An Approach to Acute Portal Vein Thrombosis
A 26 year old male with no apparent medical history presents with four days of cramping, epigastric abdominal pain. The pain is made worse after eating and when sitting up. It is associated with two days of decreased oral intake due to pain when eating. He has not had a bowel movement in two days despite taking stool softeners. He is passing gas. He has no other complaints.
His physical exam is significant for mild epigastric tenderness. Otherwise it is unremarkable.
The labs are remarkable for transaminitis. A CT abdomen/pelvis with IV contrast demonstrates portal venous thrombosis (PVT).
Further chart review revealed that patient actually had a prior history of DVT and PE and was taking Xarelto.
Take Away #1:
The presentation is often asymptomatic. Knowing the risk factors is essential.
Systemic risk factors include prothrombotic stats:
malignancy, factor V leiden, pregnancy, etc.
Local risk factors include intrabdominal inflammatory conditions:
diverticulitis, pancreatitis, CMV hepatitis, recent abdominal surgery, abdominal trauma, etc.
Cirrhotics are at increased risk of PVT (up to 16% compared to 1% in general population). This will often present as chronic PVT, which is not discussed here.
Take Away #2:
Acute PVT has varied presentations.
PVT is often asymptomatic, and labs are usually normal due to collateral circulation.
Intestinal congestion from PVT can present with abdominal pain, distension, diarrhea, nausea, vomiting, anorexia, fever, splenomegaly, ischemia, lactic acidosis, and sepsis.
Take Away #3:
Diagnosing Acute PVT
Acute PVT can be diagnosed with CT w/ & w/o IV contrast, or US w/ Doppler (60-99% sensitivity depending on study).
Consider CT if patient is ill appearing or has severe symptoms to assess for sequelae of PVT.
Watch for signs of intestinal infarction. If present, surgical exploration should be considered
Take Away #4:
Getting additional information when patient is a poor historian:
Read the triage sheet! In this case, the patient’s anticoagulation was listed in his medications on the triage sheet.
Chart review becomes important when patient is a poor historian. Further chart review revealed two prior DVTs, with instructions to stay on life long anticoagulation
Erin Duffy, M.D. is a current first year resident at Stony Brook Emergency Medicine.
Ponziani FR, Zocco MA, Campanale C, et al. Portal vein thrombosis: insight into physiopathology, diagnosis, and treatment. World J Gastroenterol. 2010;16(2):143-155. doi:10.3748/wjg.v16.i2.143
Hanlin E. Portal vein thrombosis: A primer for emergency medicine physicians. [Last accessed on 2018 May 07]. Available from: http://www.emdocs.net/portal-vein-thrombosis-primer-emergency-medicine-physicians/
Edited by Bassam Zahid, MD