Portal vein thrombosis: Difference between revisions
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==Background== | ==Background== | ||
Portal vein thrombosis (PVT) is a vascular disease of the liver that occurs when a blood clot occurs in the hepatic portal vein, leading to increased pressure in the portal vein system and reduced blood supply to the liver. | |||
===Inciting Causes=== | ===Inciting Causes=== | ||
*Abdominal sepsis | *Abdominal [[sepsis]] | ||
*Abdominal surgery | *Abdominal surgery | ||
*Behçet's syndrome | *Behçet's syndrome | ||
*Cirrhosis | *Cholangiocarcinoma | ||
*Collagen vascular | *[[Cirrhosis]] | ||
*[[Collagen vascular disease]]s (eg, lupus) | |||
*Compression or invasion of the portal vein by tumor (eg, pancreatic cancer) | *Compression or invasion of the portal vein by tumor (eg, pancreatic cancer) | ||
*[[Diverticulitis]] | |||
*Endoscopic sclerotherapy | *Endoscopic sclerotherapy | ||
*Hepatocellular carcinoma | *[[Hepatocellular carcinoma]] | ||
*[[Inflammatory bowel disease]] | *[[Inflammatory bowel disease]] | ||
*Inherited thrombophilias | *Inherited thrombophilias (e.g. factor V Leiden deficiency, protein C or S deficiency, [[antiphospholipid syndrome]]) | ||
*Myeloproliferative | *[[Myeloproliferative disorders]] (e.g. [[polycythemia vera]] or [[essential thrombocytosis]]) | ||
*[[Omphalitis]] | *[[Omphalitis]] | ||
*Oral contraceptives | *Oral contraceptives | ||
| Line 20: | Line 23: | ||
*[[Pregnancy ]] | *[[Pregnancy ]] | ||
*Retroperitoneal fibrosis | *Retroperitoneal fibrosis | ||
*Transjugular intrahepatic portosystemic shunt | *[[Splenectomy]] complication | ||
*[[Transjugular intrahepatic portosystemic shunt]] (TIPS) | |||
*[[Trauma]] | *[[Trauma]] | ||
==Clinical Features== | ==Clinical Features== | ||
===Acute=== | ===Acute=== | ||
* | *Upper [[abdominal pain]] developing suddenly or progressing over a few days | ||
*May be clinically silent in a portion of patients and diagnosed during a CT exam for other reasons (e.g. acute [[pancreatitis]]) | *Possibly accompanied by [[nausea]], [[hepatomegaly]], splenomegaly; may be accompanied by persistent non-spiking [[fever]] in the setting of systemic inflammation | ||
*Other signs/symptoms based on underlying cause (e.g. bleeding disorders, hepatic stigmata if due to cirrhosis) | |||
*May be clinically silent in a portion of patients and diagnosed incidentally during a CT exam for other reasons (e.g. acute [[pancreatitis]]) | |||
===Chronic=== | |||
*Often asymptomatic; incidental finding on imaging | |||
*Associated with portal hypertension | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Mesenteric vein thrombosis | |||
*[[Budd-Chiari syndrome]] | |||
*[[Portal vein thrombosis]] | |||
*[[Venous thromboembolism]] | |||
==Evaluation== | ==Evaluation== | ||
*Typically diagnosed on abdominal CT with contrast | *Typically diagnosed on abdominal CT with contrast | ||
*Filling defect on Doppler ultrasound | |||
*EGD to assess for gastric/esophageal varices if chronic PVT | |||
==Management== | ==Management== | ||
=== Acute === | |||
*In non-cirrhotic, [[LMWH]] -> [[warfarin]] x 6 months | |||
=== Chronic === | |||
*In non-cirrhotic or hypercoagulable, anticoagulation after screening for varices | |||
*Anticoagulate patients with cirrhosis AND 1) thrombophilia, 2) clot extension in mesenteric veins, or 3) bowel ischemia | |||
*If severe, may require shunt, liver transplant, or bowel resection | |||
==Disposition== | ==Disposition== | ||
| Line 41: | Line 61: | ||
==See Also== | ==See Also== | ||
*[[Budd-Chiari syndrome]] (hepatic vein thrombosis) | |||
*Pylephlebitis | |||
*[[Venous thromboembolism]] | |||
==External Links== | ==External Links== | ||
| Line 48: | Line 70: | ||
==References== | ==References== | ||
<references/> | <references/> | ||
1. DeLeve LD, Valla DC, Garcia-Tsao G (2009). "Vascular disorders of the liver". ''Hepatology''. '''49''':1729-64. | |||
2. O'Mara SR, Wiesner L. "Hepatic Disorders". In Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH (eds.). ''Tintinalli's Emergency Medicine: A Comprehensive Study Guide'' (9 ed.). New York, NY: McGraw-Hill. | |||
3. Simonetto DA, Singal AK, Garcia-Tsao G, Caldwell SH, Ahn J, Kamath PS (January 3, 2020). "ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation". ''Am J Gastroenterol''. '''115''': 18-40. | |||
4. Nery F, Chevret S, Condat B, de Raucourt E, Boudaoud L, Rautou P, Plessier A, Roulot D, Chaffaut C, Bourcier V, Trinchet J, Valla D (February 2015). "Causes and Consequences of Portal Vein Thrombosis in 1,243 Patients with Cirrhosis: Results of a Longitudinal Study". ''Hepatology''. '''61''': 660-667. [http://doi:10.1002/hep.27546 doi:10.1002/hep.27546] | |||
5. Friedman LS (2020). "Noncirrhotic Portal Hypertension". In Papadakis MA, McPhee SJ, Rabow MW (eds.). ''Current Medical Diagnosis and Treatment 2020''. McGraw-Hill. | |||
[[Category:Vascular]] | |||
Latest revision as of 17:43, 25 October 2020
Background
Portal vein thrombosis (PVT) is a vascular disease of the liver that occurs when a blood clot occurs in the hepatic portal vein, leading to increased pressure in the portal vein system and reduced blood supply to the liver.
