Nonmalignant portal vein thrombosis in adults

Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report

BACKGROUND

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT.

CASE PRESENTATION

A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure.

CONCLUSIONS

Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.

Intestinal Obstruction as Initial Presentation of Idiopathic Portal and Mesenteric Venous Thrombosis: Diagnosis, Management, and Literature Review

It is quite common for portal vein thrombosis to occur in subjects who present predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal diseases, or hematologic disorders. The incidence of idiopathic portal vein thrombosis in non-cirrhotic patients remains low, and despite the intensive workup that is performed in these cases, in up to 25% of cases, there is no identifiable cause. If portal vein thrombosis is untreated, complications arise and include portal hypertension, cavernous transformation of the portal vein, gastroesophageal and even small intestinal varices, septic thrombosis, or intestinal ischemia. However, intestinal ischemia develops as a consequence of arterial thrombosis or embolism, and the thrombosis of the mesenteric vein accounts for about 10% of cases of intestinal ischemia. Although acute superior mesenteric vein thrombosis can cause acute intestinal ischemia, its chronic form is less likely to cause acute intestinal ischemia, considering the possibility of developing collateral drainage. Ileus due to mesenteric venous thrombosis is rare, and only a small number of cases have been reported to date. Most patients experience a distinct episode of acute abdominal pain due to ischemia, and in the second phase, they develop an obstruction/ileus. Acute superior mesenteric venous thrombosis is a rare condition that is still associated with a high mortality rate. The management of such cases of superior mesenteric venous thrombosis is clinically challenging due to their insidious onset and rapid development. A prompt and accurate diagnosis followed by a timely surgical treatment is important to save patient lives, improve the patient survival rate, and conserve as much of the patient's bowel as possible, thus leading to fewer sequelae.

Clinical outcomes and prognostic factors in non-cirrhotic non-neoplastic patients with portal vein thrombosis: A single-centre experience

INTRODUCTION

The knowledge of natural history and prognostic factors of portal vein thrombosis (PVT) is still based on a limited number of studies.

AIM

To describe our single-center experience with 79 consecutive non-neoplastic non-cirrhotic patients with PVT (15 recent/64 chronic PVT).

RESULTS

Among patients with recent PVT, 7 received anticoagulation alone, 4 systemic thrombolysis, 3 direct thrombolysis through a TIPS and 1 TIPS alone. Portal recanalization was achieved in 11 patients. In patients with chronic PVT, the rate of variceal progression was high (20% at one year and 50% at two years). The thrombotic involvement of splenic and superior mesenteric veins was the only risk factor for variceal enlargement. The cumulative bleeding rates were 10% at one year and 20% at two years. A multisegmental thrombosis and large varices at entry and a previous variceal bleeding were the independent predictors for variceal bleeding. The cumulative rate of new thrombotic events was 14% at one year and 18% at two years. Eight patients died, 2 because of thrombotic events. There were no bleeding-related deaths. Two-year cumulative survival rate was 90%.

CONCLUSIONS

Our study supports the importance of anticoagulation especially when a more extended thrombosis is present. Moreover, in patients with chronic PVT, the timing of follow-up endoscopy should be based on the extension of thrombosis and not, as in cirrhosis, on the size of varices at first endoscopy.

Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) Facilitates Liver Transplantation in Cirrhotic Patients with Occlusive Portal Vein Thrombosis

Portal vein thrombosis (PVT) is a heterogeneous condition with multiple possible etiologies and to varying degrees has historically limited candidacy for liver transplant (LT) in the cirrhotic patient population due to resultant difficulties in constructing a robust portal vein anastomosis. While intraoperative approaches to managing PVT are well-described, methods which approximate normal portal physiology are not always feasible depending on the extent of PVT, and other nonphysiologic techniques are linked with substantial morbidity and poor long-term outcomes. Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) creation is an efficacious method of restoring physiologic portal flow in cirrhotic patients prior to LT allowing for end-to-end PV anastomosis, and is the product of decades-long institutional expertise in TIPS/LT and the support of a multidisciplinary liver tumor board. To follow is a review of the pertinent pathophysiology of PVT in cirrhosis, the rationale leading to the development and subsequent evolution of the PVR-TIPS procedure, technical lessons learned, and a summary of outcomes to date.

