曲张.中国医学影像技术2010;26:712-4.
7.杨舒萍,王康健,沈浩霖.超声造影对食管胃底静脉曲张的诊断价值.中华医学超声杂志（电子版）2010;07:1497-502.
8. Hashizume M, Kitano S, Sugimachi K, Sueishi K. Three-dimensional view ofthe vascular structure of the lower esophagus in clinical portal hypertension.Hepatology1988;8:1482-7.
9. Spence RA, Terblanche J. Venous anatomy of the lower oesophagus: a newperspective on varices. Br J Surg1987;74:659-60.
10. Spence RA. The venous anatomy of the lower oesophagus in normal subjectsand in patients with varices: an image analysis study. Br J Surg1984;71:739-44.
11.龚均,刘欣,许君望.现代食管内科学.世界图书出版社2009:8-10.
12. Limberg B.[Diagnosis of chronic inflammatory bowel disease byultrasonography]. Z Gastroenterol1999;37:495-508.
13. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management ofgastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology2007;46:922-38.
14. Esposito F, Lombardi R, Grasso AC et al. Transabdominal sonography of thenormal gastroesophageal junction in children. J Clin Ultrasound2001;29:326-31.
15. Tanomkiat W, Chongchitnan P. Transabdominal sonography ofgastroesophageal junctions. J Clin Ultrasound1999;27:505-12.
16.周平,刘浔阳,等.以胃底为声窗经腹彩超在诊断食管静脉曲张中的价值.中国医学影像技术2002:54-6.
17. Chen MH, Kikuchi Y, Chu BC et al. Demonstration of the distal end of theoesophagus by transabdominal ultrasound. Br J Radiol1997;70:1215-21.
18.朱尚勇,陈振侬,等.超声在食管静脉曲张诊断中的价值.中国超声医学杂志2003:177-9.
19. Miller LS, Kim JK, Dai Q et al. Mechanics and hemodynamics of esophagealvarices during peristaltic contraction. Am J Physiol Gastrointest Liver Physiol2004;287: G830-5.
1. Merli M, Nicolini G, Angeloni S et al. Incidence and natural history of smallesophageal varices in cirrhotic patients. J Hepatol2003;38:266-72.
2. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liverand esophageal varices. A prospective multicenter study. N Engl J Med1988;319:983-9.
3. El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an11-year period in the Department of Veterans Affairs. Am J Gastroenterol2000;95:3566-73.
4. Carbonell N, Pauwels A, Serfaty L et al. Improved survival after varicealbleeding in patients with cirrhosis over the past two decades. Hepatology2004;40:652-9.
5. Groszmann RJ, Garcia-Tsao G, Bosch J et al. Beta-blockers to preventgastroesophageal varices in patients with cirrhosis. N Engl J Med2005;353:2254-61.
6. Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet2003;361:952-4.
7. Garcia-Tsao G, Groszmann RJ, Fisher RL et al. Portal pressure, presence ofgastroesophageal varices and variceal bleeding. Hepatology1985;5:419-24.
8. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradientreduction and prevention of variceal bleeding in cirrhosis: a systematic review.Gastroenterology2006;131:1611-24.
9. Vorobioff J, Bredfeldt JE, Groszmann RJ. Increased blood flow through theportal system in cirrhotic rats. Gastroenterology1984;87:1120-6.
10. Benoit JN, Womack WA, Hernandez L, Granger DN."Forward" and"backward" flow mechanisms of portal hypertension. Relative contributions inthe rat model of portal vein stenosis. Gastroenterology1985;89:1092-6.
11. Fernandez M, Chesta J, Jiron MI et al.[Liver cirrhosis and portal hypertension:non-invasive measurement of blood flow in the portal vein withDoppler-duplex]. Rev Med Chil1991;119:524-9.
12. Haag K, Rossle M, Ochs A et al. Correlation of duplex sonography findings andportal pressure in375patients with portal hypertension. AJR Am J Roentgenol1999;172:631-5.
13.蒋莹,邵堂雷,郝燕et al.肝硬化门脉高压患者入肝血流的超声评价.中国医学影像技术2005;21:3.
