Arterioportal fistulas in patients with liver cirrhosis: usefulness of color Doppler US for screening

Hepatic Arterioportal Fistula Is Associated with Decreased Future Liver Remnant Regeneration after Stage-I ALPPS for Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) patients often developed hepatic arterioportal fistula (APF). The aim of this study is to evaluate the impact of APF on future liver remnant (FLR) regeneration and surgical outcomes after the first stage of associating liver partition and portal vein ligation for staged hepatectomy (stage-I ALPPS).

METHODS

Consecutive HCC patients who underwent ALPPS at our center between March 2017 and May 2019 were retrospectively studied. Data for the association between APF and clinicopathological details, liver volume, and surgical outcomes were analyzed.

RESULTS

The enrolled 35 HCC patients were divided into three groups: 15 patients with preoperative APF were classified as the APF I group, 10 patients developed APF after stage-I ALPPS as the APF II group, whereas the other 10 patients without APF before and after stage-I ALPPS as the control group. After stage-I ALPPS, patients in the APF I and APF II groups had lower kinetic growth rate (KGR) of FLR volume (6.1±3.2%, 11.4±8.4%, 25.0±8.8% per week, respectively, P<0.001) and took longer median time to reach the sufficient FLR volume for stage-II ALPPS (17.5 days, 12 days, 6 days, respectively, P<0.001) than those in the control group. Meanwhile, the incidence of posthepatectomy liver failure (PHLF) in the APF I and APF II groups was significantly higher than that of the control group (P=0.007). There are 27 (77.1%) patients who completed stage-II ALPPS. The overall survival (OS) rates at 1 and 3 years were 59.3% and 35.1%, whereas the disease-free survival (DFS) rates at 1 and 3 years were 44.4% and 22.9%, respectively.

CONCLUSIONS

Hepatic APF is significantly associated with decreased FLR regeneration and a higher risk of PHLF after stage-I ALPPS. HCC patients who are to undergo ALPPS may benefit from the timely perioperative intervention of APF.

Tratamento endovascular da hipertensão portal e da hemorragia digestiva recorrente e secundária à síndrome da fístula arterioportal: complicação tardia de trauma abdominal penetrante

The arterioportal fistula (APF) syndrome is a rare and reversible cause of pre-sinusoidal portal hypertension, caused by communication between a visceral artery and the portal venous system. Most patients are asymptomatic, but when they do develop symptoms, these are mainly related to gastrointestinal bleeding, ascites, congestive heart failure, and diarrhea. This therapeutic challenge presents a case of APF caused by a 20-year-old stabbing injury with unfavorable late clinical evolution, including significant malnutrition and severe digestive hemorrhages. The patient was treated using an endovascular procedure to occlude of the fistula.

Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature

Background

Hepatic arterioportal fistulas are rare, abnormal, direct communications between hepatic artery and portal venous system. Treatment options shifted from surgery to endovascular interventions. Catheterization may be challenging. We report a case of a hepatic arterioportal fistula treated successfuly with Amplatzer Vascular Plug II via percutaneous transhepatic hepatic artery access after failed transfemoral approach.

Case presentation

58 year old woman presented with right heart failure, kidney insufficiency and massive ascites related to portal hypertension caused by hepatic arterioportal fistula. She had a history of previous abdominal surgery. Colour Doppler ultrasound and computed tomography revealed a giant portal vein aneurysm related to large hepatic areterioportal fistula. Endovascular treatment was planned. Catheterization of the hepatic artery could not be realized due to severe tortuosity and angulation of the celiac artery and its branches. Access to the hepatic artery was obtained directly via percutaneous transhepatic route and fistula site was embolized with Amplatzer Vascular Plug II and coils. Immediate thrombosis of the aneurysm sac and draining portal vein was observed. Patients clinical status improved dramatically.

Conclusion

Transcatheter embolization is the first choice of the treatment of hepatic arterioportal fistulas but the type of the therapy should be tailored to the patient and interventional radiologist should decide the access site depending on his own experience if the routine endovascular access can not be obtained.

Successful surgical treatment for intrahepatic arterioportal fistula with severe portal hypertension: a case report

Background

Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension. Interventional radiology (IVR) is generally selected as the first-line therapeutic option. Surgical treatment for IAPF is required in refractory cases of IVR. As the treatment success rate with IVR is high, cases requiring surgical treatment are extremely rare.

