Describe the liver (surface nodularity, caudate hypertrophy), then the signs of portal hypertension — spleen size, portal vein flow direction and velocity, collaterals, ascites — and survey for hepatocellular carcinoma.
Orient first
- Imaging can suggest cirrhosis but early cirrhosis may look normal; elastography measures stiffness.
- Portal hypertension shows as splenomegaly, portosystemic collaterals (left gastric, paraumbilical, splenorenal), ascites and slow or reversed portal flow.
- Every cirrhotic liver on imaging is also a surveillance study for hepatocellular carcinoma — report any observation.
Acquire the study
- Curvilinear probe for the liver surface and spleen; a linear high-frequency probe for surface nodularity; spectral Doppler of the portal vein at the porta.
The manoeuvre
- Liver surface with the linear probe: nodularity; caudate lobe enlargement relative to the right lobe.
- Portal vein at the porta on spectral Doppler: direction (hepatopetal or hepatofugal), velocity and calibre in mm.
- Spleen length in cm; the splenic vein.
- Collaterals on colour Doppler: recanalised paraumbilical vein, splenorenal shunt; ascites.
- Hepatic veins: phasicity (lost in cirrhosis) and patency (Budd–Chiari).
What confirms it
- Morphological features of cirrhosis with the portal hypertension signs present or absent.
What licenses you to exclude it
- A normal ultrasound does not exclude cirrhosis; elastography or biopsy is needed when the question matters.
The classic misread
- Calling hepatofugal flow normal because the colour map was not checked against the probe direction.