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Portal Vein Thrombosis (PVT): Etiology, Presentation, and Management

Definition

PVT = thrombus in the portal vein (formed by SMV + splenic vein confluence), obstructing hepatopetal flow. Can be acute or chronic, partial or complete.

Etiology (Virchow’s Triad)

CategoryExamples
Local stasisCirrhosis (↓ portal flow, ↑ diameter), post-splenectomy, hepatic outflow obstruction (Budd-Chiari)
Endothelial injuryAbdominal surgery, trauma, pancreatitis, catheterization
HypercoagulabilityInherited (Factor V Leiden, Prothrombin G20210A, Protein C/S/AT deficiency), acquired (malignancy, pregnancy, OCPs, HIT, APS, myeloproliferative neoplasms)
InflammationDiverticulitis, appendicitis, IBD, cholangitis

Clinical Presentation

  • Acute: Severe abdominal pain (RUQ/epigastric), nausea/vomiting, fever, ileus, bloody diarrhea. May progress to bowel ischemia.
  • Chronic: Often asymptomatic; discovered incidentally. Sequelae: portal hypertension → splenomegaly, thrombocytopenia, varices (esophageal/gastric), ascites, portal hypertensive gastropathy.

Diagnosis

  • Doppler US (first-line): absent flow, thrombus echogenicity, cavernous transformation (collaterals).
  • CT/MR angiography: Gold standard for extent, mesenteric veins, collaterals, liver parenchyma.
  • Labs: LFTs, CBC, coagulation, D-dimer, JAK2 V617F (if MPN suspected).

Management

  1. Anticoagulation: LMWH → warfarin (INR 2–3) or DOAC (rivaroxaban, apixaban – growing evidence). Duration: 3–6 mo if transient risk; indefinite if permanent thrombophilia/cirrhosis.
  2. Treat underlying cause: Antibiotics for infection, manage cirrhosis, cancer therapy.
  3. Interventional: Thrombolysis (catheter-directed tPA) for acute symptomatic; TIPS for refractory portal hypertension; surgical thrombectomy rare.
  4. Monitoring: Serial imaging for recanalization, variceal screening (endoscopy).

Special Populations

  • Cirrhosis: PVT accelerates decompensation. Anticoagulation may improve survival/transplant candidacy.
  • Pregnancy: LMWH throughout; multidisciplinary.
  • Children: Often umbilical sepsis, dehydration, genetic thrombophilia.

Early recognition and anticoagulation prevent irreversible portal hypertension complications.

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