Anabolic Steroids and Portal Venous Thrombosis

Abstract

Portal venous thrombosis (PVT) is a rare and potentially fatal cause of abdominal pain. Advanced liver disease, hypercoagulable states, certain malignancies and infectious conditions predispose patients to thrombosis. Here we discuss a case of main portal vein (MPV) and superior mesenteric vein (SMV) thrombosis and its management. A 34 year old patient with no past medical history presented with 4 days of epigastric pain. Initially intermittent, the pain became constant and severe. He reported absence of nausea, vomiting, hematochezia, melena or fever. He endorsed an alcohol use of 1-3 drinks weekly and reported use of testosterone and human growth hormone supplements for the purposes of bodybuilding starting two months prior to admission. He had no family history of thrombophilia. CT scan of the abdomen demonstrated thrombosis of the MPV and SMV. Heparin was started though his abdominal pain intensified and he subsequently underwent TIPS and thrombectomy followed by tissue plasminogen activator (tPA) infusion for thrombolysis. Postprocedurally, he developed severe hypotension with intra-abdominal fluid seen on ultrasound. Heparin and tPA were ceased and he was taken for emergent exploratory laparotomy showing active bleeding within the mesentery followed by ligation. He was stabilized with resolution of his presenting symptoms and discharged on rivaroxaban for long-term anticoagulation. PVT in the young, healthy patient is an uncommon occurrence. Acute PVT may present with abdominal pain, abdominal distention, nausea, vomiting and gastrointestinal bleeding. PVT is most often associated with cirrhosis, intra-abdominal infections and malignancies though, as seen in our case, other forms of thrombophilia may be implicated and should ignite further investigation. Treatment of acute or subacute PVT depends on the severity of the patient's symptoms and clinical data though initial investigation should start with CT or ultrasound imaging. Concern for intestinal ischemia is of particular worry when mesenteric involvement is present and intervention with direct PV-SMV thrombectomy and thrombolysis via TIPS is recommended. Anticoagulation alone may be insufficient and surgery is often unnecessary unless necrosis is suspected. Alternatively, one may consider an indirect approach with thrombolytic therapy delivered via the mesenteric arterial system. Following acute treatment, the patient should be started on systemic anticoagulation to reduce risk of recurrence.Figure: Main Portal and Superior Mesenteric Venous Thrombosis.