Discover the intricate details of portal vein thrombosis, a rare yet critical condition characterized by blood clots in a vital vein. Delve into how it mimics acute mesenteric ischemia, presenting with sudden abdominal pain and other alarming symptoms. Learn about the diverse causes, from liver cirrhosis to coagulopathy and even oral contraceptives. Treatment approaches reveal the importance of aggressive fluid resuscitation, antibiotics, and possible endovascular interventions. A compelling exploration of a medical emergency that demands swift action!
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question_answer ANECDOTE
Patient Case
A patient experienced severe abdominal pain worsening over weeks.
A CT scan revealed portal vein thrombosis with mesenteric ischemia.
insights INSIGHT
Ischemia Explained
Ischemia is typically considered a lack of blood flow to an organ.
However, blocked outflow, causing congestion, also results in poor tissue perfusion.
volunteer_activism ADVICE
PVT Causes & Treatments
Portal vein thrombosis can be caused by cirrhosis, coagulopathy, OCPs, and certain cancers.
Treat with fluids, antibiotics, heparin, and sometimes endovascular or surgical intervention.
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The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver
Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels
How does it present?
Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever
How is it diagnosed?
Abdominal CT or MRI with contrast
What causes it?
Cirrhosis
Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.)
Oral Contraceptive Pills (OCPs)
Cancer such as hepatocellular carcinoma
How is it treated?
Aggressive fluid resuscitation
Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes
Heparin, same dosing as a bolus for a DVT
Endovascular treatment, such as a thrombectomy with IR
Surgical evaluation if there has been tissue death in the mesentery
References
Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. https://doi.org/10.1053/j.gastro.2024.05.017
Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265
Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. https://doi.org/10.1055/a-1642-0990
Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3
Emergency Medical Minute