Portosystemic collateral pathways
Updates to Article Attributes
Portosystemic collateral pathways (also, also called varices)spontaneousportosystemic shunts or varices, develop spontaneously via dilatation of pre-existing anastomoses between the portal and systemic venous systems. This facilitates shunting of blood away from the liver into the systemic venous system in portal hypertension, as a means for reducing portal venous pressure. However, these are not sufficient for normalising portal venous pressure.
The main sites of portosystemic collateral pathways are:
-
left gastric (see gastric varices)
left gastric (coronary) vein and short gastric veins to distal oesophageal veins
located between medial wall of gastric body and posterior margin of left hepatic lobe in lesser omentum
usually accompanied by oesophageal/paraoesophageal varices (see below)
oesophageal: dilated submucosal venous plexus of distal oesophagus (see oesophageal varices)
-
paraoesophageal
coronary vein to azygos and hemiazygos veins and vertebral venous plexus
located posterior to oesophagus in posterior mediastinum
perisplenic: splenic vein to left renal vein, traversing splenocolic ligament; may eventuate in a spontaneous splenorenal shunt
-
retrogastric
left gastric (coronary) vein or gastroepiploic vein to oesophageal or paraoesophageal veins
located in posterior/posteromedial aspect of gastric fundus
retroperitoneal-paravertebral: colic or mesenteric branches of superior mesenteric vein to retroperitoneal/lumbar veins to the inferior vena cava
paraumbilical: left portal vein to paraumbilical veins in anterior ridge of falciform ligament
anterior abdominal wall: paraumbilical and omental veins to subcutaneous periumbilical veins and superior and inferior epigastric veins; collaterals appear to radiate from the umbilicus (caput medusae)
mesenteric: dilated branches of superior mesenteric vein
anal canal: superior rectal vein (from the inferior mesenteric vein) to upper anal canal veins (haemorrhoids)
Differential diagnosis
Dilatation of splenic veins at the splenic hilum mimicking splenic hilar varices without splenomegaly may occur in situations such as increased perfusion of splenic tissue associated with an immune response 4.
-<p><strong>Portosystemic collateral pathways</strong> (also called <strong>varices</strong>) develop spontaneously via dilatation of pre-existing anastomoses between the portal and systemic venous systems. This facilitates shunting of blood away from the liver into the systemic venous system in <a href="/articles/portal-hypertension">portal hypertension</a>, as a means for reducing portal venous pressure. However, these are not sufficient for normalising portal venous pressure.</p><p>The main sites of portosystemic collateral pathways are:</p><ul>-<li>-<strong>left gastric</strong> (see <a href="/articles/gastric-varix">gastric varices</a>)<ul>-<li>-<a href="/articles/left-gastric-vein">left gastric (coronary) vein</a> and <a href="/articles/short-gastric-veins">short gastric veins</a> to distal oesophageal veins</li>-<li>located between medial wall of gastric body and posterior margin of left hepatic lobe in <a href="/articles/omentum">lesser omentum</a>-</li>-<li>usually accompanied by oesophageal/paraoesophageal varices (see below)</li>-</ul>-</li>-<li>-<strong>oesophageal</strong>: dilated submucosal venous plexus of distal oesophagus (see <a href="/articles/oesophageal-varix">oesophageal varices</a>)</li>-<li>-<strong>paraoesophageal</strong><ul>-<li>-<a href="/articles/left-gastric-vein">coronary vein</a> to <a href="/articles/azygos-vein">azygos</a> and <a href="/articles/hemiazygos-vein">hemiazygos</a> veins and <a href="/articles/vertebral-venous-plexus-1">vertebral venous plexus</a>-</li>-<li>located posterior to oesophagus in posterior mediastinum</li>-</ul>-</li>-<li>-<strong>perisplenic</strong>: <a href="/articles/splenic-vein">splenic vein</a> to left renal vein, traversing <a href="/articles/splenocolic-ligament">splenocolic ligament</a>; may eventuate in spontaneous <a href="/articles/splenorenal-shunt">splenorenal shunt</a>-</li>-<li>-<strong>retrogastric</strong><ul>-<li>left gastric (coronary) vein or gastroepiploic vein to oesophageal or <a href="/articles/paraoesophageal-vein">paraoesophageal veins</a>-</li>-<li>located in posterior/posteromedial aspect of gastric fundus</li>-</ul>-</li>-<li>-<strong>retroperitoneal-paravertebral</strong>: colic or mesenteric branches of <a href="/articles/superior-mesenteric-vein">superior mesenteric vein</a> to retroperitoneal/lumbar veins to the <a href="/articles/inferior-vena-cava-1">inferior vena cava</a>-</li>-<li>-<strong>paraumbilical</strong>: left portal vein to <a href="/articles/paraumbilical-veins">paraumbilical veins</a> in anterior ridge of <a href="/articles/falciform-ligament">falciform</a><a href="/articles/falciform-ligament"> ligament</a>-</li>-<li>-<strong>anterior abdominal wall</strong>: paraumbilical and <a href="/articles/omental-vein">omental veins</a> to subcutaneous <a href="/articles/periumbilical-vein">periumbilical veins</a> and superior and inferior epigastric veins; collaterals