Inciting Causes
- Abdominal sepsis
- Abdominal surgery
- Behçet's syndrome
- Cholangiocarcinoma
- Cirrhosis
- Collagen vascular diseases (eg, lupus)
- Compression or invasion of the portal vein by tumor (eg, pancreatic cancer)
- Diverticulitis
- Endoscopic sclerotherapy
- Hepatocellular carcinoma
- Inflammatory bowel disease
- Inherited thrombophilias (e.g. factor V Leiden deficiency, protein C or S deficiency, antiphospholipid syndrome)
- Myeloproliferative disorders (e.g. polycythemia vera or essential thrombocytosis)
- Omphalitis
- Oral contraceptives
- Pancreatic islet cell transplantation
- Pancreatitis
- Paroxysmal nocturnal hemoglobinuria
- Pregnancy
- Retroperitoneal fibrosis
- Splenectomy complication
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Trauma
Clinical Features
Acute
- Upper abdominal pain developing suddenly or progressing over a few days
- Possibly accompanied by nausea, hepatomegaly, splenomegaly; may be accompanied by persistent non-spiking fever in the setting of systemic inflammation
- Other signs/symptoms based on underlying cause (e.g. bleeding disorders, hepatic stigmata if due to cirrhosis)
- May be clinically silent in a portion of patients and diagnosed incidentally during a CT exam for other reasons (e.g. acute pancreatitis)
Chronic
- Often asymptomatic; incidental finding on imaging
- Associated with portal hypertension
Differential Diagnosis
- Mesenteric vein thrombosis
- Budd-Chiari syndrome
- Portal vein thrombosis
- Venous thromboembolism
Evaluation
- Typically diagnosed on abdominal CT with contrast
- Filling defect on Doppler ultrasound
- EGD to assess for gastric/esophageal varices if chronic PVT
Management
Acute
Chronic
- In non-cirrhotic or hypercoagulable, anticoagulation after screening for varices
- Anticoagulate patients with cirrhosis AND 1) thrombophilia, 2) clot extension in mesenteric veins, or 3) bowel ischemia
- If severe, may require shunt, liver transplant, or bowel resection
Disposition
See Also
- Budd-Chiari syndrome (hepatic vein thrombosis)
- Pylephlebitis
- Venous thromboembolism
External Links
References
1. DeLeve LD, Valla DC, Garcia-Tsao G (2009). "Vascular disorders of the liver". Hepatology. 49:1729-64.
2. O'Mara SR, Wiesner L. "Hepatic Disorders". In Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH (eds.). Tintinalli's Emergency Medicine: A Comprehensive Study Guide (9 ed.). New York, NY: McGraw-Hill.
3. Simonetto DA, Singal AK, Garcia-Tsao G, Caldwell SH, Ahn J, Kamath PS (January 3, 2020). "ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation". Am J Gastroenterol. 115: 18-40.
4. Nery F, Chevret S, Condat B, de Raucourt E, Boudaoud L, Rautou P, Plessier A, Roulot D, Chaffaut C, Bourcier V, Trinchet J, Valla D (February 2015). "Causes and Consequences of Portal Vein Thrombosis in 1,243 Patients with Cirrhosis: Results of a Longitudinal Study". Hepatology. 61: 660-667. doi:10.1002/hep.27546
5. Friedman LS (2020). "Noncirrhotic Portal Hypertension". In Papadakis MA, McPhee SJ, Rabow MW (eds.). Current Medical Diagnosis and Treatment 2020. McGraw-Hill.