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Cavernous transformation of the portal vein
#1
Presentation

Abdominal pain and jaundice.

Patient Data
AGE: 70 years
GENDER: Female

CT
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Axial C+ arterial phase

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Axial C+ portal venous phase

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Axial C+ delayed

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Coronal C+ portal venous phase

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Sagittal C+ portal venous phase

The gallbladder is not seen at anatomical location due to prior resection.
Intra and extra hepatic bile ducts are dilated and CBD measured 15 mm in maximum caliber. An 18 mm hyperdense lesion is noted at distal of CBD inferring stone.

There are several vascular structures in the region of the portal vein consistent with cavernous transformation of the portal vein and causing mass effect on mid portion of CBD.  

The spleen is enlarged and its cephalocaudal height measured 158 mm.

Case Discussion
Cavernous transformation of the portal vein is a sequela of portal vein thrombosis and is the replacement of the normal single channel portal vein with numerous tortuous venous channels.

Cavernous transformation of the portal vein (CTPV) is a sequela of portal vein thrombosis and is the replacement of the normal single channel portal vein with numerous tortuous venous channels.

For a discussion of demographics and presentation, please refer to the article on portal vein thrombosis.

Pathology
Following thrombosis, the portal vein may or may not re-canalize. Re-canalization is seen more frequently in patients without cirrhosis or disease of the liver leading to inherently increased resistance to portal flow. In patients whose portal vein does not recanalize, or only partially re-canalizes, collateral veins (thought to be paracholedochal veins) dilate and become serpiginous.

This process takes a variable amount of time, from as little as a week to a year . 

These vessels drain variably into the left and right portal veins or more distally into the liver. Additional communications can also be identified with the pericholecystic veins.

Cavernous transformation of the portal vein is most of the times inefficient in guaranteeing adequate portal vein inflow to the liver parenchyma far from the hilum and, therefore, is associated with an increased hepatic arterial flow to those peripheral liver segments. These changes lead to central liver hypertrophy and peripheral liver atrophy .  

Radiographic features
In addition to direct visualization of the dilated vessels, the resultant portal hypertension results in other frequent changes: see portal hypertension. Additionally, there are changes in liver shape which are somewhat different to those seen in cirrhosis .  Typically these changes are:

atrophy of the left lateral segment (segments 2 and 3) whereas hypertrophy is more common in cirrhosis
hypertrophy of segment 4 whereas atrophy is more common in cirrhosis
hypertrophy of the caudate lobe which is also seen in cirrhosis
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