Portal Vein Thrombosis

GENERAL PRINCIPLES

Portal vein thrombosis (PVT) is seen in a variety of clinical settings, including abdominal trauma, cirrhosis, malignancy, hypercoagulable states, intra-abdominal infections, pancreatitis, and after portocaval shunt surgery and splenectomy.

DIAGNOSIS

Clinical Presentation

• PVT can present as an acute or chronic condition.

• The acute phase may go unrecognized. Symptoms include abdominal pain/distension, nausea, anorexia, weight loss, diarrhea, or features of the underlying disorder. Bowel ischemia may result from extensive PVT with extension to the superior mesenteric vein.

• Chronic PVT may present with variceal hemorrhage or other manifestations of portal hypertension.

Diagnostic Testing

• In patients with no obvious etiology, a hypercoagulable workup should be performed.

• Doppler ultrasound examination is sensitive and specific for establishing the diagnosis. Portal venography, CT, or magnetic resonance venography can also be used.

TREATMENT

Medications

• In patients with acute PVT with or without cirrhosis, anticoagulation is recommended in the absence of any obvious contraindications. Treatment is aimed to prevent further thrombosis and recanalization, to treat complications and concurrent disease, and to mitigate underlying risk factors.

• In patients with chronic PVT, anticoagulation is recommended if they have hypercoagulable conditions without cirrhosis. Anticoagulation in cirrhotic patients with chronic PVT remains controversial, but should be considered in potential liver transplant candidates.^23,24

• Optimal type of anticoagulant is not established, but recent meta-analysis suggests DOACs are most efficacious in recanalization compared to vitamin K antagonists and low-molecular-weight heparin with similar bleeding risk.²⁵

Nonpharmacologic Therapies

In the setting of chronic PVT, treatment should focus on the complications of portal hypertension and include nonselective #946;-blockers, endoscopic band ligation, and diuretics for ascites.

Surgical Management

Portosystemic derivative surgery carries a high morbidity and mortality, especially in patients with cirrhosis. In some instances where surgery is precluded or the thrombus expands despite adequate anticoagulation, interventional radiology may be able to deploy TIPS. This may theoretically resolve symptomatic portal hypertension and prevent the thrombus recurrence or extension by the creation of a portosystemic shunt.²⁵