Portal vein thrombosis
OVERVIEW
- thrombus formation in the portal vein +/- tributaries (SMV, IMV and splenic vein)
PATHOPHYSIOLOGY
- can be acute or chronic
- clot can be within liver or external
- clot can be occluding or non-occluding
- isolated thrombus can occur in the splenic vein (rare in SMV or IMV alone)
- mesenteric thrombosis occurs when all the mesenteric veins are occluded with thrombus
- over time recanalisation and collateral vessel formation can occur (portal cavernoma)
Complications
- portal hypertension without ascites
- organ ischaemia/ infarction (e.g. liver, spleen, intestines)
CAUSE
Virchow triad
- stasis — cirrhosis with portal hypertension, local tumour (e.g. HCC)
- hypercoagulable state — thrombophilia, malignancy, pregnancy, trauma, inflammatory bowel disease (IBD), hypovolemia, oral contraceptive pill (OCP)
- endothelial activation — surgery, inflammation (e.g. pancreatitis, cholecystitis)
CLINICAL FEATURES
- N&V, abdominal pain and diarrhoea are typical of acute PVT
- chronic PVT may be asymptomatic
- if cirrhosis, then mimics portal hypertension with ascites
- if no cirrhosis, then ascites is absent
- splenomegaly
- varices +/- haemorrhage
- abdominal pain due to intestinal ischemia from congestion or infarction of other organs
INVESTIGATIONS
- liver ultrasound — loss of flow on colour Doppler, thrombus may be visible
- CT abdomen with contrast — may visualise clot, intestinal ischemia
- endoscopy — varices
- thrombophilia screen
- lactate (intestinal ischemia)
- other investigations depending on likely underlying cause and complications (e.g. haemorrhage)
MANAGEMENT
Resuscitation
- immediate life threats are typically variceal haemorrhage or intestinal ischemia
Specific therapy
- variceal haemorrhage — haemostatic resuscitation, correct coagulopathy, urgent endoscopy (sclerosing injections, banding) +/- surgical repair
- intestinal ischemia — resection of infarcted bowel
- cirrhosis — PVT usually incidental, exclude hepatocellular cancer, treat portal hypertension, exclude PVT as part of transplant work up
- non-cirrhotic — anticoagulation (IV heparin/ LMWH then warfarin); life-long if thrombophilia
- options for recanalisation — endovascular thrombolysis, thrombectomy, percutaneous transhepatic angioplasty
Seek and treat underlying causes and complications
- e.g. malignancy, pancreatitis
- long-term management of portal hypertension in chronic PVT
Supportive care and monitoring
References and Links
Journal articles
- Hoekstra J, Janssen HL. Vascular liver disorders (II): portal vein thrombosis. Neth J Med. 2009 Feb;67(2):46-53
- 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.
FOAM and web resources
- Hartung MP. Abdominal CT: abdominal veins. LITFL
- Radiopaedia — Portal vein thrombosis
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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