appear to radiate from the <a href="/articles/umbilicus">umbilicus</a> (<a href="/articles/caput-medusae-sign-portal-hypertension-2">caput medusae</a>)</li>-<li>-<strong>mesenteric</strong>: dilated branches of superior mesenteric vein</li>-<li>-<strong>anal canal</strong>: superior rectal vein (from the <a href="/articles/inferior-mesenteric-vein">inferior mesenteric vein</a>) to <a href="/articles/upper-anal-canal-vein">upper anal canal veins</a> (<a href="/articles/haemorrhoids">haemorrhoids</a>)</li>- +<p><strong>Portosystemic collateral pathways</strong>, also called <strong></strong><strong>spontaneous</strong> <strong>portosystemic shunts</strong> or <strong>varices</strong>, develop spontaneously via dilatation of pre-existing anastomoses between the portal and systemic venous systems. This facilitates shunting of blood away from the liver into the systemic venous system in <a href="/articles/portal-hypertension">portal hypertension</a>, as a means for reducing portal venous pressure. However, these are not sufficient for normalising portal venous pressure.</p><p>The main sites of portosystemic collateral pathways are:</p><ul>
- +<li>
- +<p><strong>left gastric</strong> (see <a href="/articles/gastric-varix">gastric varices</a>)</p>
- +<ul>
- +<li><p><a href="/articles/left-gastric-vein">left gastric (coronary) vein</a> and <a href="/articles/short-gastric-veins">short gastric veins</a> to distal oesophageal veins</p></li>
- +<li><p>located between medial wall of gastric body and posterior margin of left hepatic lobe in <a href="/articles/omentum">lesser omentum</a></p></li>
- +<li><p>usually accompanied by oesophageal/paraoesophageal varices (see below)</p></li>
- +</ul>
- +</li>
- +<li><p><strong>oesophageal</strong>: dilated submucosal venous plexus of distal oesophagus (see <a href="/articles/oesophageal-varix">oesophageal varices</a>)</p></li>
- +<li>
- +<p><strong>paraoesophageal</strong></p>
- +<ul>
- +<li><p><a href="/articles/left-gastric-vein">coronary vein</a> to <a href="/articles/azygos-vein">azygos</a> and <a href="/articles/hemiazygos-vein">hemiazygos</a> veins and <a href="/articles/vertebral-venous-plexus-1">vertebral venous plexus</a></p></li>
- +<li><p>located posterior to oesophagus in posterior mediastinum</p></li>
- +</ul>
- +</li>
- +<li><p><strong>perisplenic</strong>: <a href="/articles/splenic-vein">splenic vein</a> to left renal vein, traversing <a href="/articles/splenocolic-ligament">splenocolic ligament</a>; may eventuate in a <a href="/articles/spontaneous-splenorenal-shunt">spontaneous splenorenal shunt</a></p></li>
- +<li>
- +<p><strong>retrogastric</strong></p>
- +<ul>
- +<li><p>left gastric (coronary) vein or gastroepiploic vein to oesophageal or <a href="/articles/paraoesophageal-vein">paraoesophageal veins</a></p></li>
- +<li><p>located in posterior/posteromedial aspect of gastric fundus</p></li>
- +</ul>
- +</li>
- +<li><p><strong>retroperitoneal-paravertebral</strong>: colic or mesenteric branches of <a href="/articles/superior-mesenteric-vein">superior mesenteric vein</a> to retroperitoneal/lumbar veins to the <a href="/articles/inferior-vena-cava-1">inferior vena cava</a></p></li>
- +<li><p><strong>paraumbilical</strong>: left portal vein to <a href="/articles/paraumbilical-veins">paraumbilical veins</a> in anterior ridge of <a href="/articles/falciform-ligament">falciform ligament</a></p></li>
- +<li><p><strong>anterior abdominal wall</strong>: paraumbilical and <a href="/articles/omental-vein">omental veins</a> to subcutaneous <a href="/articles/periumbilical-vein">periumbilical veins</a> and superior and inferior epigastric veins; collaterals appear to radiate from the <a href="/articles/umbilicus">umbilicus</a> (<a href="/articles/caput-medusae-sign-portal-hypertension-2">caput medusae</a>)</p></li>
- +<li><p><strong>mesenteric</strong>: dilated branches of superior mesenteric vein</p></li>
- +<li><p><strong>anal canal</strong>: superior rectal vein (from the <a href="/articles/inferior-mesenteric-vein">inferior mesenteric vein</a>) to <a href="/articles/upper-anal-canal-vein">upper anal canal veins</a> (<a href="/articles/haemorrhoids">haemorrhoids</a>)</p></li>
References changed:
- 8. Nardelli S, Riggio O, Turco L et al. Relevance of Spontaneous Portosystemic Shunts Detected with CT in Patients with Cirrhosis. Radiology. 2021;299(1):133-40. <a href="https://doi.org/10.1148/radiol.2021203051">doi:10.1148/radiol.2021203051</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/33529134">Pubmed</a>
- 9. Philips C, Arora A, Shetty R, Kasana V. A Comprehensive Review of Portosystemic Collaterals in Cirrhosis: Historical Aspects, Anatomy, and Classifications. Int J Hepatol. 2016;2016:1-15. <a href="https://doi.org/10.1155/2016/6170243">doi:10.1155/2016/6170243</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28074159">Pubmed</a>
- 10. Grant E, Tessler F, Gomes A et al. Color Doppler Imaging of Portosystemic Shunts. AJR Am J Roentgenol. 1990;154(2):393-7. <a href="https://doi.org/10.2214/ajr.154.2.2105035">doi:10.2214/ajr.154.2.2105035</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/2105035">Pubmed</a>