Liver: Venous Thrombosis

Portal Vein Thrombosis (PVT)

Basics

  • Thrombosis Within the Portal Vein
    • Usually Extra-Hepatic Site
  • Risk Factors:
    • Hypercoagulable Disease
    • Cirrhosis or Hepatocellular Carcinoma
    • Trauma
    • Inflammatory Bowel Disease
    • Pancreatitis
    • Pregnancy
    • TIPS
    • Splenectomy

Complications

  • Portal Hypertension/Ascites Without Liver Failure
  • Mesenteric Ischemia
  • Portal Cholangiopathy
    • Venous Collaterals Compress & Obstruct Bile Ducts
    • Tx: Endoscopic Stent vs Portosystemic Shunt
  • Pylephlebitis

Diagnosis

  • Dx: Doppler US or CT

Treatment

  • Primary Tx: Anticoagulation
  • If Mesenteric Ischemia: Bowel Resection & Surgical Thrombectomy
  • If Recurrent Variceal Bleeding & Endoscopy Fails:
    • If SMV Patent: Mesocaval (Rex) Shunt
    • If Diffuse Thrombosis (Portal/Mesenteric/Splenic): Sugiura Procedure
    • Consider TIPS if Able to Access/Dilate/Stent Thrombosed Vein
      • TIPS Unlikely to Succeed if Cavernous Transformation Seen

Special Populations

  • Pregnancy
    • Most Common Cause: Thrombus Originating in Ovarian Vein
      • Infective Component Present
    • Sx: Postpartum Liver Failure (If Intrahepatic) & Ascites
    • Tx: Heparin & ABX
  • Pediatrics
    • Usually Extrahepatic
    • Most Common Cause: Umbilical Vein Infection
    • PVT is the Most Common Pediatric Cause of: Portal Hypertension, Esophageal Varices & Massive Hematemesis

Portal Vein Thrombosis

Splenic Vein Thrombosis

Causes

  • Chronic Pancreatitis (Most Common)
  • Pancreatic CA Causing Occlusion

Presentation

  • Isolated Gastric Varices (From Collaterals to Short Gastrics)
  • Splenomegaly

Diagnosis

  • Dx: CTA or Doppler US

Treatment

  • Tx: Splenectomy

Splenic Vein Thrombosis 1

Gastric Varices 2

References

  1. Mujtaba G, Josmi J, Arya M, Anand S. Spontaneous splenic rupture: a rare complication of acute pancreatitis in a patient with Crohn’s disease. Case Rep Gastroenterol. 2011 Apr 13;5(1):179-82. (License: CC BY-NC-ND-3.0)
  2. Biecker E. Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension. ISRN Hepatol. 2013 Jul 22;2013:541836. (License: CC BY-4.0)