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. PMID: 19299846.

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.