What’s Next in Workup for Portal Vein Thrombosis?
A 60-year-old man with HCV cirrhosis and known esophageal varices presents with new onset ascites. An ultrasound in the emergency room reveals new portal vein thrombosis.
Answer: A. Abdominal CT scan
Portal vein thrombosis, which occurs in up to 20% of patients with cirrhosis, may be the initial presentation of hepatocellular carcinoma. Therefore, the correct answer is to further evaluate for malignancy with a CT scan of the abdomen. Although this patient may require TIPS and even a transplant evaluation in the future, particularly if he develops refractory ascites, the first step is to rule out malignancy. The role of anticoagulation for the treatment of portal vein thrombosis in cirrhosis is not clear becuase some patients may recanalize spontaneously without therapy. In addition, in the setting of large varices, the potential benefits of anticoagulation must be weighed carefully against the risk of gastrointestinal bleeding.