Portal Vein Thrombosis

Yet more bleeding

Step 1: View clinicals

A 30-year-old man presents with mild epigastric pain for around a month, which worsens following meals, and is associated with post-prandial nausea. Close questioning reveals the passage of black, tarry, foul-smelling stools twice in a single day, around 3 days ago. His bowel habits are unchanged from earlier, and there is no history of recent trauma or bleeding disorders. His medical, surgical, and family histories are unremarkable. He does not smoke, but has been consuming an estimated 3 to 5 units of alcohol each week for over a decade now.


Step 2: Order all relevant investigations

Upper GI Endoscopy

Endoscopy of the distal esophagus reveals nonbleeding grade II-III varices in the 1 o'clock, 5 o'clock, and 9 o'clock positions.

Abdominal Ultrasound

The liver parenchyma appears normal. Moderate splenomegaly is present. There is increased periportal echogenicity, with multiple echogenic structures within the portal vein. Doppler scanning confirms partial obliteration of the lumen of portal vein, with hepatofugal flow.

Liver function tests

Total Protein: 7.3 g/dL (6.3 - 7.9) Albumin: 4.2 g/dL (3.5 - 5.0) AST: 25 U/L (8 - 48) ALT: 30 U/L (7 - 55) Alkaline phosphatase (ALP): 50 U/L (45 - 115) Total bilirubin: 0.2 mg/dL (0.1 - 1.2)

Coagulation profile

INR: 1.01 (0.9 - 1.1) aPTT: 28.6 seconds (21 - 34) Platelets: 200,000/mm3 (150,000 - 400,000)


Step 3: Select appropriate management

Banding of varices
Thrombectomy
Anticoagulation
TIPS


Score: ★★☆