Case Of the Month (COM) May 2016
Findings
CT showed an isolated thrombosis of the left portal vein with an intact remaining splenoportal circulation. The pancreas showed no inflammation. There were no gall calculi. The SMV was intact and there was no evidence of ischaemic bowel. Of incidental note were a 2cm right renal midpole mass, probably a RCC, a Right inguinal hernia containing unobstructed small bowel loops & significant prostatomegaly and cardiomegaly. Ultrasound performed the following day showed significant progression of portal venous thrombosis. (all relevant images are posted).
Discussion
This case is being presented to highlight isolated portal venous thrombosis in the absence of pancreatitis, cirrhosis or hepatocellular carcinoma. Portal vein thrombosis may be seen in a variety of clinical contexts, and when acute can be a life-threatening condition. It is a major cause of noncirrhotic presinusoidal portal hypertension. Portal vein thrombus may be either bland or malignant, and it is a critical finding in liver transplant candidates as it precludes transplantation. Portal vein thrombosis, like thrombosis elsewhere, can occur due to disturbance of any one of Virchow triad, and causes can be thought of in these terms: reduced flow / portal hypertension cirrhosis: most common hepatobiliary malignancies hepatocellular carcinoma (HCC) pancreatic ductal carcinoma, or other pancreatic neoplasms cholangiocarcinoma gastric carcinoma hypercoagulable state inherited prothrombotic conditions protein S deficiency protein C deficiency factor V Leiden mutation antiphospholipid syndrome malignancy myeloproliferative disorders inflammatory bowel disease dehydration oral contraceptive pills pregnancy trauma endothelial disturbance local inflammation/infection acute pancreatitis ascending cholangitis abdominal surgery Also, hepatocellular carcinoma (HCC) has a predilection for invading the portal vein, with tumour thrombus occluding the lumen.
Findings
CT showed an isolated thrombosis of the left portal vein with an intact remaining splenoportal circulation. The pancreas showed no inflammation. There were no gall calculi. The SMV was intact and there was no evidence of ischaemic bowel. Of incidental note were a 2cm right renal midpole mass, probably a RCC, a Right inguinal hernia containing unobstructed small bowel loops & significant prostatomegaly and cardiomegaly. Ultrasound performed the following day showed significant progression of portal venous thrombosis. (all relevant images are posted).
Discussion
This case is being presented to highlight isolated portal venous thrombosis in the absence of pancreatitis, cirrhosis or hepatocellular carcinoma. Portal vein thrombosis may be seen in a variety of clinical contexts, and when acute can be a life-threatening condition. It is a major cause of noncirrhotic presinusoidal portal hypertension. Portal vein thrombus may be either bland or malignant, and it is a critical finding in liver transplant candidates as it precludes transplantation. Portal vein thrombosis, like thrombosis elsewhere, can occur due to disturbance of any one of Virchow triad, and causes can be thought of in these terms: reduced flow / portal hypertension cirrhosis: most common hepatobiliary malignancies hepatocellular carcinoma (HCC) pancreatic ductal carcinoma, or other pancreatic neoplasms cholangiocarcinoma gastric carcinoma hypercoagulable state inherited prothrombotic conditions protein S deficiency protein C deficiency factor V Leiden mutation antiphospholipid syndrome malignancy myeloproliferative disorders inflammatory bowel disease dehydration oral contraceptive pills pregnancy trauma endothelial disturbance local inflammation/infection acute pancreatitis ascending cholangitis abdominal surgery Also, hepatocellular carcinoma (HCC) has a predilection for invading the portal vein, with tumour thrombus occluding the lumen.