Case presentation

A 54-year-old man was admitted to another hospital complaining of hematemesis due to rupture of the esophageal varices. A computed tomography revealed ascites and arterioportal fistula in the left lobe of the liver. Transcatheter arterial embolization (TAE) was performed to occlude the fistula; however, it could not reach complete occlusion. Thereafter, there were a total of four hematemeses, and six endoscopic variceal ligations were required. The second TAE also failed to reach complete occlusion. He was transferred to our hospital for further treatment. Because liver function was low due to frequent hematemeses and there was also uncontrollable ascites, it was confirmed that hepatectomy could not be performed safely at this time. Therefore, we ligated the left portal branch and ligated and dissected the left gastric vein to decrease portal vein pressure. However, on the 5th day after surgery, the esophageal varices reruptured. As the disappearance of ascites was observed in the postoperative course and the general condition also improved, left hepatectomy was performed to remove IAPF. There was no recurrence of portal hypertension for 1 year and 3 months since hepatectomy.

Conclusions

This case was difficult to treat with IVR and required surgical treatment. Our experience in the present case suggests that hepatectomy to remove arterioportal fistula was considered effective for improving portal hypertension due to IAPF. However, careful treatment selection according to the patient’s overall condition and clinical course is necessary for IAPF presenting with severe portal hypertension.

A traumatic hepatic artery pseudoaneurysm and arterioportal fistula, with severe diarrhea as the first symptom: A case report and review of the literature

RATIONALE

Hepaticarterioportal fistula (APF) is a rare cause of portal hypertension and gastrointestinal hemorrhage, and presents as abnormal communication between the hepatic artery and portal vein. Percutaneous liver biopsy is a main iatrogenic cause of AFP. However, non-iatrogenic, abdominal, trauma-related APF is rarely reported.

PATIENT CONCERNS

A 29-year-old man presenting with severe, watery diarrhea was transferred to our hospital, and his condition was suspected to be acute gastroenteritis because he ate expired food and suffered a penetrating abdominal stab wound 5 years ago. After admission, the patient suffered from hematemesis, hematochezia, ascites, anuria, and kidney failure, and he developed shock.

DIAGNOSES

The patient was finally diagnosed as a traumatic hepatic artery pseudoaneurysm and APF.

INTERVENTIONS

This patient was treated with emergency transarterial embolization using coils. Since a secondary feeding vessel was exposed after the first embolization of the main feeding artery, a less-selective embolization was performed again.

OUTCOMES

During the 6-month follow-up period, the patient remained asymptomatic.

LESSONS

A penetrating abdominal stab wound is a rare cause of hepatic APFs, and occasionally leads to portal hypertension, the medical history and physical examination are the most important cornerstones of clinical diagnosis. Interventional radiology is essential for the diagnosis and treatment of an APF.

Portal Vein Thrombosis and Arterioportal Fistula in Post Liver Transplant Recipient: A Case Report

An intrahepatic Arterioportal Fistula Refers (APF) to abnormal shunt or fistulous connection between the portal venous system and a hepatic arterial system within the liver. Here, we present a case of portal vein thrombosis with APF in post-transplant liver, developed 2 years and 6 months after transplantation. The condition was diagnosed by Triphasic CT angiography. In this case report we have discussed various causes and pathophysiology of APF with its imaging findings.

Fluctuating portal velocity tracing with rhythmicity: ultrasonic differential diagnosis and clinical significance

Background

To evaluate the usefulness of the routine sonographic evaluation of the pattern of fluctuate portal velocity tracings and the hepatic veins for the diagnosis of arterioportal fistula (APF) and cardiogenic trans-sinusoidal shunting (CTS).

Materials and methods.

Color Doppler flow imaging and pulsed-wave Doppler (PW) examinations of the portal vein were performed in 282 subjects. The waveforms of the velocity tracings in the portal main trunk and its branches were determined to infer APF or CTS. Suspected cases of APFs or CTSs were always confirmed by echocardiography, contrast-enhanced ultrasound, computed tomography, or digital subtraction angiography findings. The portal maximum velocity (V_max), minimum velocity(V_min), V_max/V_min, arterial peak systolic velocity and resistance index, and venous reverse and forward velocities were used to estimate their haemodynamics.

