Male 53 years old; Reason: RIGHT UPPER QUADRANT TO EVAL FOR GALLBLADDER PATHOLOGY AND TO EVAL FLOW THROUGH TIPS History: acute on chronic liver failure, hyperbilirubinemia LIVER: The liver measures 14.5 cm in length. There is increased coarse echogenicity of the liver parenchyma with a nodular appearance. No focal hepatic lesions. No intrahepatic ductal dilation is seen. Pleural effusion is seen above the liver as well as ascites.GALLBLADDER/BILIARY TRACT: The gallbladder wall measures 6.1 mm. There is layering sludge within the gallbladder. Edema around the gallbladder is seen. No stones are seen. The common bile duct measures 5.1 mm in diameter. Negative sonographic Murphy sign.PANCREAS: Portions of the pancreas are obscured by bowel gas with visualized portions normal in appearance.SPLEEN: The spleen measures 13.8 cm and no significant abnormalities are noted.RIGHT KIDNEY: The right kidney measures 10.9 cm in length. The cortex has heterogeneously increased echogenicity. No hydronephrosis, stones, or worrisome masses are seen.LEFT KIDNEY: The left kidney measures 11.6 cm in length. The cortex has heterogeneously increased echogenicity. No hydronephrosis, stones, or worrisome masses are seen.DOPPLERS:PORTAL VEIN:The main portal vein is patent with hepatopetal flow measuring 31.0 cm/s. The left portal vein is patent with hepatofugal flow measuring 22.4 cm/s. Right portal vein was not well visualized.INFERIOR VENA CAVA: The inferior vena cava is patent with hepatofugal flow. This is measured at 69.5 cm/s.HEPATIC VEINS: The main hepatic vein is patent with hepatofugal flow measuring 42.3 cm/s. The left hepatic vein is patent and hepatofugal in flow measuring 70.0 cm/s. The right hepatic vein is patent with hepatofugal flow measuring 32.3 cm/s.HEPATIC ARTERIES: The hepatic artery is patent with hepatopedal flow and peak systolic velocity measurements ranging from 228.4 cm/s to 260.8 cm/s, and RI 0.6. The left hepatic artery is patent with hepatopetal flow with peak systolic velocity measured at 31.6 cm/s, RI 0.6. The right hepatic artery is patent with hepatopetal flow and peak systolic velocity measuring 45.1 cm/s and RI of 2.0. TIPS: The TIPS is patent with hepatofugal flow measuring 223.9 cm/s at the proximal limb, 265.8 cm/s at the midportion, and 176.6 cm/s to 134.1 cm/s at the distal portion.SPLENIC ARTERY: The splenic artery is patent with anterior grade flow to the spleen with peak systolic velocity measured at 68.4 cm/s and RI of 0.8.SPLENIC VEIN: The splenic vein is patent with retrograde flow from the spleen measuring 20.6 cm/s.
1. Flow within the TIPS is concerning for proximal stenosis with increased velocity through the more proximal portion of the TIPS.2.The gallbladder wall is thickened with layering sludge and there is edema around the gallbladder likely due to volume overload/ascites. Right pleural effusion and ascites is present.3.The liver has coarse echogenicity consistent with cirrhotic morphology. No discrete masses are seen or intrahepatic ductal dilation. There is splenomegaly.4. Heterogeneously increased kidney parenchyma suggestive of medical renal disease.