A Rare Postoperative Complication of Acute Appendicitis: Portal Vein Thrombosis Required Small Intestine Resection

This case report aims to present the diagnosis and treatment process of portal vein thrombosis, which occurred one week after laparoscopic appendectomy and required small bowel resection. A thirty-eight-year-old man was admitted with abdominal pain in the periumbilical and epigastric regions. He had a history of appendectomy and occlusive cerebrovascular disease. In the physical examination of the abdomen, tenderness was detected in the epigastric region on deep palpation. Leucocytosis, increased levels of alanine transaminase level, aspartate transaminase, gamma-glutamyl transferase, lactate dehydrogenase, c-reactive protein, and d-dimer were detected in laboratory analyses. CT scan revealed total thrombus in the portal vein, oedema in the segment of approximately 10 cm in the distal ileum, and free fluid in the pelvic region. Enoxaparin sodium was started. During follow-up, widespread defence and rebound in all quadrants of the abdomen occurred. 20 cm ileal resection with end ileostomy was performed. Enoxaparin sodium treatment was continued. On the 6th day of the service follow-up, the patient had left leg pain, and a subacute thrombus was detected in the main femoral, superficial femoral and deep femoral veins on doppler USG. Edoxaban tosylate 60 mg tablet every 24 hours started as an anti-coagulant treatment, and the patient was discharged without complications on the 18th day of hospitalisation.

Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A systematic review and meta-analysis

OBJECTIVES

The optimal management of patients with acute pancreatitis (AP) and splanchnic vein thrombosis (SVT) remains unknown. This systematic review and meta-analysis aimed to see if therapeutic anticoagulation (AC) improves outcomes in patients with AP and SVT.

METHODS

A systematic review was performed according to PRISMA guidelines. Main outcomes were recanalization, recurrent venous thromboembolism, development of varices, collaterals or cavernoma, haemorrhage and mortality. Meta-analysis were performed with the Mantel-Haenszel random effect models.

RESULTS

Seven retrospective cohort studies (3495 patients) were included. SVT occurred in 233 (7%) patients and involved most frequently the splenic vein (44%). Therapeutic AC was administered to 109 (47%) patients, most frequently to those with triple vessel thrombosis (72%) and least to those with isolated splenic vein (22%) or superior mesenteric vein thrombosis (0%). Most studies administered (low molecular weight) heparin followed by warfarin (duration ranged between 1.5 and 12 months). This meta-analysis showed an absolute risk difference of 9% (95% confidence interval [CI] = -11-28%) for recanalization, -3% (95% CI = -19-12%) for the development of varices, collaterals or cavernoma, 3% (95% CI = -6-12%) for haemorrhage and 2% (95% CI = -8-12%) for mortality.

CONCLUSIONS

Based on the currently available data, it remains unclear if therapeutic anticoagulation provides benefit to acute pancreatitis patients with splanchnic vein thrombosis. These results are based on low quality data underlining the need for further higher quality studies.

Portal Vein Thrombosis in Cirrhosis

Patients with cirrhosis of the liver are at high risk of developing portal vein thrombosis (PVT), which has a complex, multifactorial cause. The condition may present with a myriad of symptoms and can occasionally cause severe complications. Contrast-enhanced computed tomography (CT) is the gold standard for the diagnosis of PVT. There are uncertainties regarding the effect on PVT and its treatment outcome in patients with cirrhosis. The main challenge for managing PVT in cirrhosis is analyzing the risk of hemorrhage compared to the risk of thrombus extension leading to complications. All current knowledge regarding non-tumor PVT in cirrhosis, including epidemiology, risk factors, classification, clinical presentation, diagnosis, impact on natural history, and treatment, is discussed in the present article.

Transhepatic Pharmacomechanical Thrombectomy of Symptomatic Acute Noncirrhotic, Nonmalignant Portomesenteric Venous Thrombosis: Midterm Results

OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of transhepatic pharmacomechanical thrombectomy of symptomatic acute portomesenteric venous thrombosis. MATERIALS AND METHODS. Transhepatic pharmacomechanical thrombectomy (catheter-directed thrombolysis with mechanical thrombectomy) was performed in the treatment of nine patients with symptomatic acute noncirrhotic, nonmalignant porto-mesenteric venous thrombosis. The medical records, imaging examinations, technique of transhepatic pharmacomechanical thrombectomy, and clinical outcomes were reviewed. RESULTS. The mean follow-up period was 23.1 months (range, 8-34) months. Successful recanalization of the portomesenteric venous thrombosis, restoration of hepatopetal portal flow, clinically significant improvement in the signs and symptoms of acute mesenteric ischemia, and prevention of bowel resection were achieved in all patients. The most frequent minor complication (in three patients) was minor hemorrhage through the transhepatic access track. No procedure-related major complications occurred during hospitalization. No patient had rethrombosis or complications related to portal hypertension due to portomesenteric venous thrombosis. One patient died of massive pulmonary embolism on the 7th day after treatment. Cavernous transformation of the right portal vein occurred in one patient. CONCLUSION. Transhepatic pharmacomechanical thrombectomy is a safe and effective method of treatment of symptomatic acute portomesenteric venous thrombosis and prevention of bowel infarction.

SARS-CoV-2 and Portal Vein Thrombosis: A Rare Gastrointestinal Manifestation of COVID-19

Portal vein thrombosis is defined as a clot within the trunk or intrahepatic branches of the portal vein. Sequelae involves either partial or complete recanalization. However, in patients with liver disease, it can progress to a cavernoma instead of recanalization. This can result in gastrointestinal bleeding and intestinal infarction. Its rising incidence in severe acute respiratory syndrome coronavirus 2 is an important clinical aspect that needs to be addressed and treated.

Postoperative Portomesenteric Venous Thrombosis After Colorectal Cancer Surgery

BACKGROUND

Portomesenteric venous thrombosis (PMVT) can occur after colorectal surgery. Most previous studies included patients with various diseases, especially inflammatory bowel disease. The prevalence and clinical significance of PMVT developing after surgery for colorectal cancer (CRC) remain unclear.

METHODS

Consecutive patients who underwent resection for CRC between June 2003 and April 2016 were retrospectively analyzed. Postoperative PMVT was diagnosed based on pre- and postoperative computed tomography (CT).

RESULTS

Postoperative PMVT developed in 10 (0.24%) of 4232 patients who underwent resection for CRC. One patient had alcoholic liver cirrhosis, whereas nine did not have prior or current liver disease. PMVT in eight patients was detected within 2 weeks after surgery by CT, performed to evaluate non-specific symptoms such as mild fever and abdominal pain, or performed postoperatively after deep pelvic dissection. PMVT in the remaining two asymptomatic patients was diagnosed following surveillance CT 3 and 7 months after surgery, respectively. PMVT in the patient with liver cirrhosis was detected 13 days after surgery and found to involve the main portal vein, causing hyperbilirubinemia and requiring emergency thrombectomy with thrombolysis. PMVT in the nine patients without liver disease was resolved by anticoagulation therapy or conservative care without long-term complications.

CONCLUSION

PMVT after CRC surgery is likely an early postoperative event in most patients. The incidence of clinically significant PMVT in patients with CRC may be lower than previously reported. CT was reliable in the diagnosis and follow-up of these patients. Most patients with PMVT can be managed conservatively without serious long-term morbidity.

Acute portal vein thrombosis in noncirrhotic patients - different prognoses based on presence of inflammatory markers: a long-term multicenter retrospective analysis

Background: Portal vein thrombosis (PVT) is a partial or complete thrombotic occlusion of the portal vein and is rare in noncirrhotic patients.Patients and methods: 78 adult patients with noncirrhotic acute PVT without known malignity were evaluated. Patients with initial CRP level 61-149 mg/l were excluded.Results: Patients were divided into two groups - the first one (33 patients) was characterized with signs of inflammation and CRP over 149 mg/l. The second group (45 patients) was without signs of inflammation and CRP level less than 61 mg/l. The frequency of prothrombotic hematologic factors was statistically significantly different in levels of factor VIII and MTHFR 677 C mutation. All patients from both groups underwent the same oncologic and hemato-oncologic screening which was positive in 23 patients (51.1%) in the group without signs of inflammation. In the group of patients with clinical and laboratory signs of inflammation oncologic and hemato-oncologic screening was positive only in 1 patient (3.0%). Complete portal vein recanalization was achieved in 19.2%, partial recanalization in 26.9%.Conclusions: Patients with clinical signs of inflammation and acute PVT have a low risk of malignancy in contrast to patients without signs of inflammation and acute PVT, which have a high risk of oncologic or hemato-oncologic disease. Patients with negative hemato-oncologic screening should be carefully observed over time because we expect they are at higher risk for the development of hemato-oncologic disease, independent from the presence and number of procoagulation risk factors.

Splanchnic Vein Thrombosis: Current Perspectives

Splanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT presents with a lower incidence than deep vein thrombosis of the lower limbs and pulmonary embolism, with portal vein thrombosis and Budd-Chiari syndrome being respectively the most and the least common presentations of SVT. SVT is classified as provoked if secondary to a local or systemic risk factor, or unprovoked if the causative trigger cannot be identified. Diagnostic evaluation is often affected by the lack of specificity of clinical manifestations: the presence of one or more risk factors in a patient with a high clinical suspicion may suggest the execution of diagnostic tests. Doppler ultrasonography represents the first line diagnostic tool because of its accuracy and wide availability. Further investigations, such as computed tomography and magnetic resonance angiography, should be executed in case of suspected thrombosis of the mesenteric veins, suspicion of SVT-related complications, or to complete information after Doppler ultrasonography. Once SVT diagnosis is established, a careful patient evaluation should be performed in order to assess the risks and benefits of the anticoagulant therapy and to drive the optimal treatment intensity. Due to the low quality and large heterogeneity of published data, guidance documents and expert opinion could direct therapeutic decision, suggesting which patients to treat, which anticoagulant to use and the duration of treatment.