Results

The waveform of the velocity tracing for the draining portal vein of APF was typically arterial-like or diphase, as indicated by a systolic hepatofugal dwarf peak and a diastolic hepatopetal low flat shape. The flow in the affected portal vein was always hepatofugal in an intrahepatic patient, whereas a hepatopetal flow was observed in an extrahepatic APF patient. The waveform of the velocity tracing for the portal vein of CTS patients, especially its intrahepatic branches, showed a typical hump-like shape with or without a transitory hepatofugal tracing. The PW results displayed an increase in the retrograde phase of the hepatic venous flow with increased velocities in the two phases.

Conclusions

Portal velocity tracings should be evaluated during routine detecting for APF or CTS, especially in patients with gastrointestinal upsets.

Congenital intrahepatic arterioportal fistula presenting as severe undernutrition and chronic watery diarrhea in a 2-year-old girl

Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension in young children. We report the case of a 2-year-old girl with severe undernutrition, chronic watery diarrhea, and gastrointestinal bleeding because of a congenital intrahepatic arterioportal fistula. Radiographic embolization and surgical ligation of the left hepatic artery were attempted, with no resolution of the symptoms. So, a left lobectomy was performed, with excellent results and prompt disappearance of the diarrhea. Hepatectomy should be considered as a definitive and reliable therapy for congenital IAPF.

Nontumorous arterioportal shunts in the liver: CT and MRI findings considering mechanisms and fate

The intrahepatic non-tumorous arterioportal shunt (APS) is one of the important causes of transient hepatic enhancement differences (THED) on dynamic CT or MRI. Most small APSs are located in the peripheral portion of the liver. Because of the parenchymal distortion in the advanced cirrhotic liver, many small APSs tend to show an amorphous or nodular appearance, making them difficult to distinguish from hypervascular tumors. In addition to the use of dynamic CT or MRI, iso-attenuation densities or iso-intensities on pre-contrast and equilibrium phases, MRI using a liver-specific contrast agent can be useful to characterize the hypervascular pseudolesions. Because there is no difference in water diffusion in the hepatic parenchyma in the region of the APS, diffusion-weighted MRI also has great potential to distinguish non-tumorous shunts from true focal lesions. Larger (>2 cm) APSs of direct arterio-portal venous fistulas from extrinsic insults show typical subcapsular wedge-like THEDs that are only temporarily depicted several months after the traumatic event; most of these THEDs gradually decrease in size or vanish completely. By understanding the nature of non-tumorous APSs, radiologists will be able to provide a more accurate assessment of many THEDs during daily interpretations of CT or MR images of the liver.

Color Doppler sonography of intrahepatic vascular shunts

PURPOSE

To illustrate the sonographic and Doppler features of the different types of intrahepatic vascular shunts.

METHODS

Patients presenting in our department with intrahepatic vascular shunts with healthy livers or with a variety of liver pathologies underwent color Doppler interrogation and spectral analysis.

RESULTS

Intrahepatic vascular shunts may involve all liver vessels. Arterioportal and arteriosystemic venous connections can be recognized in normal and cirrhotic livers, following trauma, within tumors, and within nontumoral arteriovenous malformations. Portosystemic intrahepatic venous shunts are categorized into 4 morphologic types. Systemic-to-systemic shunts are more often recognized in patients with chronic hepatic venous congestion or with Budd-Chiari syndrome. Portal-to-portal intrahepatic venous shunts are rare, with few cases described.

CONCLUSION

In general, all the liver vessels can be associated with formation of arterioportal, arteriosystemic, and portosystemic venous shunts and, rarely, systemic venous shunts and portal-to-portal communications. Sonography allows characterization of the different intrahepatic shunts.

Liver involvement in a large cohort of patients with hereditary hemorrhagic telangiectasia: echo-color-Doppler vs multislice computed tomography study

BACKGROUND/AIMS

Hepatic arterio-venous malformations (HAVMs) have been found in 74% of hereditary hemorrhagic telangiectasia (HHT) patients with multislice CT (MSCT). This single-blind study aimed to compare the diagnostic accuracy of echo-color-Doppler with MSCT and identify the most sensitive ultrasound criteria indicating hepatic shunts.

