What does periportal cuffing on an ultrasound (USG) of the abdomen indicate?

Periportal Cuffing on Abdominal Ultrasound: Clinical Significance and Implications

Periportal cuffing on abdominal ultrasound indicates inflammation, edema, or lymphatic congestion around the portal tracts, and is commonly associated with acute hepatitis, portal hypertension, congestive heart failure, or fluid overload states. 1

Definition and Appearance

Periportal cuffing appears as circumferential zones of altered echogenicity around the peripheral portal venous branches on ultrasound:

• Echo-poor (hypoechoic) cuffing: Appears as dark bands surrounding portal vessels
• Echo-rich (hyperechoic) cuffing: Appears as bright bands surrounding portal vessels

Clinical Significance by Etiology

1. Acute Hepatitis

• Periportal edema is a common finding in acute hepatitis, appearing as hypoechoic bands around portal vessels
• Present in approximately 43.5% of patients with acute hepatitis 1
• Often accompanied by other sonographic findings:
  • Hepatomegaly
  • Gallbladder wall thickening
  • Perihepatic lymphadenopathy
  • Heterogeneous liver parenchyma

2. Portal Hypertension

• Periportal cuffing may represent early collateral formation or lymphatic congestion
• Development of new periportal collaterals during follow-up is associated with:
  • Higher rates of variceal formation (56.2% vs 22.2%)
  • Increased variceal growth (52.9% vs 30.6%) 2
• May be an early warning sign of worsening portal hypertension

3. Fluid Overload States

• Primary periportal edema (pPPE) can serve as a surrogate marker for:
  • Intravenous volume overload
  • Excessive crystalloid administration 3
• Secondary periportal edema (sPPE) may indicate:
  • Venous congestion
  • Right heart failure 3

4. Inflammatory Bowel Disease

• Echo-rich periportal cuffing is most frequently associated with inflammatory bowel disease 4
• Particularly common with diseases of the lower gastrointestinal tract

5. Malignancy

• Echo-poor periportal cuffing is significantly associated with malignant diseases (78% vs 36% for echo-rich) 4
• Particularly common in hematological malignancies like lymphoma and leukemia

Clinical Implications and Management

Diagnostic Workup

1. Laboratory tests:

   • Liver function tests (AST, ALT, bilirubin, alkaline phosphatase, GGT)
   • Complete blood count
   • Coagulation profile

2. Additional imaging:

   • For suspected hepatitis: Consider MRI with MRCP
   • For suspected portal hypertension: Doppler ultrasound to assess portal flow
   • For suspected malignancy: Contrast-enhanced CT or MRI

Management Considerations

• For acute hepatitis: Monitor liver function tests and provide supportive care
• For portal hypertension: Consider endoscopy when new periportal collaterals are detected 2
• For fluid overload: Address underlying cause (heart failure, excessive fluid administration)
• For malignancy: Further diagnostic workup and appropriate oncological management

Prognostic Value

• New development of periportal cuffing during follow-up may indicate disease progression
• In cirrhotic patients, new periportal collaterals suggest worsening portal hypertension
• In trauma patients, periportal edema may indicate fluid overload requiring adjustment of resuscitation strategies

Common Pitfalls

1. Misinterpretation: Periportal cuffing is a nonspecific finding and should be interpreted in clinical context
2. Overlooking the finding: Subtle periportal cuffing may be missed without careful examination
3. Failure to follow up: New periportal collaterals warrant endoscopic evaluation in cirrhotic patients
4. Ignoring echo characteristics: Echo-poor vs echo-rich cuffing has different clinical implications

Remember that while periportal cuffing is a nonspecific finding, it is abnormal and should prompt careful evaluation of the liver and clinical context to identify the underlying cause.