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Portal vein thrombosis in cirrhosis — ESEGH MCQ

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HardHepatologyPortal vein thrombosis in cirrhosisESEGH

A 59-year-old man with Child-Pugh B cirrhosis is undergoing assessment for liver transplantation. CT identifies a recent, non-tumoral partial thrombosis of the main portal vein extending into the proximal superior mesenteric vein. There is no cavernous transformation or radiological evidence of intestinal ischaemia. He has no active bleeding, his platelet count is 74 × 10^9/L, and renal function is normal. He is taking carvedilol, and recent endoscopy showed small oesophageal varices without red signs. What is the most appropriate management?

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Correct answer: D — Initiate anticoagulation after specialist multidisciplinary review

Anticoagulation is indicated because he is a potential liver-transplant candidate and the recent portal vein thrombosis extends into the superior mesenteric vein. Recanalisation or prevention of progression preserves physiological portal inflow and may reduce transplant complexity. His platelet count is above the level associated with the greatest anticoagulant-related bleeding risk, and his variceal risk has already been assessed and addressed with carvedilol. Observation is more appropriate for selected limited thromboses without high-risk features, not mesenteric extension in a transplant candidate. Varices do not need to be eradicated before anticoagulation when adequate prophylaxis is in place. Portal vein recanalisation with TIPSS is generally reserved for progression or failure of anticoagulation, another TIPSS indication, or when required to facilitate transplantation. Waiting until surgery risks thrombus progression.

Reference: British Society of Gastroenterology, British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis – part 3: special circumstances, section ‘Portal vein thrombosis’, 2023. https://fg.bmj.com/content/14/6/474