METHODS

One hundred and fifty-three HHT patients were systematically screened for HAVMs by biological tests, abdominal MSCT and echo-color-Doppler. Twenty-five normal subjects and 15 cirrhotic patients were also included as control groups. Both intrahepatic ("color spots" and hypervascularization) and extrahepatic parameters (diameter, flow velocity and tortuosity of hepatic artery and diameter and flow velocity of portal/hepatic vein) were utilized. "Color-spots" are defined as subcapsular vascular spots with a high-velocity arterial blood flow and low resistivity index and can identify extremely small HAVMs.

RESULTS

CT was positive in 128/153 (84%) patients and Doppler color spots were found in 131/153 (86%) patients. The sensitivity, specificity and diagnostic accuracy of "color spots" compared to MSCT were 95.3%, 68.0% and 91.8%, respectively. The "color-spot" showed a greater correlation to CT (V(index)=0.655; p<0.0001) than extrahepatic criteria (V=0.317). In 20/29 (69%) subjects, echo-color-Doppler, confirmed by CT, identified the third criterion for definite HHT diagnosis.

CONCLUSIONS

Intrahepatic criteria was superior to extrahepatic criteria for identification of HAVMs. A new Doppler parameter ("color-spots") with an optimal accuracy for detecting HAVMs is proposed for easy periodic screening of HHT patients.

Research progress on transient hepatic peritumoral enhancement

Multi-slice computed tomography (MSCT) has been widely used in the clinical examination for livers. CT can not only complete scanning in a short time, but also achieve multi-phase scanning, so MSCT has unique advantages in the diagnosis of abnormal hepatic perfusion, showing as transient hepatic peritumoral enhancement (THPE). Based on this, in combination with the mechanism of THPE, the image characteristics of MSCT and clinical data, MSCT can make great contribution to identify the causes of THPE and diagnose the lesion property.

The congenital intrahepatic arterioportal fistula syndrome: elucidation and proposed classification

Congenital intrahepatic arterioportal fistula is a rare but treatable cause of portal hypertension for which early recognition may lead to successful radiological management. We report an infant presenting with severe failure to thrive, melena and splenomegaly due to a congenital intrahepatic arterioportal fistula, successfully ablated after multiple trials of superselective transarterial embolization. Comprehensive review of congenital cases provides an understanding of the key clinical features defining this syndrome. A classification system is proposed, upon which treatment decisions may be based.

Intrahepatic arterioportal fistula and its treatment with detachable balloon and transcatheter embolization with coils and microspheres

BACKGROUND

Although intrahepatic arterioportal fistula (APF) due to acquired or congenital causes are infrequent, they are listed among the causes of portal hypertension.

PURPOSE

The aim of this study was to present the results of intrahepatic APF treatment with embolotherapy in six cases.

MATERIAL AND METHODS

Transarterial detachable balloon and coil embolization was used on six consecutive cases with traumatic intrahepatic APF from 1989 to 2003. Six-month follow-up angiography was obtained in every case.

RESULTS

Successful disconnection of hepatic arterial and portal system was achieved in five cases. At least symptomatic improvement was achieved in one.

CONCLUSION

Transcatheter embolization may be the first line of treatment for intrahepatic APF.

Physical hemodynamic interaction between portal venous and hepatic arterial blood flow in humans

OBJECTIVE

The hepatic arterial end-diastolic velocity (HAEDV) is normally equal to portal vein peak velocity (PVPV). However, there is no report of quantitative measurement that HAEDV was equal to PVPV. We investigated the interaction in PVPV and HAEDV in both chronic and acute hepatic hemodynamic changes.

METHODS

One hundred and nineteen patients (54 with cirrhosis, 23 with chronic hepatitis, and 42 with no diffuse liver disorder) were enrolled. We investigated the differences in PVPV and HAEDV among the patients with and without liver disorder. In addition, we measured the intraindividual changes in HAEDV when PVPV was mechanically changed by percutaneous isolated hepatic perfusion in six patients and by percutaneous transhepatic portal embolization (PTPE) in six more.

