In 1945 Blakemore and Lord published their work on the treatment of Banti's Syndrome by anastomosing the splenic to the left renal vein, or the portal vein to the inferior vena cava. In the same year Whipple (1945) classified portal hypertension into cases with an obstruction in the portal system outside the liver, and those with a block inside the liver, the result of hepatic fibrosis. The cases with extrahepatic blockage of the portal circulation present clinically as cases of Banti's Syndrome. In this latter group repeated haematemeses are a common, and often fatal symptom. The operation of portacaval anastomosis has as its main object the lowering of the pressure in the portal system, with a reduction in the frequency, and severity of the haematemeses. The operations are difficult and dangerous, and the patients suitable for operation must be selected carefully. The exact site of obstruction causing portal hypertension must be determined either at, or preferably before operation, as it will determine the type of operation. Thus an anastomosis between the portal vein and the inferior vena eava will be useless if haematemeses are the result of obstruction of the splenic vein.

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Objectives: Pelvic vein incompetence (PVI) has been suggested as a cause for chronic pelvic pain. The overall objective of this thesis is to determine how PVI affects women, identify suitable methods of diagnosis and provide evidence regarding its association with chronic pelvic pain. This thesis will also evaluate the evidence behind its treatment. Methods: Four observation studies were completed during this thesis. A characterisation study encompassing 120 participants was performed to determine symptoms commonly experienced by women with PVI. Two observation studies analysed the ability of trans-vaginal ultrasound to detect PVI and compared its accuracy with reflux venography; considered the reference standard. A further 70 participants were recruited in a case-control study to determine the prevalence of PVI in women with and without chronic pelvic pain. A randomised control trial treating women with PVI and pelvic pain was also designed. Results: Women with PVI had an increased frequency of CPP when compared with healthy controls or women with varicose veins. This pain was associated with the menstrual cycle and intercourse. It was also found to frequently radiate into the upper thighs. Trans-vaginal ultrasound was shown to have a sensitivity and positive predictive value of 100% and 95% respectively when compared with reflux venography. The frequency of PVI in women with chronic pelvic pain was found to be 47% compared with 25% in women with no history of CPP (p < 0.001). Conclusion: The results of this thesis suggest PVI to be a possible cause of CPP in women and likely to be under-diagnosed. It can be identified by trans-vaginal ultrasound although the degree of accuracy is still yet to be determined. PVI merits further research and attention from clinicians and researchers. The proposed randomised control trial is needed both to further understanding of the role of PVI in CPP and to assess the efficacy of an under-researched treatment approach currently used in practice.

Despite the vast myriad of applications and the long way it has come, MRI is still a relatively new field of knowledge with much prospect for more advancement and expansion. This work is mainly concerned with two gradient echo imaging methods which are directly or indirectly related to blood vessel imaging as well as iron depiction in the human brain. In each case, new methods are introduced that overcome existing limitations. For blood vessel imaging, 3D Time-of-Flight (TOF) MR angiography (MRA) with its known capability to image arteries as well as veins was implemented at 3.0 T. At this field strength, the significant RF profile variability due to RF inhomogeneity is a liability for circle-of-Willis imaging in the human brain that was overcome by introducing a new means to counter the RF effects through increased slope of the ramped pulse. In addition a new method is introduced for TOF MRA with two-in-one arterial and venous 3D TOF imaging to overcome the significant scan time overhead of a traditional second venous scan and for cutting down RF power utilization. Using this method, total scan time could be reduced by as much as 46% and specific absorption rate (SAR) due to spatial saturation could be reduced by as much as 92%. For iron sensitive imaging, Susceptibility Weighted Imaging (SWI) was developed at 4.7 T. The phase SWI method was used to visualize lesions in Multiple Sclerosis (MS) patients and was experimentally compared to the visibility on standard T2 weighting with results demonstrating visualization of new lesions, with 18% of total lesions exclusively visible on SWI. A new approach to 3D imaging was also introduced to enable accurate oblique SWI scanning while overcoming the current restriction to axial imaging to produce correct phase effects for oblique imaging. New results from oblique phase imaging were presented and the phase measurements from key brain structures were successfully validated against images obtained by the current standard of axial imaging.

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京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20564号 / 医博第4249号 / 新制||医||1022(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 増永 慎一郎, 教授 妹尾 浩, 教授 鈴木 実 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM