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Key Features

Essentials of Diagnosis

  • Upper gastrointestinal bleeding from esophageal or gastric varices in patients without liver disease

  • Splenomegaly

  • Portal vein thrombosis complicating cirrhosis

General Considerations

  • Causes include

    • Extrahepatic portal vein obstruction (portal vein thrombosis often with cavernous transformation [portal cavernoma])

    • Splenic vein obstruction (presenting as gastric varices without esophageal varices)

    • Schistosomiasis

    • Nodular regenerative hyperplasia

    • Arterial-portal vein fistula

  • Risk factors

    • Oral contraceptive use

    • Pregnancy

    • Chronic inflammatory diseases (including pancreatitis)

    • Injury to the portal venous system (including surgery)

    • Hepatocellular carcinoma and other malignancies

    • Treatment of thrombocytopenia with eltrombopag

  • Idiopathic noncirrhotic portal hypertension

    • Common in India

    • Rare in Western countries

    • Has been attributed to

      • Chronic infections

      • Exposure to medications or toxins

      • Prothrombotic disorders

      • Immunologic disorders

      • Genetic disorders that result in obliterative vascular lesions in the liver

  • Portal vein thrombosis

    • May be classified as

      • Type 1: involving the main portal vein

      • Type 2: involving one (2a) or both (2b) branches of the portal vein

      • Type 3: involving the trunk and branches of the portal vein

      • Additional descriptors are occlusive or nonocculsive, acute or chronic, the extent (eg, into the mesenteric vein), and the nature of any underlying liver disease

    • May occur in 10–25% of patients with cirrhosis

      • Associated with the severity of the liver disease

      • May be associated with hepatocellular carcinoma but not with increased mortality

  • "Obliterative portal venopathy" is used to describe primary occlusion of intrahepatic portal veins in the absence of cirrhosis, inflammation, or hepatic neoplasia

  • Cases of noncirrhotic portal hypertension due to nodular regenerative hyperplasia have been reported in HIV-infected patients treated with didanosine or with a combination of didanosine and stavudine or didanosine and tenofovir

Clinical Findings

Symptoms and Signs

  • Acute portal vein thrombosis usually causes abdominal pain

  • Aside from splenomegaly, physical examination is unremarkable

  • Hepatic decompensation can follow severe gastrointestinal bleeding or a concurrent hepatic disorder, and intestinal infarction may occur when portal vein thrombosis is associated with mesenteric venous thrombosis

  • Ascites may occur in 25% of persons with noncirrhotic portal hypertension

  • Low-grade hepatic encephalopathy is common in patients with noncirrhotic portal vein thrombosis

Diagnosis

Laboratory Tests

  • Complete blood count may reveal thrombocytopenia and other findings of hypersplenism

  • Liver chemistries are usually normal

  • An underlying hypercoagulable state is found in many patients with portal vein thrombosis

Imaging Studies

  • Color Doppler ultrasonography and contrast-enhanced CT are usually the initial diagnostic tests for portal vein thrombosis

  • Magnetic resonance angiography (MRA) of the portal system is generally confirmatory

  • Endoscopic ultrasonography may be helpful in some cases

  • In patients with jaundice, magnetic resonance cholangiography may demonstrate compression of the bile duct by a large portal cavernoma (portal biliopathy)

  • In patients with pyelephlebitis, CT may demonstrate

    • An intra-abdominal source of infection

    • Thrombosis or gas in the portal venous system

    • Hepatic abscess

Diagnostic Studies

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