RESULTS

HAEDV was nearly equal to PVPV not only in patients with both normal and hepatitis but also in those with cirrhosis (PVPV-HAEDV = 3.0 +/- 5.2, 2.2 +/- 5.4, 2.3 +/- 6.5 cm/s, respectively). In the intraindividual study, both PVPV and HAEDV decreased during hepatic mechanical perfusion and HAEDV was equal to PVPV (8.2 +/- 2.8, 10.5 +/- 1.5 cm/s, respectively). After PTPE, PVPV was increased and hepatic arterial peak systolic velocity was reciprocally decreased. However, HAEDV was nearly equal to PVPV 7 days after PTPE (PVPV-HAEDV = 5.9 +/- 5.1 cm/s).

CONCLUSIONS

Since arterial end-diastolic velocity depends on the downstream vascular resistance, lower HAEDV in patients with cirrhosis was considered to reflect a high outflow resistance. If there is no collateral pathway, we consider that HAEDV may actually reflect sinusoidal resistance to the same degree as PVPV.

Color Doppler ultrasound predicting variceal hemorrhage in patients with liver cirrhosis

AIM: To investigate the portal hemodynamics and its correlation with esophageal variceal bleeding (EVB) in cirrhotics with portal hypertension and to search for the most sensitive parameters predicting variceal hemorrhage.

METHODS: Hemodynamics of portal trunk (PT), splenic vein (SV) and left gastric vein (LGV), including the diameter, the timed-average mean velocity, flow volume, flow direction and its dynamic changes were assessed in 76 cirrhosis patients (39 with positive bleeding history, 36 without previous bleeding history) using color Doppler ultrasound.

RESULTS: In cirrhotics with portal hypertension, EVB (+) subgroup had no difference in the Doppler parameters of the portal vein compared with EVB (-); the diameter, flow volume of the splenic vein and the diameter of the LGV were significantly higher in EVB (+) subgroup group (P < 0.05). In patients with EVB (+), the hepatofugal flow of the LGV was significantly increased and the flow hepatofugal velocity was significantly higher than that in EVB (-) group (P < 0.05).

CONCLUSION: Increased hepatofugal flow velocity (≥ 16 cm/s) in color Doppler sonography may be the better parameter for current hemorrhage in cirrhotics with portal hypertension.

Color Doppler ultrasonic diagnosis of congenital portal vein malformations

AIM: To evaluate the value and clinical significance of the color Doppler ultrasound in the diagnosis of congenital portal vein malformations.

METHODS: The sonographic traits by color Doppler ultrasound in 14 patients with portal malformations were reviewed and analyzed.

RESULTS: The color Doppler ultrasonograms for 7 patients with portal vein carvernous angioma, 2 patients with intrahepatic arterial-portal fistula, 2 patients with intrahepatic portal-vein fistula and 3 patients with portal stenosis were consistent with those of DSA or CT examination. There were 10 patients with liver dysfunction and portal hypertension among them.

CONCLUSION: The color Doppler ultrasound plays an important role in the diagnosis of the congenital port vein malformations.

Nontumorous vascular malformations in the liver: color Doppler ultrasonographic findings

OBJECTIVE

To investigate color Doppler and spectral wave characteristics of nontumorous vascular malformations in the liver.

METHODS

From September 1995 to January 2001, 32 cases of vascular malformations were identified by means of color Doppler ultrasonography and spectral wave analysis. Computed tomography, angiography, or both were performed in all cases.

RESULTS

Five arterioportal and 14 portovenous malformations, 1 arteriovenous malformation, and 4 portoportal and 8 venovenous shunts were detected. Associations with Rendu-Osler-Weber syndrome in 6 cases and with cirrhotic liver in 12 cases were found Fourteen patients were liver disease free. In 3 cases, interventional procedures were necessary to reduce portal hypertension or cardiac dysfunction. The incidence of finding vascular malformations in 12,000 patients was 0.1%.

CONCLUSIONS

Nontumorous vascular malformations are rare disorders in the liver. They may appear in patients with healthy livers and in patients with portal hypertension. Color Doppler ultrasonography and spectral wave analysis are capable of showing and differentiating different types of hepatic vascular malformations.

