Hepatic portal vein thrombosis
- The portal vein is a large vein that carries blood comes from the spleen and intestine to the liver.
- Portal vein thrombosis is the blockage of the veins with clots.
- Vein = venous thrombosis = occlusion with thrombosis.
- Portal vein occlusion with a clot causes complaints such as vomiting and abdominal pain
- But it is often difficult to diagnose in the first moments.
- Illness in the early period rarely leads to intestinal gangrene.
- After the peak of the disease has passed, the person will have long-term problems.
- Such as enlargement of the spleen, and the occurrence of varices in the esophagus and bleeding in the stomach.
- Although it is said that the portal vein cannot be opened, it is in fact possible to open this vein using a scouting catheter (angiography).
- It is easier to open the vein in the early period as it becomes more difficult in longer duration.
- But since the collateral veins grow well in most patients, there will be no need to open this vein.
- Most patients come in after their problems have started for months and years.
- In the later stages, there is an opportunity to reduce the patient’s complaints by opening the vein using catheter or other interventional methods.
What is portal vein thrombosis?
(Portal: the vein that carries blood from the intestine to the liver. Vein, veins, blood clot = means clotting)
Portal vein occlusion is a partial blockage of the portal vein that feeds the liver and removes blood from the digestive system.
The portal vein is the vein that collects blood from the spleen and intestine and transports it to the liver. Portal vein thrombosis is a blockage of the main vein by a clot that transports blood from the intestine to the liver.
Its is a very rare disease, it can be seen at any age and its very common in patients with cirrhosis.
Because it is a rare disease, it can sometimes be difficult to diagnose. Most patients who come to us are found to have had a thrombosis in the past. The treatment begins with the use of blood thinners as soon as the disease is diagnosed. However, treatment of blood clots usually dose not open the vein by removing the clot. Usually, the portal vein remains blocked for life. When this vein is blocked in the long term, there may be complaints such as spleen enlargement (splenomegaly), esophageal varices, gastric varices, associated stomach bleeding and fluid accumulation in the abdomen.
Who suffers from portal vein thrombosis?
Portal vein thrombosis sometimes occurs even when there is no problem in the person, and sometimes it occurs in people who suffer from liver disease (Cirrhosis or some types of cancer).
An important reason is the tendency of thrombosis that genetically present. This can be proven by genetic testing.
A part from this, intra-abdominal infections, some type of cancer such as adult liver and pancreatic cancer, cirrhosis, and pregnancy after some operations (especially splenectomy or gastric bypass surgery) are very common.
Diagnosis of portal vein thrombosis
Patients suspected of having a portal vein thrombosis should undergo radiological examinations to detect the presence of a blood clot. Ultrasound and color echocardiography can show intravascular secretions as well as excessive thrombus in the portal vein, with a sensitivity ranging from 60-100 %. An evaluation using non-enhanced computed tomography along with ultrasound and color echocardiography is also recommended. Magnetic resonance angiography is often helpful in this case.
Patients with multiple organ failure or those on the trauma list should be evaluated using computed tomography. Mesenteric ischemia and intestinal perforation can be detected by computed tomography.
In addition, patients with GIS in the blood (bleeding from the end of the duodenum into the anal canal) should be evaluated by endoscopy.
In stable patients, contrast-enhanced MRI is recommended to assess the extent of thrombosis in the mesenteric circulation.
In a comparison of stained echocardiography with USG, endoscopic USG can be used with an increased sensitivity of 81% and specificity of 93% which can aid in visualization of non-obstructive thrombus and local tumor invasion. However, evaluation of the superior mesenteric vein and intrahepatic portal veins remains limited.
Portal vein thrombosis occurs in one of four patients with Cirrhosis of the liver.
What are the symptoms of portal vein thrombosis?
Some patients do not have any complaints, so the disease is calm in a way that dose not show any symptoms.
The most important symptom in the early period is abdominal pain. This may be accompanied by nausea and vomiting. Some people may not experience abdominal pain at all.
