Portal Vein Thrombosis

Today we discussed a patient with a portal vein thrombosis (PVT) in the setting of acute cholecystitis. Following the management of acute cholecystitis, the discussion turned to the management of a PVT.

Here's an excellent review article on an approach to managing a PVT.

A few things to keep in mind:

1) The causes of a PVT include inflammatory, malignant, infectious and hypercoaguable states, however the most common cause is cirrhosis (25%).

2) An incidentally found PVT should trigger a search for cirrhosis, a hypercoaguable state or occult malignancy (including a myeloproliferative disorder).

3) An acute PVT is usually asymptomatic.

4) The rationale for treating a PVT is to prevent clot extension and compromise of intestinal perfusion and to prevent portal HTN.

5) It's estimated that 85-90% of patients with a chronic PVT thrombosis have esophageal varices.

6) There is very limited evidence to inform the decision to anticoagulate or not. Management is often extrapolated from the lower extremity DVT literature.

7) In the context of cirrhosis, anticoagulation is generally NOT recommended due to the increased risk of bleeding.

8) In a chronic PVT with portal HTN and NO cirrhosis, it may be reasonable to anticoagulate if there is a history of a hypercoaguable state or previous thrombosis. Otherwise, the risk of bleeding in the context of portal HTN (varices) may outweigh the benefits.

10) In an acute PVT and NO cirrhosis, it is reasonable to investigate for and treat any underlying etiology (including a hypercoaguable state) and consider anticoagulating for a minimum of 3-6 months or longer if there is a persistent risk factor.

11) If anticoagulating, the same medications (warfarin, LMWH, IV heparin) and targets (i.e. INR 2-3) can be used as for lower extremity DVTs.

12) The management of a PVT is highly variable, clinician dependent and must be tailored to the individual patient and clinical scenario.