The risk factors of portal vein thrombosis in patients with liver cirrhosis

This study was designed to identify and assess risk factors for portal vein thrombosis (PVT) in patients with cirrhosis. A total of 98 cirrhosis patients with PVT were identified and 101 cirrhosis patients without PVT were chosen as the control group in this retrospective study. Several variables were measured and the two groups PVT and non-PVT were compared statistically. PVT was identified in 98 patients (10%). Significant differences in hematocrit, international normalized ratio, albumin, bilirubin and glucose were determined between the groups (P<0.05). Out of the thrombophilic risk factors in the patients with PVT factor V Leiden was identified in 8.8%, prothrombin gene 6.6% and methylenetetrahydrofolate reductase 2.2%. There was no difference in survival time between groups (P>0.05).

Acute Portal Vein Thrombosis: Current Trends in Medical and Endovascular Management

Acute portal vein thrombosis (PVT) is a relatively rare diagnosis with a nonspecific clinical presentation. Imaging plays an important role in establishing the diagnosis as well as the etiology and complications of acute PVT. Prompt diagnosis is essential to prevent catastrophic short-term complications including bowel infarction, sepsis, and possible death; missed diagnosis can also result in the long-term sequelae of portal hypertension. Differentiation of acute from chronic PVT is crucial as management strategies differ. Currently, guidelines for treating acute PVT recommend immediate initiation of systemic anticoagulation. Catheter-directed therapy may be used in combination with systemic anticoagulation in the setting of bowel ischemia or as an adjunct in patients with a contraindication to systemic anticoagulation. In this review article, we discuss the diagnosis and clinical features of acute PVT, focusing on current medical and endovascular management strategies including mechanical thrombectomy and fibrinolytic therapy.

Natural history of patients with non cirrhotic portal hypertension: Comparison with patients with compensated cirrhosis

BACKGROUND

The knowledge of natural history of patients with portal hypertension (PH) not due to cirrhosis is less well known than that of cirrhotic patients.

AIM

To describe the clinical presentation and the outcomes of 89 patients with non-cirrhotic PH (25 with non-cirrhotic portal hypertension, INCPH, and 64 with chronic portal vein thrombosis, PVT) in comparison with 77 patients with Child A cirrhosis.

METHODS

The patients were submitted to a standardized clinical, laboratory, ultrasonographic and endoscopic follow-up. Variceal progression, incidence of variceal bleeding, portal vein thrombosis, ascites and survival were recorded.

RESULTS

At presentation, the prevalence of varices, variceal bleeding and ascites was similar in the 3 groups. During follow-up, the rate of progression to varices at risk of bleeding (p < 0.0001) and the incidence of first variceal bleeding (p = 0.02) were significantly higher in non-cirrhotic then in cirrhotic patients. A PVT developed in 32% of INCPH patients and in 18% of cirrhotics (p = 0.02).

CONCLUSIONS

In the patients with non-cirrhotic PH variceal progression is more rapid and bleeding more frequent than in cirrhotics. Patients with INCPH are particularly prompt to develop PVT. This observational study suggests that the management of patients with non-cirrhotic PH should take into consideration the natural history of portal hypertension in these patients and cannot be simply derived by the observation of cirrhotic patients.

Imaging and minimally invasive endovascular therapy in the management of portal vein thrombosis

Thrombosis of the portal venous system, although rare in the general population, is commonly diagnosed in patients with specific underlying conditions including prothrombotic diseases, cirrhosis, hepatobiliary malignancy, and intraabdominal inflammation. Recent improvements in imaging have played a fundamental role in increased detection of portal vein thrombosis (PVT), frequently reported in asymptomatic patients as an incidental finding. Minimally invasive, endovascular therapy is a medically rational option to achieve recanalization of the portal vein as an adjunct to conservative medical management. This review focuses on the advances in imaging modalities to diagnose, stage and follow-up PVT, and gives a short overview of the available endovascular techniques in this field.

