Portal Vein Thrombosis

Portal Vein Thrombosis (PVT) – John Laurenzano

Background

  • Sluggish flow within the portal system, localized endothelial inflammation, and alterations in the coagulation/fibrinolytic cascade
  • There is a bidirectional relationship between PVT and decompensation, as portal vein thrombosis can worsen decompensation (i.e. variceal hemorrhage), though at the same time PVT can result from worsening portal HTN and more sluggish flow 

 

Presentation

  • Identified asymptomatically on ultrasound, but can be identified by new or worsening decompensation of portal HTN
  • Esophageal variceal hemorrhage—most common decompensating event assoc. w/ PVT
  • Intestinal ischemia (abdominal pain, hematochezia)—exceedingly rare but assoc. w/significant morbidity and mortality

 

Evaluation

  •  
  • Initial: RUQ with doppler
  • Once identified, should be further assessed with ctriple phase CT or MRI w/Gadovist contrast to exclude HCC w/tumor thrombus (excludes pts from LT as noted above)
    • AFP can be an adjunctive test to assess for HCC if significantly elevated
  • Pts with newly identified PVT should undergo EGD to evaluate for high-risk varices, both for diagnostic and therapeutic considerations
  • PVT in pts w/o cirrhosis should prompt evaluation for hypercoagulable disorders

 

Management

  • Individualized and based on risk factors for bleeding; should be discussed with the attending/fellow. There is no need for urgent anticoagulation in the absence of signs/symptoms of intestinal ischemia
  • Anticoagulation with VKA, LMWH, or UFH
    • DOAC’s not as extensively studied in cirrhosis, but may be considered Child A pts
    • If pt is to be listed for transplant and has normal INR, coumadin can give additional MELD points and is more easily reversed
  • Anticoagulation is associated with improved recanalization in recent PVT (<6 mos), and may improve post-transplant outcomes in those awaiting transplantation; pts with chronic occlusive PVT (>6 mos) or with cavernous transformation with collaterals do not generally benefit from anticoagulation
  • Pts with high-risk varices should undergo endoscopic management or be on BB for ppx for variceal hemorrhage, as noted above
  • TIPS with portal vein recanalization has recently emerged as a therapeutic modality for PVT
  • Pts should undergo follow up intermittently with ultrasound imaging to assess for recanalization. AC may be stopped if there is failure to recanalize.
    • If pts are not candidates for AC, they'll simply be treated for complications of portal HTN