PORTAL VEIN THROMBOSIS – AN UNUSUAL OR UNUSED TREATMENT?
Doenças hepatobiliares - E-Poster
Congresso ID: P395 - Resumo ID: 153
1 Hospital Pedro Hispano, Matosinhos, Portugal; 2 Universitätsklinikum Bonn, Bonn, Germany;
Sofia Monteiro1,2, Carsten Meyer2, Michael Praktiknjo2
Introduction: Non-cirrhotic nontumoral portal vein thrombosis (NCPVT) is a rare disease and can cause portal hypertensive complications as well as intestinal ischemia, if not treated. Recent and chronic NCPVTs are successive stages of the same disease and although they share similar causes, the clinical presentation and management differs. In recent NCPVT the treatment goals are recanalization and prevention of intestinal infarction and portal hypertension.
We present a case of successful, interventional recanalization of PVT in a young patient.
Clinical case: Healthy 24 year old pregnant woman presents in a hospital with dull epigastric pain with circumferential irradiation and recent history of diarrhea. Blood tests showed slightly elevated lipase. After symptomatic therapy of pancreatitis, she was discharged. Thirty days later emergency c-section was performed due to partial placental abruption without surgical complications. Seven days later she developed bloody diarrhea and ascites. CT scan revealed a complete NCPVT of the main trunk and intrahepatic branches. Therapeutic anticoagulation was initiated with intravenous heparin. Ten days after starting anticoagulation, recanalization was not achieved. Clinically the patient had ongoing bloody diarrhea. Therefore, the patient was submitted to transjugular transhepatic thrombolysis and thromboaspiration (performed with AngioJet system, local alteplase 0.5mg/h and systemic heparin goal APTT 60sec) for 48 hours. Recanalization of main trunk and right branch was successful. Due to slow inflow, risk of recurrent thrombosis was high and TIPS placement was decided to increase inflow and prevent recurrent thrombosis.
Histology of sigmoid colon was compatible with ulcerative colitis and no other prothrombotic causes for PVT, rather than pregnancy and pancreatitis were so far diagnosed.
Discussion: With this clinical case the authors want to remind that in the presence of abdominal pain, PVT diagnosis must be considered. Furthermore, data on interventional transhepatic local thrombolysis is limited. However, to avoid emergency surgery for bowel ischemia it should be in clinicians´ minds as an existing option. In this case, bloody diarrhea is possibly attributed to inflammatory bowel disease, however this diagnosis was made afterwards and threatening intestinal ischemia could not be ruled out. The presence of factors that have been associated with absence of recanalization (ascites and delay in initiating anticoagulation) or suspicion of imminent bowel ischemia may lower the threshold for intervention.
Moreover, TIPS placement for keeping venous patency is not a formal indication and since outcome of chronic NCPVT is relatively good decisions should be made case by case. However, TIPS placement can allow prevention of portal hypertensive complications.
Finally, clinicians should remember that often in NCPVT multiple etiological factors coexist and complete etiological study is always required.
We present a case of successful, interventional recanalization of PVT in a young patient.
Clinical case: Healthy 24 year old pregnant woman presents in a hospital with dull epigastric pain with circumferential irradiation and recent history of diarrhea. Blood tests showed slightly elevated lipase. After symptomatic therapy of pancreatitis, she was discharged. Thirty days later emergency c-section was performed due to partial placental abruption without surgical complications. Seven days later she developed bloody diarrhea and ascites. CT scan revealed a complete NCPVT of the main trunk and intrahepatic branches. Therapeutic anticoagulation was initiated with intravenous heparin. Ten days after starting anticoagulation, recanalization was not achieved. Clinically the patient had ongoing bloody diarrhea. Therefore, the patient was submitted to transjugular transhepatic thrombolysis and thromboaspiration (performed with AngioJet system, local alteplase 0.5mg/h and systemic heparin goal APTT 60sec) for 48 hours. Recanalization of main trunk and right branch was successful. Due to slow inflow, risk of recurrent thrombosis was high and TIPS placement was decided to increase inflow and prevent recurrent thrombosis.
Histology of sigmoid colon was compatible with ulcerative colitis and no other prothrombotic causes for PVT, rather than pregnancy and pancreatitis were so far diagnosed.
Discussion: With this clinical case the authors want to remind that in the presence of abdominal pain, PVT diagnosis must be considered. Furthermore, data on interventional transhepatic local thrombolysis is limited. However, to avoid emergency surgery for bowel ischemia it should be in clinicians´ minds as an existing option. In this case, bloody diarrhea is possibly attributed to inflammatory bowel disease, however this diagnosis was made afterwards and threatening intestinal ischemia could not be ruled out. The presence of factors that have been associated with absence of recanalization (ascites and delay in initiating anticoagulation) or suspicion of imminent bowel ischemia may lower the threshold for intervention.
Moreover, TIPS placement for keeping venous patency is not a formal indication and since outcome of chronic NCPVT is relatively good decisions should be made case by case. However, TIPS placement can allow prevention of portal hypertensive complications.
Finally, clinicians should remember that often in NCPVT multiple etiological factors coexist and complete etiological study is always required.