Portal vein thrombosis after cesarean section in a patient on prolonged bed rest due to threatened preterm labor

Portal vein thrombosis is a rare but life-threatening complication during pregnancy and postpartum period. Color Doppler ultrasound is useful for prompt diagnosis. Although the risk of complications should be considered, successful pregnancy with comorbid portal vein thrombosis is possible with appropriate anticoagulation therapy and close monitoring.

Transjugular local thrombolysis with/without TIPS in patients with acute non-cirrhotic, non-malignant portal vein thrombosis

BACKGROUND & AIMS

Therapeutic anticoagulation is the standard treatment in patients with acute non-cirrhotic portal vein thrombosis (PVT). In critically ill patients, anticoagulation only may not suffice to achive rapid and stable recanalization. This study evaluates efficacy and safety of transjugular interventional therapy in acute non-cirrhotic PVT.

METHODS

This retrospective study includes 17 consecutive patients with acute noncirrhotic, non-malignant PVT. Main indication for interventional therapy was imminent intestinal infarction (n=10). Treatment consisted of a combination of transjugular thrombectomy, local fibrinolysis and - depending on thrombus resolution - transjugular intrahepatic portosystemic shunt.

RESULTS

Recanalization was successful in 94.1%. One- and two-year secondary PV patency rates were 88.2%. Major complications (n=3) resolved spontaneously in all but one patient (heparin induced thrombocytopenia type 2 with intestinal infarction). Symptoms improved in all patients. However, segmental bowel resection had to be performed in two (11.8%). During a median follow-up of 28.6 months, no patient experienced portal hypertensive complications. Presence of JAK2 V617F mutation predicted both short-term and long-term technical success.

CONCLUSIONS

Transjugular recanalization is safe and effective in patients with acute non-cirrhotic, non-malignant PVT. It should be considered especially in patients with imminent bowel infarction and low likelihood of recanalization following therapeutic anticoagulation. Patients with JAK2 mutation ought to be followed meticulously.

Sport-Related Portal Vein Thrombosis: An Unusual Complication

Portal vein thrombosis (PVT) is an uncommon condition usually associated with hypercoagulable states or liver cirrhosis. PVT due to sports-related injuries is rarely reported and, to the best of our knowledge, only two cases have been reported thus far. Brazilian jiu-jitsu (BJJ) is a form of martial arts and is considered very safe with minimal risk for injury. It has growing popularity worldwide. Here, we report the first case of PVT secondary to abdominal trauma related to the practice of (BJJ) in an otherwise healthy 32-year-old man with no other traditional risk factors for PVT.

Portal vein thrombosis - a primer for the general physician

Portal vein thrombosis (PVT) is thrombosis of the portal -circulation, which may present with varied symptoms. However, increased use of abdominal imaging has noted a large number of incidental PVT. At the same time, PVT may be overlooked in the absence of the characteristic symptoms. More recently, a JAK2 mutation has been recognised as a cause of PVT. Anticoagulation is the mainstay of treatment, but can pose a dilemma because of the associated coagulopathy, the presence of varices and thrombocytopenia.

A systematic review of portomesenteric vein thrombosis after sleeve gastrectomy

BACKGROUND

Portomesenteric vein thrombosis (PMVT) is considered an uncommon complication in general surgery; nevertheless, with the growing popularity of sleeve gastrectomy (SG) as a bariatric procedure we have seen an increase in the occurrence of this complication.

OBJECTIVES

To elucidate the question if it is a procedure-related complication and explore the modalities of prevention and treatment of this complication, a systematic review of available literature regarding PMVT events after SG was conducted.

METHODS

Our systematic review yielded 28 studies enclosing 89 patients. Perioperative data was collected from each study and analyzed.

RESULTS

The incidence of PMVT after SG ranged from .37% to 1%, 65% of the patients were female, and the mean body mass index was 41.63 kg/m². Perioperative co-morbidities including hypertension, diabetes, and dyslipidemia were recorded in 39.7%, 41.63%, and 38.23% of cases respectively. Tachycardia and fever were reported only in 23.9% and 20.89%, respectively, and hereditary thrombophilia studies were positive in 30.43% of cases. The rate of acute major complications after PMVT was 14.6% (13 cases), and mortality was reported in 3 cases (average 3.37%).

CONCLUSION

PMVT seems to be an uncommon multifactorial disease, with unpredictable symptoms and varieties of the treatments options, but additional studies are required to further define optimal management and prevention algorithms.

Anticoagulation in cirrhosis: a new paradigm?

