Segmental reversal of intrahepatic portal flow due to a liver metastasis

A 60-year-old woman who had a Dukes C colonic adenocarcinoma resected four years previously presented with malaise, hepatomegaly and elevated serum tumour markers. Her radiological investigations included liver ultrasonography, computed tomography (CT) (Fig. 1), and magnetic resonance imaging. These revealed a 6 cm solitary metastasis mainly in the right lobe (segments S8 and S4) not extending to the porta hepatis. The tumour compressed the inferior vena cava (IVC) and the right hepatic vein. No portal vein thrombosis was demonstrated. Angiography was performed prior to surgical removal of the tumour. The portal phase of a selective superior mesenteric arteriogram unexpectedly revealed abrupt “cut-oft” the main right portal branch at the porta hepatis, and no portal branches were demonstrated within the right lobe of the liver (Fig. 2). A selective common hepatic arteriogram demonstrated the tumour blush in the upper part of the right lobe of the liver as well as a faint blush-like impression of the main branch of the right portal vein in the late phase. In view of these portal venographic appearances, a duplex ultrasonographic examination was performed for further assessment (Fig. 3a). Due to the patient's abdominal discomfort, she was most at ease whilst lying supine with her knees flexed. In this position, normal flow in all the hepatic veins as well as the intrahepatic portal branches was observed (Fig. 3b). However, when the patient extended her knees fully the haemodynamics altered.