The inability of the blood to move from the intestine to the liver leads to the accumulation of blood and edema in the intestinal walls. Sometimes this affects the blood circulation in the intestine more and gangrene may occur in the intestine. In this case, the abdominal pain is very severe and emergency surgery may be required. If the diagnosis is made before gangrene occurs in the intestine, it may be possible to treat it with intrusive methods through the liver vein.
Apart from that, an enlarged spleen can be seen. Usually, an enlarged spleen occurs weeks to months after blockage. An enlarged spleen leads to a decrease in the blood elements (platelets) that make up clotting in the blood, which leads to a tendency to bleed.
Disorders in the intestinal circulation can lead to the accumulation of fluid (ascitic fluid) in the abdomen.
Since the main vein is closed, many collateral branches (the spare veins) develop and grow in the abdomen, which works on the formation of varicose veins. If these varicose veins occur in the esophagus or stomach, they may cause frequent stomach bleeding in the future.
How is portal vein thrombosis diagnosed?
a patient suspected of having a portal vein thrombosis should be evaluated by the department of Internal Medicine or Gastroenterology.
After the first examination, the color ultrasound examination may be sufficient for the diagnosis. But the most specific method of diagnosis is computed tomography of the abdomen or magnetic resonance imaging (MR). using these imaging methods, the diagnosis will be certain. If the disease diagnosed early, it may be possible to open the vein completely by removing the clot from the vein.
Is the clot in the portal vein formed in the lungs or in the heart?
Some patients have this fear. The portal vein is like a closed box. Therefore, it is impossible for a clot in the portal vein to travel to any organ (heart, brain or lung). Only a clot in open veins such as the arms or legs can rupture at an early stage and travel to another organ.
Can portal vein thrombosis be treated?
Treatment for portal vein thrombosis consist of two steps:
- Anticoagulants: once the disease is diagnosed, anticoagulants are used. Patients believe that these blood thinners will open the blockage completely, but the blood thinners cannot open the clot, only dilute the blood and prevent the formation of new clots from forming. The body makes an effort on its own from the inside to open this clot.
- Thrombosis or obstruction in the portal vein using a catheter: This considered the only operation to open the obstruction of the portal vein.
With interventional treatments such as angiography or the Intravenous scout catheter, all these veins have a chance to open up.
These veins can only be opened by the liver or spleen. This means that the portal cannot be opened using a catheter from the thigh or arm.
Portal vein occlusion consists of two parts, the early period and the late period:
- Acute portal vein thrombosis (early stage, new thrombosis period):
When there is a clot in a vein in the first 1-2 weeks, the clot is very new and it is very easy to remove by using a catheter. This applies to all veins in the body.
But this treatment can only be done through a catheter, which means entering a vein. In addition, blood thinners are used, this prevents clot formation.
- Chronic portal vein thrombosis (late stage, old clot period):
If the clot occurred less than a month ago, the clot is now in a chronic stage, meaning it is old. The old clot sticks to the wall, hardens and causes mechanical damage to the wall.
No longer can the vein look normal.
In this period, the treatment of opening the blood vessels by catheterization is also performed. This treatment may not be suitable for all patients, but it is applied to patients who are eligible to relieve and prevent portal hypertension, enlargement of the spleen, accumulation of fluid in the abdomen and most importantly varicose veins in the esophagus and stomach and associated stomach bleeding.
Treatment of portal vein thrombosis by catheterization
It is possible to open the blocked portal vein with a catheter. But this vein dose not need to be opened for every patient. When the blockage causes serious problems, in this time we must open the blockage.
The treatment is not an operation, the treatment takes place in the catheter room, but its different from the catheter we know.
Portal hypertension is not the same, but the conditions that causes it need treatment:
- Gastroesophageal varices bleeding
- Gastropathy caused by portal hypertension
- Spontaneous bacterial Peritonitis
- Complains of hypersplenism and Cirrhosis of the live
- Weight loss and weakness
- Alcoholism and hepatitis
- Arachnoid hemangioma
- Testicular atrophy
- Palpable spleen
- Solid liver with irregular surface
- Abdominal vein dilation
- Shivering thumping
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