Portal vein thrombosis
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.