14.谭友文,於学军,等.肝硬化门静脉高压门脉血流动力学检测及其临床意义.中华超声影像学杂志2001:151-3.
15. Rector WG, Jr., Campra J, Ralls PW, Charms M. Utility and limitations ofsplanchnic venous ultrasonography in diagnosis of portal hypertension. J ClinUltrasound1986;14:689-96.
16. Goyal AK, Pokharna DS, Sharma SK. Ultrasonic measurements of portalvasculature in diagnosis of portal hypertension. A controversial subjectreviewed. J Ultrasound Med1990;9:45-8.
17. von Herbay A, Frieling T, Haussinger D. Color Doppler sonographic evaluationof spontaneous portosystemic shunts and inversion of portal venous flow inpatients with cirrhosis. J Clin Ultrasound2000;28:332-9.
18. Gaiani S, Bolondi L, Li Bassi S et al. Prevalence of spontaneous hepatofugalportal flow in liver cirrhosis. Clinical and endoscopic correlation in228patients. Gastroenterology1991;100:160-7.
19. Chiu KC, Sheu BS, Chuang CH. Portal venous flow pattern as a useful tool forpredicting esophageal varix bleeding in cirrhotic patients. Dig Dis Sci2005;50:1170-4.
20. Iwao T, Toyonaga A, Oho K et al. Value of Doppler ultrasound parameters ofportal vein and hepatic artery in the diagnosis of cirrhosis and portalhypertension. Am J Gastroenterol1997;92:1012-7.
21. Perisic M, Ilic-Mostic T, Stojkovic M et al. Doppler hemodynamic study inportal hypertension and hepatic encephalopathy. Hepatogastroenterology2005;52:156-60.
22. Bolognesi M, Sacerdoti D, Merkel C, Gatta A. Relationship between portalblood flow measured by image-directed Doppler ultrasonography and hepaticblood flow measured by indocyanine green constant infusion in patients withcirrhosis. J Clin Ultrasound1995;23:297-303.
23. Taourel P, Blanc P, Dauzat M et al. Doppler study of mesenteric, hepatic, andportal circulation in alcoholic cirrhosis: relationship between quantitativeDoppler measurements and the severity of portal hypertension and hepaticfailure. Hepatology1998;28:932-6.
24.鹿皎,崔建华.肝硬化患者门静脉脾静脉血流动力学多普勒检测及其临床意义.徐州医学院学报2005;25:3.
25. Moriyasu F, Nishida O, Ban N et al."Congestion index" of the portal vein. AJRAm J Roentgenol1986;146:735-9.
26. Merkel C, Sacerdoti D, Bolognesi M et al. Doppler sonography and hepaticvein catheterization in portal hypertension: assessment of agreement inevaluating severity and response to treatment. J Hepatol1998;28:622-30.
27. Abu-Yousef MM. Normal and respiratory variations of the hepatic and portalvenous duplex Doppler waveforms with simultaneous electrocardiographiccorrelation. J Ultrasound Med1992;11:263-8.
28. Baik SK, Kim JW, Kim HS et al. Recent variceal bleeding: Doppler US hepaticvein waveform in assessment of severity of portal hypertension and vasoactivedrug response. Radiology2006;240:574-80.
29. Kawanaka H, Kinjo N, Anegawa G et al. Abnormality of the hepatic veinwaveforms in cirrhotic patients with portal hypertension and its prognosticimplications. J Gastroenterol Hepatol2008;23: e129-36.
30. Kim MY, Baik SK, Park DH et al. Damping index of Doppler hepatic veinwaveform to assess the severity of portal hypertension and response topropranolol in liver cirrhosis: a prospective nonrandomized study. Liver Int2007;27:1103-10.
31. Kim SY, Jeong WK, Kim Y et al. Changing waveform during respiration onhepatic vein Doppler sonography of severe portal hypertension: comparisonwith the damping index. J Ultrasound Med2011;30:455-62.
32. Zhang L, Yin J, Duan Y et al. Assessment of intrahepatic blood flow byDoppler ultrasonography: relationship between the hepatic vein, portal vein,hepatic artery and portal pressure measured intraoperatively in patients withportal hypertension. BMC Gastroenterol2011;11:84.