The liver plays a crucial role in coagulation cascade. Global hemostatic process is profoundly influenced by the presence of liver disease and its complications. Patients with cirrhosis have impaired synthesis of most of the factors involved in coagulation and fibrinolysis process due to a reduced liver function and altered platelet count secondary to portal hypertension. Altered routine tests and thrombocytopenia were considered in the past as associated with increased risk of bleeding. These concepts explain both the routine use of plasma and/or platelets transfusion in patients with liver cirrhosis, especially before invasive procedures, and why these patients were considered "auto-anticoagulated". New recent evidences show that patients with liver cirrhosis have a more complex hemostatic alteration. Despite the presence of altered levels of factors involved in primary hemostasis, coagulation and fibrinolysis, patients with stable cirrhosis have a rebalanced hemostatic, which however can easily be altered by decompensation or infection, both in hemorrhagic or thrombotic direction. Patients with cirrhosis have an increased risk of venous thrombotic events (namely portal vein thrombosis) while bleeding seems to be related to the grade of portal hypertension rather than to a hemostatic imbalance. The use of anticoagulants both as treatment or prophylaxis is safe, reduces the rate of portal vein thrombosis and decompensation, and improves survival. Standard laboratory coagulation tests are unable to predict bleeding and are inadequate for the assessment of hemostatic status in these patients, hence more comprehensive tests are required to guide the management of thrombotic and bleeding complications.

[Natural history of portal cavernoma without liver disease. A single centre retrospective study of 32 cases]

PURPOSE

Portal cavernoma follows a chronic occlusion of the portal vein. The long-term consequences of portal cavernoma are not well known. The objective of this study was to report the aetiology of the portal cavernoma and its natural course after excluding liver diseases causes.

METHODOLOGY

A single centre retrospective study based on the data collected from the radiology department of the Clermont-Ferrand hospital was conducted from 2000 to 2011. All the patients for whom an imagery found a portal cavernoma have been looked for excluding the patients having a liver disease whatever the aetiology and the Budd-Chiari syndrome.

RESULTS

Thirty-two cases (18 women and 14 men) were selected. The mean age at diagnosis was 54.2 years and the mean follow-up period was 5.4 years. The discovery of a portal cavernoma was incidental for 8 cases. An aetiology was found for 24 cases: it was an haematological aetiology in 15 cases (10 myeloproliferative syndromes, 2 antiphospholid syndromes, 1 thalassemia major, 1 hyperhomocysteinemia, 1 prothrombin gene mutation), a general aetiology in 2 cases (1 coeliac disease, 1 pancreatic neoplasia), and a local inflammation in 7 cases. A dysmorphic aspect of the liver was noticed on medical imaging for 11 out of the 32 cases. A liver biopsy was performed in 4 patients and was normal for all of them. Sixteen patients developed oesophageal varices, 4 patients developed ascites, 3 developed asymptomatic biliary compression by the portal cavernoma, and the patient who had been followed for the longest time (15 years) developed an encephalopathy.

CONCLUSION

In addition to its underlying etiology, the prognosis of portal is mainly related to the occurrence of oesophageal varices that may develop during the follow-up of the patients.

Acute Cholecystitis Complicated with Portal Vein Thrombosis: A Case Report and Literature Review

Patient: Male, 31

Final Diagnosis: Acute cholecystitis complicated with portal vein thrombosis

Symptoms: Abdominal discomfort • fever • vomiting

Medication: —

Clinical Procedure: Abdominal ultrasound and MRI

Specialty: Gastroenterology and Hepatology

Portal vein thrombosis

Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.

Review article: portal vein obstruction--epidemiology, pathogenesis, natural history, prognosis and treatment

BACKGROUND

Portal vein obstruction may be due to portal vein thrombosis (PVT) or its sequale, the portal cavernoma. PVT is a common complication in liver cirrhosis, however, it may also occur as a primary vascular disorder, in absence of any liver disease.

AIM

To review the current knowledge on nomenclature, etiology, pathophysiology, clinical presentation, diagnostic workup and management of adult patients with obstruction in the portal vein, either as a primary vascular disease in adults, or as a complication of liver cirrhosis.

METHODS

A structured search in PubMed was performed using defined keywords (portal vein obstruction, extra-hepatic portal vein obstruction, PVT and portal cavernoma), including full text articles and abstracts in English language.

RESULTS

Several causes, operating both at local and systemic level, might play an important role in the pathogenesis of PVT. Frequently, more than one risk factor could be identified; however, occasionally no single factor is discernible. Diagnosis of portal vein obstruction depends on clinical presentation, imaging and laboratory investigations. Prompt treatment greatly affects the patient's outcome.

