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home - Liver - Vascular Problems - Extrahepatic Portal Venous Thrombosis Written by Dr Sebastian Zeki
Knowledge


Understands the risk of variceal bleeding as a complication of with
portal hypertension


Knows risk of variceal haemorrhage in cirrhotics who have not bled

Knows risk of bleeding related to variceal size endoscopic findings
and severity of liver dysfunction


Knows range of therapeutic options (both endoscopic and
pharmacological).

Skills
Recognises and can treat portal hypertension.
Behaviours
Manages patients with oesophageal varices with skill and
compassion

Able to convey the serious risks to patients and their relatives.

Also...

Knowledge


Recognises and shows understanding of vascular liver disease
including Budd-Chiari syndrome veno-occlusive disease and
portomesenteric venous thrombosis; understands the underlying
anatomy and physiology of these often complex conditions

Aware of need for investigation for associated myeloproliferative and
procoagulant conditions

Understands the role of anticoagulation and indications for further
intervention including TIPS surgery or transplantation

Skills
Can make careful clinical of these conditions and has
heightened awareness of liver vascular disease in differential
diagnosis

Able to make a potentially difficult diagnosis of less common variants
of vascular conditions

Behaviours
Shows ability to keep patient and relatives informed and to refer
appropriately for specialist management

Extrahepatic Portal Venous Thrombosis

Written by Dr Sebastian Zeki Usually more than in cirrhoticsAscites/ jaundice/ deranged LFT’s usually absent Common (85% have oesophageal varices, and 35% also have gastric) Adults: Children: Management Extrahepatic portal vein obstruction (PVT) Aetiologies:Omphalitis (most common).Congenital agenesis or malformation of the portal vein.-Cirrhosis (25%, annual incidence of <1%)- correlates with severity of underlying liver disease.50% have probable hypercoagulable state.-Coagulopathy. Complications:Varices.Ectopic varices are common.Variceal bleeding- occurs in 60% of chronic PVT but liver failure less likely if no cirrhosisSplenomegaly- occurs in 50 % if chronic PVT.Mesenteric infarction (rare- consider if abdo pain present).Pyelophlebitis (consider if septic). Histological Features25 % of patients have gross morphologic abnormalities (primarily irregularity with some surface nodularity).50 % have histologic abnormalities (portal fibrosis and nonspecific inflammatory infiltrates- adults >children). AssessmentDiagnosis is made on imaging (contrast enhanced CT or colour duplex).OGD is needed to assess for varices.Assess for coagulopathy. Recent (between acute and chronic)Chronic anticoagulation is a reasonable option in a very select subset of patients who:Do not have underlying liver diseaseHave an acute or subacute symptomatic presentationDo not have evidence of a recanalization already underway AcuteAnticoagulation therapy for 3 months; continue long term if pro-coagulation condition AcuteRecurrence is rareIf septic consider pyelophlebitisIf abdo pain consider intestinal infarctionChronicChronic PVT diagnosed when collaterals seen1. Recent abdominal pain2. No evidence of PHTN3. Contrast-enhanced CT or duplex-Doppler ultrasound showing no portoportal collaterals at the porta hepatis. ChronicThe treatment of chronic PVT depends upon the stage of the disease and the patient's comorbidities.Screen for varicesCan use beta-blockers in this settingThere is no role for anticoagulation in patients who have already developed cavernous transformation.Surgery if recurrent variceal bleeding/ isolated gastric or ectopic varices:1.Splenectomy curative if splenic vein thrombosis and bleeding gastric varices.2. Diffuse thrombosis of the portal, mesenteric, and splenic veins, a shunt operation may not be possible.Such patients isnefit from a nonshunting operation (eg. modified Sugiura procedure)3. If patent esenteric vein a mesocaval shunt combined with splenectomy and left gastric vein ligature can be performed.Some patients may have a large spontaneous splenorenal collateral, which must be tied off during the procedure.TIPS. Possible in patients without cavernous transformation in whom the thrombosed vein can be accessed, dilated, and stented.Usually not reliableAnticoagulation- Consider long term if pro-coagulant condition. Initiate only variceal prophylaxis started. Type:

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