Portal Vein Thrombosis (PVT)

Background

Portal Vein Thrombosis (PVT) can worsen decompensation (i.e. variceal hemorrhage), however, worsening portal HTN à more sluggish flow à increased risk PVT

Often identified asymptomatically on U/S, but can be identified by new or worsening decompensation of portal HTN
Variceal hemorrhage is the most common decompensating event associated with PVT
Intestinal ischemia (abdominal pain, hematochezia) from PVT is exceedingly rare but associated with significant morbidity/mortality

RUQ U/S with doppler
- Once identified, should be further assessed with triple phase CT or MRI with Gadovist contrast to exclude HCC with tumor thrombus
Pts with newly identified PVT should undergo EGD to evaluate for high-risk varices, both for diagnostic and therapeutic considerations
PVT in pts without cirrhosis should prompt evaluation for hypercoagulable disorders

Start AC if acute thrombus occludes >50% of main portal vein, <50% but extends into SMV, thrombus is symptomatic, or patient is a transplant candidate (irrespective of size). Requires discussion with attending/transplant team.
- AC options: warfarin, LMWH, or DOAC
- DOAC’s are safe in Childs Class A, can be used with caution in Childs B, and are contraindicated in Childs C
Pts with chronic occlusive PVT (>6 mos) or with cavernous transformation with collaterals do not generally benefit from AC
Pts with high-risk varices should undergo endoscopic management or be on NSBB for prophylaxis for variceal hemorrhage, as noted above
TIPS with portal vein recanalization has recently emerged as a therapeutic modality for PVT in LT candidates to allow for anastomosis, in patient’s with chronic PVT and recurrent bleeding/refractory ascites, or in patients whom intestinal ischemia persists despite AC.
Pts should undergo follow up intermittently with US to assess for recanalization. AC may be stopped if there is failure to recanalize.
If pts are not candidates for AC, they’ll simply be treated for complications of portal HTN