CONCLUSIONS

Portal vein obstruction occurring either due to thrombosis in the portal vein or due to the portal cavernoma, can contribute to significant morbidity and mortality in patients with or without cirrhosis. In recent years our understanding of etio-pathogenesis of portal vein obstruction has evolved tremendously, which has led to significant improvement in treatment outcomes. There are still areas where more studies are needed to better clarify the management issues of portal vein obstruction.

Extrahepatic portal vein obstruction and portal vein thrombosis in special situations: Need for a new classification

Extrahepatic portal vein obstruction is a vascular disorder of liver, which results in obstruction and cavernomatous transformation of portal vein with or without the involvement of intrahepatic portal vein, splenic vein, or superior mesenteric vein. Portal vein obstruction due to chronic liver disease, neoplasm, or postsurgery is a separate entity and is not the same as extrahepatic portal vein obstruction. Patients with extrahepatic portal vein obstruction are generally young and belong mostly to Asian countries. It is therefore very important to define portal vein thrombosis as acute or chronic from management point of view. Portal vein thrombosis in certain situations such as liver transplant and postsurgical/liver transplant period is an evolving area and needs extensive research. There is a need for a new classification, which includes all areas of the entity. In the current review, the most recent literature of extrahepatic portal vein obstruction is reviewed and summarized.

How I treat splanchnic vein thrombosis

Antithrombotic treatment of splanchnic vein thrombosis (SVT) is a clinical challenge. Depending on the site of thrombosis, patients are at risk of developing liver insufficiency, portal hypertension, or bowel infarction and may experience recurrence in both the splanchnic veins and other vein segments. To prevent recurrence, anticoagulant therapy should be started as soon as possible after diagnosis and is often continued for an indefinite period of time. However, active bleeding is not infrequent at the time of SVT diagnosis, and major risk factors for bleeding, such as esophageal varices or a low platelet count, are frequently present in these patients. In real-world clinical practice, a proportion of SVT patients are left untreated because the risks associated with anticoagulant therapy are felt to exceed its benefits. However, the majority of patients receive anticoagulant drugs, with heterogeneous timing of initiation, drug choice, and dosages. Evidence to drive treatment decisions is limited because no randomized controlled trials have been carried out in these patients. This review provides practical guidance for the use of anticoagulant drugs in patients presenting with SVT, including symptomatic as well as incidentally detected events.

Etiology and Complications of Portal Vein Thrombosis

BACKGROUND

Portal venous occlusion represents a disorder with considerable clinical relevance. The underlying causes of portal vein thrombosis (PVT) are frequently multifactorial and include malignancies, progressive chronic liver diseases, processes localized to the epigastrium and hepatobiliary system, and acquired as well as inherited thrombophilia. The three main categorical groups are malignant thrombosis, cirrhotic PVT, and non-malignant, non-cirrhotic PVT.

METHODS

Review of the literature.

RESULTS

The site, the extent, its chronicity, and the course of thromboses characterize a relatively heterogeneous clinical presentation and the ensuing complications in affected patients. While the occlusion of the extrahepatic portal and splenic vein likely provokes mainly complications related to portal hypertension, mesenteric venous obstruction shows a high rate of complications and mortality due to intestinal infarction. Especially in patients with liver cirrhosis, special care is warranted with regard to PVTs due to their pathogenetic role and influence on patient survival.

CONCLUSION

This article aims to summarize the current opinion on etiologies, risk factors, and complications of this heterogeneous condition in adults.

Postoperative portomesenteric venous thrombosis: lessons learned from 1,069 consecutive laparoscopic colorectal resections

BACKGROUND

Portomesenteric venous thrombosis (PVT) is a known complication after open and laparoscopic colorectal (LCR) surgery. Risk factors and the prognosis of PVT have been poorly described.

METHODS

This study is a retrospective analysis of a prospectively collected database. Patients with new-onset postoperative abdominal pain were evaluated with a computed tomography scan of the abdomen. Patients found to have PVT were analyzed. A multivariate analysis was performed to identify predictors of PVT.

RESULTS

A total of 1,069 patients undergoing LCR surgery for inflammatory bowel disease (IBD) or nonmetastatic cancer between June 2002 and June 2012 were included. Altogether, 37 (3.5 %) patients experienced symptomatic postoperative PVT. On univariate analysis, IBD (p < 0.001), ulcerative colitis (p = 0.016), preoperative therapy with steroids (p = 0.008), operative time ≥220 min (p = 0.004), total proctocolectomy (TPC) (p < 0.001), ileoanal pouch anastomosis (p = 0.006), and postoperative intraabdominal septic complications (p < 0.001) were found to be significant risk factors. By multivariate analysis, TPC (p = 0.026) and postoperative intraabdominal septic complications (p < 0.001) were independent predictors of PVT. In the PVT group, postoperative length of stay was longer (14.8 vs. 7.4 days, p < 0.001). Of the patients evaluated with a hematologic workup, 72.7 % were found to have a hypercoagulable condition. All patients were managed with oral anticoagulation for at least 6 months. No death or complications related to PVT occurred.

