A 35-year-old woman presents with generalised abdominal pain, associated with 3 weeks of abdominal distension.
She has a previous history of recurrent thrombosis and multiple previous miscarriages, with no identified thrombophilia. She is not on any anticoagulation.
Blood work up reveals a mild LFT derangement ALP 174, GGT 75, ALT 40 with a normal Bilirubin and CRP 180
An abdominal CT is performed
Describe and interpret the CT scan
These CT images are taken with contrast in the portal venous phase. There is acute thrombosis of the portal vein and superior mesenteric vein.
On CT, acute thrombus is differentiated from chronic thrombosis by the presence of a dilated vein with surrounding fat stranding due to reactive inflammation as we see in this case.
Another distinguishing feature is the presence of venous collaterals which will only be seen in cases of chronic thrombus.
This patient also has a small non-occlusive (not filling the entire lumen) thrombus in the infrarenal IVC.
The digital subtraction venography image shows the same thrombi, seen as irregular filling defects in the portal and superior mesenteric vein and no contrast opacification of the proximal SMV.
Reminder of the anatomy of the venous system
Portal vein thrombosis is a life-threatening condition. Patients often present with non-specific abdominal pain or if extensive with ischaemic bowel.
The cause can be categorised depending on which branch of Virchow’s triad has been disrupted
Reduced flow /portal hypertension
- Hepatobiliary malignancies (HCC, pancreatic, cholangiocarcinoma)
- Inherited thrombophilia
- Oral contraceptive pill
- Local infection or inflammation; eg pancreatitis, cholangitis
This case demonstrates portal vein and SMV thrombosis which resulted in mesenteric venous congestion and eventually ischemia of the small bowel.
The goals in treating portal vein thrombosis are to re-establish portal vein flow, prevent secondary infection which results from bowel ischaemia and to identify and treat any underlying precipitant.
This patient was managed initially with IV heparinisation and prophylactic IV antibiotics.
Unfortunately, despite treatment her condition deteriorated. Due to extension of the thrombus management was escalated to include catheter directed thrombolysis, multiple attempts of IR guided thrombectomy, and eventually systemic thrombolysis.
Unfortunately, this patient developed bowel ischaemia with resultant septic shock and passed away seven days after her presentation to hospital.
- Hartung MP. Abdominal CT: Phases. LITFL
- Hartung MP. Abdominal CT: Liver. LITFL
- Hartung MP. Abdominal CT: abdominal veins. LITFL
- Simonetto DA, Singal AK, Garcia-Tsao G, Caldwell SH, Ahn J, Kamath PS. ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation. Am J Gastroenterol. 2020 Jan;115(1):18-40.
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Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).