33. Zhang L, Duan YY, Li JM, Yin JK. Hemodynamic features of Dopplerultrasonography in patients with portal hypertension: intraoperative directmeasurement of portal pressure in the portal venous system. J Ultrasound Med2007;26:1689-96.
34.梁红梅,李艳玲,刘莉蓉,齐志国.彩色多普勒超声相关指数与门脉高压病例门脉压力相关性的实验研究.实用医学影像杂志2010;11:185-8.
35. Sheth SG, Amarapurkar DN, Chopra KB et al. Evaluation of splenomegaly inportal hypertension. J Clin Gastroenterol1996;22:28-30.
36. Berzigotti A, Zappoli P, Magalotti D et al. Spleen enlargement on follow-upevaluation: a noninvasive predictor of complications of portal hypertension incirrhosis. Clin Gastroenterol Hepatol2008;6:1129-34.
37. Vizzutti F, Arena U, Rega L et al. Performance of Doppler ultrasound in theprediction of severe portal hypertension in hepatitis C virus-related chronicliver disease. Liver Int2007;27:1379-88.
38. Wachsberg RH, Simmons MZ. Coronary vein diameter and flow direction inpatients with portal hypertension: evaluation with duplex sonography andcorrelation with variceal bleeding. AJR Am J Roentgenol1994;162:637-41.
39. Ditchfield MR, Gibson RN, Donlan JD, Gibson PR. Duplex Doppler ultrasoundsigns of portal hypertension: relative diagnostic value of examination ofparaumbilical vein, portal vein and spleen. Australas Radiol1992;36:102-5.
40. Kim PT, Chandy TT, Ghanekar A. Massive enlargement of a paraumbilical veinin a patient with advanced portal hypertension. Surgery2011.
41. Gupta D, Chawla YK, Dhiman RK et al. Clinical significance of patentparaumbilical vein in patients with liver cirrhosis. Dig Dis Sci2000;45:1861-4.
42. Gibson RN, Gibson PR, Donlan JD, Clunie DA. Identification of a patentparaumbilical vein by using Doppler sonography: importance in the diagnosisof portal hypertension. AJR Am J Roentgenol1989;153:513-6.
43. Sacerdoti D, Bolognesi M, Bombonato G, Gatta A. Paraumbilical vein patencyin cirrhosis: effects on hepatic hemodynamics evaluated by Dopplersonography. Hepatology1995;22:1689-94.
44. Dorffel T, Wruck T, Ruckert RI et al. Vascular complications in acutepancreatitis assessed by color duplex ultrasonography. Pancreas2000;21:126-33.
45. Denninger MH, Chait Y, Casadevall N et al. Cause of portal or hepatic venousthrombosis in adults: the role of multiple concurrent factors. Hepatology2000;31:587-91.
46. Cedrone A, Rapaccini GL, Pompili M et al. Portal vein thrombosiscomplicating hepatocellular carcinoma. Value of ultrasound-guided fine-needlebiopsy of the thrombus in the therapeutic management. Liver1996;16:94-8.
47. Lencioni R, Caramella D, Sanguinetti F et al. Portal vein thrombosis afterpercutaneous ethanol injection for hepatocellular carcinoma: value of colorDoppler sonography in distinguishing chemical and tumor thrombi. AJR Am JRoentgenol1995;164:1125-30.
48. Tanaka K, Numata K, Okazaki H et al. Diagnosis of portal vein thrombosis inpatients with hepatocellular carcinoma: efficacy of color Doppler sonographycompared with angiography. AJR Am J Roentgenol1993;160:1279-83.
49. Furuse J, Matsutani S, Yoshikawa M et al. Diagnosis of portal vein tumorthrombus by pulsed Doppler ultrasonography. J Clin Ultrasound1992;20:439-46.
50. Tarantino L, Francica G, Sordelli I et al. Diagnosis of benign and malignantportal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: colorDoppler US, contrast-enhanced US, and fine-needle biopsy. Abdom Imaging2006;31:537-44.