Hepatic arterial blood flow in large hepatocellular carcinoma with or without portal vein thrombosis: assessment by transcutaneous duplex Doppler sonography

BACKGROUND

As liver cirrhosis progresses, the portal venous blood (PVBF) flow decreases, accompanied by an increase in hepatic arterial blood flow. Large hepatocellular carcinoma is a hypervascular tumour with a rapid growth, which seems to require an increase of the tumoral arterial blood flow. Furthermore, hepatocellular carcinoma is frequently associated with portal vein thrombosis, which subsequently impedes portal blood supply.

METHODS

The purpose of our study was to estimate alterations in the hepatic arterial blood flow in large hepatocellular carcinomas occurring in liver cirrhosis, in comparison with liver cirrhosis and controls. Liver blood flow measurements were determined by duplex Doppler sonography in 47 patients with large hepatocellular carcinomas (13 with portal vein thrombosis and 34 without this thrombosis), 42 liver cirrhosis patients and 30 controls. The Doppler perfusion index was calculated as the ratio of hepatic arterial blood flow to total hepatic blood flow.

RESULTS

The patients with liver cirrhosis had a significant increase of hepatic arterial blood flow as compared to controls (P < 0.001), accompanied by a significant reduction in PVBF (P < 0.005). As a result, the Doppler perfusion index was increased in patients with liver cirrhosis as compared to controls (P < 0.001). The hepatic arterial blood flow was increased in patients with hepatocellular carcinoma but without portal vein thrombosis as compared to the cirrhotic patients (P < 0.001), with a significant reduction of PVBF (P < 0.001). Hepatic arterial blood flow was also increased in patients with both hepatocellular carcinoma and portal vein thrombosis as compared to the patients without this thrombosis (P < 0.001).

CONCLUSION

These results suggest that in large hepatocellular carcinomas there is a decreased PVBF, accompanied by an increased hepatic arterial blood flow. The hepatic arterial buffer response seems to be active in hepatocellular carcinomas and maintains liver perfusion to adequate levels.

Doppler in hepatic cirrhosis and chronic hepatitis

Doppler ultrasound and color Doppler are being used routinely in the study of vascular structures of the abdomen, and more particularly the liver. Reports published in the literature to date have shown that all patients with hepatic cirrhosis and chronic hepatitis should be studied in the first stage of their illness and in follow-up by using Doppler techniques. With new ultrasound software and the latest generation of contrast agents, we can obtain a better and more complete vascular study of the liver, which previously could be achieved only with triple-phase CT. Therefore, hepatic cirrhosis and chronic hepatitis, as well as their vascular complications, can be followed up more closely. The vascular complications include flow alterations in the hepatic artery and veins, portal hypertension, portal vein thrombosis, portosystemic shunts, and vascularization associated with liver tumors.

Hepatofugal flow in the portal venous system: pathophysiology, imaging findings, and diagnostic pitfalls

Hepatofugal flow (ie, flow directed away from the liver) is abnormal in any segment of the portal venous system and is more common than previously believed. Hepatofugal flow can be demonstrated at angiography, Doppler ultrasonography (US), magnetic resonance imaging, and computed tomography (CT). The current understanding of hepatofugal flow recognizes the role of the hepatic artery and the complementary phenomena of arterioportal and portosystemic venovenous shunting. Detection of hepatofugal flow is clinically important for diagnosis of portal hypertension, for determination of portosystemic shunt patency and overall prognosis in patients with cirrhosis, as a potential pitfall at invasive arteriography performed to evaluate the patency of the portal vein, and as a contraindication to specialized imaging procedures (ie, transarterial hepatic chemoembolization and CT during arterial portography). Hepatofugal flow is generally diagnosed at Doppler US without much difficulty, but radiologists should beware of pitfalls that can impede correct determination of flow direction in the portal venous system.

Intrahepatic spontaneous retrograde portal flow in patients with cirrhosis of the liver: reversal by food intake

OBJECTIVE

The purpose of our study was to assess whether intrahepatic spontaneous retrograde portal flow in patients with cirrhosis of the liver can be reversed to a normal portal venous flow by food intake.

CONCLUSION

Of the 18 cirrhotic patients with intrahepatic spontaneous retrograde portal flow, 16 (89%) showed a marked change in portal flow direction after food intake. This evidence strongly suggests that intrahepatic spontaneous retrograde portal flow may be reversible. Furthermore, this finding implies that regular food intake may be important in the maintenance of effective hepatic blood flow in cirrhotic patients.