Portal vein thrombosis in cirrhosis: Controversies and latest developments

Abstract

Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.

Keywords: Anticoagulation; Liver cirrhosis; Portal vein thrombosis; Transjugular intrahepatic portosystemic stent-shunt.

Figure 1

Yerdel’s Classfication of portal vein thrombosis[15]. A: Grade I portal vein thrombosis. Partial portal vein thrombosis (< 50% lumen) with or without minimal extension in to the superior mesenteric vein (SMV); B: Grade II portal vein thrombosis; > 50% occlusion with or without minimal extension into the SMV; C: Complete thrombosis of both portal vein and proximal SMV. Distal SMV is open; D: Complete thrombosis of portal vein, proximal and distal SMV.