51. Ricci P, Cantisani V, Biancari F et al. Contrast-enhanced color Doppler US inmalignant portal vein thrombosis. Acta Radiol2000;41:470-3.
52. Danila M, Sporea I, Popescu A et al. The value of contrast enhanced ultrasoundin the evaluation of the nature of portal vein thrombosis. Med Ultrason2011;13:102-7.
53. Chang CY, Yang PM, Hung SP et al. Cavernous transformation of the portalvein: etiology determines the outcome. Hepatogastroenterology2006;53:892-7.
54. De Gaetano AM, Lafortune M, Patriquin H et al. Cavernous transformation ofthe portal vein: patterns of intrahepatic and splanchnic collateral circulationdetected with Doppler sonography. AJR Am J Roentgenol1995;165:1151-5.
55. Ueno N, Sasaki A, Tomiyama T et al. Color Doppler ultrasonography in thediagnosis of cavernous transformation of the portal vein. J Clin Ultrasound1997;25:227-33.
56. Raby N, Meire HB. Duplex Doppler ultrasound in the diagnosis of cavernoustransformation of the portal vein. Br J Radiol1988;61:586-8.
57. Kessler A, Graif M, Konikoff F et al. Vascular and biliary abnormalitiesmimicking cholangiocarcinoma in patients with cavernous transformation ofthe portal vein: role of color Doppler sonography. J Ultrasound Med2007;26:1089-95.
58. Janssen HL, Garcia-Pagan JC, Elias E et al. Budd-Chiari syndrome: a reviewby an expert panel. J Hepatol2003;38:364-71.
59. Orloff MJ, Daily PO, Orloff SL et al. A27-year experience with surgicaltreatment of Budd-Chiari syndrome. Ann Surg2000;232:340-52.
60. Tanaka M, Wanless IR. Pathology of the liver in Budd-Chiari syndrome: portalvein thrombosis and the histogenesis of veno-centric cirrhosis, veno-portalcirrhosis, and large regenerative nodules. Hepatology1998;27:488-96.
61. Robles-Medranda C, Lukashok H, Biccas B et al. Budd-Chiari like syndrome indecompensated alcoholic steatohepatitis and liver cirrhosis. World JGastroenterol2006;12:6564-6.
62. Chaubal N, Dighe M, Hanchate V et al. Sonography in Budd-Chiari syndrome.J Ultrasound Med2006;25:373-9.
63. Bargallo X, Gilabert R, Nicolau C et al. Sonography of Budd-Chiari syndrome.AJR Am J Roentgenol2006;187: W33-41.
64. Chawla Y, Kumar S, Dhiman RK et al. Duplex Doppler sonography in patientswith Budd-Chiari syndrome. J Gastroenterol Hepatol1999;14:904-7.
65. Gulzar GM, Zargar SA, Jalal S et al. Correlation of hepatic venous pressuregradient with variceal bleeding, size of esophageal varices, etiology, ascites anddegree of liver dysfunction in cirrhosis of liver. Indian J Gastroenterol2009;28:59-61.
66. Tarzamni MK, Somi MH, Farhang S, Jalilvand M. Portal hemodynamics aspredictors of high risk esophageal varices in cirrhotic patients. World JGastroenterol2008;14:1898-902.
67. Hong WD, Zhu QH, Huang ZM et al. Predictors of esophageal varices inpatients with HBV-related cirrhosis: a retrospective study. BMC Gastroenterol2009;9:11.
68. Sarangapani A, Shanmugam C, Kalyanasundaram M et al. Noninvasiveprediction of large esophageal varices in chronic liver disease patients. Saudi JGastroenterol2010;16:38-42.
69. Medhat A, Iber FL, Dunne M, Baum R. Ultrasonographic findings withbleeding and nonbleeding esophageal varices. Am J Gastroenterol1988;83:58-63.
70. Nelson RC, Sherbourne GM, Spencer HB, Chezmar JL. Splenic venous flowexceeding portal venous flow at Doppler sonography: relationship toportosystemic varices. AJR Am J Roentgenol1993;161:563-7.
