COVID-19-Associated Portal Vein Thrombosis Post-Cholecystitis

Abstract

This case study describes a 45-year-old Caucasian male with a past medical history of obesity, hypertension, and non-insulin-dependent diabetes mellitus, who in the setting of coronavirus disease 2019 (COVID-19) pneumonia, developed portal vein thrombosis (PVT) presenting as an acute abdomen after hospital discharge from a cholecystitis episode. PVT is a very infrequent thromboembolic condition, classically occurring in patients with systemic conditions such as cirrhosis, malignancy, pancreatitis, diverticulitis, autoimmunity, and thrombophilia. PVT can cause serious complications, such as intestinal infarction, or even death, if not promptly treated. Due to the limited number of reports in the literature describing PVT in the COVID-19 setting, its prevalence, natural history, mechanism, and precise clinical features remain unknown. Therefore, clinical suspicion should be high for PVT, in any COVID-19 patient who presents with abdominal pain or associated signs and symptoms. To the best of our knowledge, this is the first report of COVID-19-associated PVT causing extensive thrombosis in the portal vein and its right branch, occurring in the setting of early-stage cirrhosis after a preceding episode of cholecystitis.

Keywords: COVID-19; SARS-CoV-2; acute abdomen; portal vein thrombosis; thromboembolic condition.

Fig. 1

( A and B ) Axial, contrast MRI showing morphologic changes in the liver compatible with cirrhosis; hypertrophy of segment IV and the caudate lobe. ( C , yellow arrowheads ) Furthermore, typical collateral vessels from cirrhosis are present. ( C , light blue arrow, and D , 3D reconstruction ) Cavernous transformation of the portal vein (CTPV), which is a classical sequela of PVT, can be visualized.

Fig. 2

Axial, post-contrast magnetic resonance images (weighted images) showing hypointense and partially circumferential portal vein thrombosis in ( A , yellow arrows ) main portal vein and ( C, yellow arrows ) right portal vein. In T2 weighted images, ( D, orange arrows) perihepatic and ( D, blue arrows ) perisplenic fluid collections are revealed. ( B , 3D reconstruction; green arrows ) The complete extension of the thrombus in the portal vein can be seen with the digital reconstruction.

Fig. 3

3D reconstruction, ( A, blue arrows, 3B; green surface ) contrast magnetic resonance images revealing portal vein thrombosis and ( B , blue surface ) its sequela of cavernous transformation of the portal vein (CTPV).