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Portal Vein Thrombosis (PVT)

Pakinam Mekki

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

  • Pts with newly identified PVT should undergo EGD to evaluate for high-risk varices, both for diagnostic and therapeutic considerations

  • PVT in pts without cirrhosis should prompt evaluation for hypercoagulable disorders

Management

  • Start AC 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

  • 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 NSBB for prophylaxis for variceal hemorrhage, as noted above

  • TIPS with portal vein recanalization has recently emerged as a therapeutic modality for PVT in LT candidates to allow for anastomosis, in patient’s with chronic PVT and recurrent bleeding/refractory ascites, or in patients whom intestinal ischemia persists despite AC.

  • Pts should undergo follow up intermittently with ultrasound 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