71. Yin XY, Lu MD, Huang JF et al. Color Doppler velocity profile assessment ofportal hemodynamics in cirrhotic patients with portal hypertension: correlationwith esophageal variceal bleeding. J Clin Ultrasound2001;29:7-13.
72.罗蓉,赵健雄.彩超对肝硬化门、脾静脉血流量检测与电子胃镜食管胃底静脉曲张相关性的观察.重庆医学2011;40.
73. Agha A, Abdulhadi MM, Marenco S et al. Use of the platelet count/spleendiameter ratio for the noninvasive diagnosis of esophageal varices in patientswith schistosomiasis. Saudi J Gastroenterol2011;17:307-10.
74. Barikbin R, Hekmatnia A, Omidifar N et al. Prediction severity of esophagealvarices: a new cutoff point for Platelet count/spleen diameter ratio. MinervaGastroenterol Dietol2010;56:1-6.
75. Li X, Wu K, Fan D. Insulin resistance and platelet count/spleen diameter ratio:two simple, easy-to-get tests for predicting esophageal varices in cirrhosis.Hepatology2009;49:1394; author reply-5.
76. Stefanescu H, Grigorescu M, Lupsor M et al. Spleen stiffness measurementusing fibroscan for the noninvasive assessment of esophageal varices in livercirrhosis patients. J Gastroenterol Hepatol2011;26:164-70.
77. Adithan S, Venkatesan B, Sundarajan E et al. Color Doppler evaluation of leftgastric vein hemodynamics in cirrhosis with portal hypertension and itscorrelation with esophageal varices and variceal bleed. Indian J Radiol Imaging2010;20:289-93.
78.黎强,周良,张煜成et al.二维及能量多普勒超声在食管腹段静脉曲张诊断的探讨.影像诊断与介入放射学2008;17:3.
79.李瑞珍,周平,等.经腹彩色多普勒超声与内镜检查诊断食管静脉曲张的对比研究.中华超声影像学杂志2002:286-8.
80. Tamano M, Yoneda M, Kojima K et al. Evaluation of esophageal varices usingcontrast-enhanced coded harmonic ultrasonography. J Gastroenterol Hepatol2004;19:572-5.
81.孙英,王传英,李秀清.超声造影诊断食管胃底静脉曲张.中国医学影像技术2010;26:712-4.
82.杨舒萍,王康健,沈浩霖.超声造影对食管胃底静脉曲张的诊断价值.中华医学超声杂志（电子版）2010;07:1497-502.
83. Sabba C, Merkel C, Zoli M et al. Interobserver and interequipment variabilityof echo-Doppler examination of the portal vein: effect of a cooperative trainingprogram. Hepatology1995;21:428-33.
84. Annet L, Materne R, Danse E et al. Hepatic flow parameters measured withMR imaging and Doppler US: correlations with degree of cirrhosis and portalhypertension. Radiology2003;229:409-14.
85. Choi YJ, Baik SK, Park DH et al. Comparison of Doppler ultrasonography andthe hepatic venous pressure gradient in assessing portal hypertension in livercirrhosis. J Gastroenterol Hepatol2003;18:424-9.
86. Sebastianes PM, Sales DM, Santos JE et al. Interobserver variability ofultrasound parameters in portal hypertension. Mem Inst Oswaldo Cruz2010;105:409-13.
87. Sacerdoti D, Gaiani S, Buonamico P et al. Interobserver and interequipmentvariability of hepatic, splenic, and renal arterial Doppler resistance indices innormal subjects and patients with cirrhosis. J Hepatol1997;27:986-92.
88. Albrecht T, Blomley MJ, Cosgrove DO et al. Non-invasive diagnosis of hepaticcirrhosis by transit-time analysis of an ultrasound contrast agent. Lancet1999;353:1579-83.
89. Hirota M, Kaneko T, Sugimoto H et al. Intrahepatic circulatory time analysis ofan ultrasound contrast agent in liver cirrhosis. Liver Int2005;25:337-42.
90. Maruyama H, Ishibashi H, Takahashi M et al. Effect of signal intensity from theaccumulated microbubbles in the liver for differentiation of idiopathic portalhypertension from liver cirrhosis. Radiology2009;252:587-94.