Portal hipertansiyonda portosistemik kollateraller

Özet

Portosistemik kollateraller portal basınç artışında splanknik kanın sistemik venöz dolaşıma yöneldiği genişlemiş damar yollarıdır; siroz dışında portal ven tıkanıklığı ve bölgesel venöz obstrüksiyonda da gelişebilir. Portal venöz fazlı BT, özofagogastrik, paraözofageal, splenorenal/gastrorenal ve paraumbilikal yolları anatomik seyirleriyle gösterir. Bu damarlar varis kanaması veya spontan şant varlığını ortaya koyabilir; dağılımı portal ve splenik ven açıklığıyla eşleştirmek altta yatan basınç bölgesini anlamaya yardım eder. İnce kollateral damarları atlamak kanama açısından önemli varisleri veya girişim planlamasını etkileyen şantları rapor dışında bırakabilir.

Faz ve pencere

Portal tanısal

Portal venöz kontrastlanmada kollateraller, portal venöz kan havuzuyla dolan kıvrımlı tübüler damarlar olarak izlenir; sol gastrik ven boyunca gastroözofageal/paraözofageal damarlar, dalak hilusu-fundus arasında gastrik varisler, splenik hilus-sol renal ven arasında şantlar ve sol portal daldan falciform ligaman boyunca paraumbilikal ven aranır. Damarların portal sisteme ve sistemik çıkışa bağlantısı ardışık aksiyel/kısmi koronal görüntülerde takip edilir.

Önerilen pencereler: Batın (G 400 / M 50), Karaciğer (G 150 / M 30), Anjiyo (G 600 / M 150).

BT bulguları

• Gastroözofageal varisler — küçük kurvaturdaki sol gastrik ven bağlantısından kardiya/fundusa ve distal özofagus çevresine uzanan kıvrımlı damarlar.
• Paraözofageal kollateraller — özofagus duvarı dışındaki mediastinal/periözofageal venöz kanallar; lümen içi varislerden ayrı yerleşir.
• Gastrorenal şant — fundik gastrik varislerden sol renal vene ulaşan geniş kollateral yol.
• Splenorenal şant — splenik hilustan sol renal ven veya renal hilus çevresine uzanan serpiginöz damar bağlantısı.
• Rekanalize paraumbilikal ven — sol portal ven dalından ligamentum teres/falciform ligaman boyunca ön karın duvarına ilerleyen kontrastlı kanal.
• Karın duvarı kollateralleri — paraumbilikal venin ön karın duvarı damarlarına yaptığı drenaj sonucu oluşan kıvrımlı venöz ağlardır; bazen 'Medusa başı' görünümü verebilir.
• Portal hipertansiyon eşlikçileri — splenomegali, asit, portal ven akım değişikliği ve sirotik karaciğer morfolojisi.

Normalde

Normal portal venöz BT'de sol gastrik ve kısa gastrik damarlar ince veya izlenmez; paraumbilikal ven genellikle oblitere ligamentum teres halindedir—mide fundusu, distal özofagus ve umbilikus çevresinde geniş kıvrımlı damar kümeleri patolojik portosistemik kollaterallerdir. Aynı bölgede tübüler damarları portal hilustan sistemik drenaj noktalarına kadar izleyin; özofagus varisi özofagus duvarı içinde yer alırken, paraözofageal kollateral duvarın dışında bulunduğundan konumlarıyla ayırın.

Ayırıcı tanı

Gastrik varisler endoskopi veya barium grafide solid duvar kalınlaşması veya kalın rugalar taklit edebilir.

Portal kavernom

damar ağı hepatik hilusta kayıp ana portal ven yatağının yerini alır; kollateral şantların mide, retroperiton veya karın duvarına uzanımıyla aynı kavram değildir.

Edinsel portal ven trombozu

periportal kollateraller eşlik edebilir; kolateral ağ ile birlikte doğrudan trombüs ayrıca değerlendirilmelidir.

Splenik ven trombozuna bağlı izole gastrik varis

fundus ve kısa gastrik dağılım baskındır, ana portal ven açık kalabilir; yaygın siroz bulguları olmayabilir.

Tuzaklar

• Özofagus duvarı içi varisleri paraözofageal damarlarla karıştırmayın; damarların duvara göre iç/dış yerleşimini çok düzlemli görüntüde kontrol edin.
• Küçük gastrik damarları kollateral diye aşırı yorumlamayın; belirgin kalibrasyon artışı, kıvrımlı seyir ve portal-sistemik devamlılık arayın.
• Paraumbilikal venin falciform ligaman içindeki seyrini yüzeyel epigastrik damarlara bağlamadan bırakmayın; bu bağlantı yolun portal kökenini açıklar.
• Bir şantın bulunması tek başına sirozun şiddetini veya kanama olasılığını sayısal olarak belirlemez; BT'de görülen anatomik yolu ve eşlik eden bulguları tanımlayın.

Kendini dene

1. Sirozlu hastada sol portal daldan falciform ligaman boyunca umbilikusa ilerleyen kontrastlı ven görülüyor. Bu kollateralin adı nedir?

   • Rekanalize paraumbilikal ven
   • Gonadal ven
   • Azygos kollaterali
   • Sistik ven
   Cevabı göster

   Rekanalize paraumbilikal ven. Sol portal daldan ligamentum teres/falciform ligaman boyunca ön karın duvarına uzanan kanal rekanalize paraumbilikal vendir. Diğer seçenekler bu portal giriş ve umbilikal seyri tanımlamaz.

2. Fundik varislerden sol renal vene doğrudan uzanan geniş damar yolu hangi şantı tanımlar?

   • Gastrorenal şant
   • Paraumbilikal şant
   • Portokaval şant
   • Splenoazigos şant
   Cevabı göster

   Gastrorenal şant. Fundik gastrik varislerle sol renal ven arasındaki devamlılık gastrorenal şanttır. Paraumbilikal yol ön karın duvarına gider; portokaval ve splenoazigos yollar farklı sistemik drenaj bağlantılarını ifade eder.

Kaynaklar

Bu sayfadaki 35 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 3 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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