A 70 y.o. male presents with abdominal pain
The pain is intermittent after eating. His CT is shown below.
what is wrong?
Our patient has portal vein thrombosis(PVT). This can result in abdominal pain caused by congestion in the mesentery as the result of portal hypertension. Often the pain will occur after eating.
Portal vein thrombosis (PVT) is a vascular disease of the liver that occurs when a blood clot occurs in the hepatic portal vein leading to a reduced blood supply to the liver. The mortality rate is approximately 1 in 10. This is not to be confused with a clot which occurs in the vasculature that exits the liver as a hepatic vein thrombosis or Budd-Chiari syndrome. Either syndrome can cause ascites and portal hypertension and varices.
varices on cxr
The most common cause of PVT is cirrhosis in Western countries with only 10% being from non cirrhotic causes. World-wide schistosomisis is a common cause of portal hypertension with parasite eggs lodged in the portal vein causing inflammation and stenosis. More than 200 million people are affected by schistosomiasis.
schistosomes migrate to the liver
Other causes of portal vein thrombosis
Pro-thrombotic states: myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, homocystinuria, malignancy, pregnancy
Infection: septic emboli
Post hepatic cardiac causes: constrictive pericarditis, restrictive cardiomyopathy
Intra-abdominal inflammatory conditions can cause portal vein thrombosis. These include pancreatitis, cholangitis, appendicitis, and liver abscesses. Local injury to the portal venous axis following splenectomy, laparoscopic colectomy, or abdominal trauma can cause portal vein thrombosis
TIPS
Our patient was treated with beta blockers and variceal banding. He underwent a TIPS (transjugular intrahepatic portosystemic shunt) procedure.
Ali J, Kinden R, Emsley J. A case of septic portal vein thrombosis in a 71-year-old female. Cureus 14(7):e27256.doi:10.7759/cureus.27256
Kanellopoulou T, Alexopoulou A, Theodossiades G, et al Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis. 2010,42:804-11.
Basheda S, O’Donovan P, Golish J. Giant esophageal varices: an unusual cause of a porterior mediastinal mass. Chest. 1993. Vol 103(4):1284-1285
https://www.hennepinultrasound.com/tips-evaluation/
Nromberg G, Rasmussen R, Sherman K, et al. Case 6-2025: a 62 year-old man with abdominal pain Feb 20,2025 392(8) 809-812.
TIPS on US is shown below
