Management of Chronic Portal Vein Thrombosis: An Anticoagulation Dilemma?

Abstract

Purpose: Portal vein thrombosis (PVT) is an uncommon cause of presinusoidal portal HTN. Etiology includes cirrhosis, malignancy, hypercoagulable state, intrabdominal infections, and surgical trauma. Anticoagulation is indicated in non-cirrhotic acute and chronic PVT without variceal bleed to reverse and halt the progression of thrombosis. The role of anticoagulation in patients with PVT complicated by variceal bleed is controversial. We present a patient with PVT and variceal bleed that improved with anticoagulation and deteriorated after self-discontinuation of therapy. Methods: 44 year old Hispanic female with DM, HTN, and dyslipidemia was admitted with abdominal pain and hemetemesis. EGD revealed grade IV esophageal and gastric varices indicative of portal HTN. CT abdomen showed PVT without underlying cirrhosis. Further workup showed low protein C and antithrombin III activity. She was started on Coumadin therapy. Follow up EGD at 6 months showed improvement in gastroesophageal varices. Subsequently patient was poorly compliant with Coumadin therapy and was readmitted with massive hemetemesis, with EGD showing worsening of gastroesophageal varices. Repeat CT abdomen showed liver cirrhosis with extension of the PVT into the splenic and superior mesenteric veins. She was treated conservatively with PPI's, Octreotide and Beta blockers. Because of increased risk of variceal bleed at this stage, Coumadin was not restarted. The patient was not considered a candidate for TIPS or spleno-renal shunt due to extensive thrombosis and was transferred to a liver transplant center. Results: Acute and chronic PVT can have similar presentations but abdominal pain, fever, and ascítes are common in acute, and variceal bleed is more common in chronic PVT. Variceal bleeding in non-cirrhotic PVT has a better prognosis and lower risk of rebleeding than in cirrhotic PVT. Doppler USG, and CT abdomen are diagnostic of PVT. Recommendations for anticoagulation in PVT are not clear, thus individual risks and benefits should be considered. In cases where anticoagulation is contraindicated or fails in recanalisation of the vessel, porto-systamic shunt and liver transplantation can be considered.Figure: CT Abdomen showing Portal vein thrombosis with dilatation of the splenic vein.