Portal Vein Thrombosis (PVT)¶
John Laurenzano
Background¶
- Portal Vein Thrombosis (PVT) can worsen decompensation (i.e. variceal hemorrhage), however, worsening portal HTN -> more sluggish flow -> increased risk PVT
Presentation¶
- Often identified asymptomatically on U/S, but can be identified by new or worsening decompensation of portal HTN
- Variceal hemorrhage is the most common decompensating event associated with PVT
- Intestinal ischemia (abdominal pain, hematochezia) from PVT is exceedingly rare but associated with significant morbidity and mortality
Evaluation¶
- RUQ U/S with doppler
- Once identified, should be further assessed with triple phase CT or MRI with Gadovist contrast to exclude HCC with tumor thrombus
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Pts with newly identified PVT should undergo EGD to evaluate for high-risk varices, both for diagnostic and therapeutic considerations
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PVT in pts without cirrhosis should prompt evaluation for hypercoagulable disorders
Management¶
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Start anticoagulation if acute thrombus occludes >50% of main portal vein, <50% but extends into SMV, thrombus is symptomatic, or patient is a transplant candidate (irrespective of size). Requires discussion with attending/transplant team.
- Anticoagulation options: warfarin, LMWH, or DOAC
- DOAC’s are safe in Childs Class A, can be used with caution in Childs B, and are contraindicated in Childs C
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Pts with chronic occlusive PVT (>6 mos) or with cavernous transformation with collaterals do not generally benefit from anticoagulation
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Pts with high-risk varices should undergo endoscopic management or be on NSBB for prophylaxis for variceal hemorrhage, as noted above
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TIPS with portal vein recanalization has recently emerged as a therapeutic modality for PVT
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Pts should undergo follow up intermittently with ultrasound to assess for recanalization. AC may be stopped if there is failure to recanalize.
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If pts are not candidates for AC, they'll simply be treated for complications of portal HTN