CONCLUSIONS

PVT is a potentially serious complication that is more likely to occur after TPC and in the presence of postoperative intraabdominal septic complications, particularly in patients with a coagulation disorder. Prompt diagnosis and treatment with oral anticoagulation are recommended to avoid long-term sequelae.

Rational classification of portal vein thrombosis and its clinical significance

Portal vein thrombosis (PVT) is commonly classified into acute (symptom duration <60 days and absence of portal carvernoma and portal hypertension) and chronic types. However, the rationality of this classification has received little attention. In this study, 60 patients (40 men and 20 women) with PVT were examined using contrast-enhanced computed tomography (CT). The percentage of vein occlusion, including portal vein (PV) and superior mesenteric vein (SMV), was measured on CT image. Of 60 patients, 17 (28.3%) met the criterion of acute PVT. Symptoms occurred more frequently in patients with superior mesenteric vein thrombosis (SMVT) compared to those without SMVT (p<0.001). However, there was no significant difference in PV occlusion between patients with and without symptoms. The frequency of cavernous transformation was significantly higher in patients with complete PVT than those with partial PVT (p<0.001). Complications of portal hypertension were significantly associated with cirrhosis (p<0.001) rather than with the severity of PVT and presence of cavernoma. These results suggest that the severity of PVT is only associated with the formation of portal cavernoma but unrelated to the onset of symptoms and the development of portal hypertension. We classified PVT into complete and partial types, and each was subclassified into with and without portal cavernoma. In conclusion, neither symptom duration nor cavernous transformation can clearly distinguish between acute and chronic PVT. The new classification system can determine the pathological alterations of PVT, patency of portal vein and outcome of treatment in a longitudinal study.

Portal Cavernoma during Pregnancy

Portal vein thrombosis (PVT) is characterized by the obstruction of the portal venous system. The venous obstruction can be partial or complete and it is caused by thrombogenic conditions (acquired or hereditary) or nonthrombotic factors. The acquired conditions include abdominal inflammation, infections, surgery, myeloproliferative disorders, obesity, oral contraceptive intake, pregnancy, and postpartum period. Occasionally, it is not possible to recognize any overt cause of PVT. During pregnancy there is an increased venous thromboembolism risk mainly in the systemic venous system and the PVT can occur, but there are no data about its exact prevalence, etiology, and outcome. The portal cavernoma is the cavernomatous transformation of the portal vein. It is a consequence of chronic PVT and occurs when myriads of collateral channels develop to bypass the occlusion. The clinical presentation includes hematemesis due to variceal bleeding, ascites or anaemia, and splenomegaly. The cavernous transformation of the portal vein is easily diagnosed by sonography. We report our case of a 32-year-old, gravida 3 para 2, pregnant woman admitted to our hospital at 13 weeks and 1 day of gestation, clinically asymptomatic. Laboratory test, ultrasound, and endoscopic evaluation were negative. After a detailed counseling, the patient decided on termination of pregnancy at 15 weeks and 1 day of gestation.

Clinical approach to splanchnic vein thrombosis: risk factors and treatment

Splanchnic vein thrombosis (SVT) is an unusual manifestation of venous thromboembolism which involves one or more abdominal veins (portal, splenic, mesenteric and supra-hepatic veins). SVT may be associated with different underlying disorders, either local (abdominal cancer, liver cirrhosis, intra-abdominal inflammation or surgery) or systemic (hormonal treatment, thrombophilic conditions). In the last decades, myeloproliferative neoplasm (MPN) emerged as the leading systemic cause of SVT. JAK2 mutation, even in the absence of known MPN, showed a strong association with the development of SVT, and SVT was suggested to be the first clinical manifestation of MPN. Recently, an association between SVT, in particular supra-hepatic vein thrombosis, and paroxysmal nocturnal hemoglobinuria has also been reported. SVT occurs with heterogeneous clinical presentations, ranging from incidentally detected events to extensive thrombosis associated with overt gastrointestinal bleeding, thus representing a clinical challenge for treatment decisions. In the absence of major contraindications, anticoagulant therapy is generally recommended for all patients presenting with acute symptomatic SVT, but there is no consensus about the use of anticoagulant drugs in chronic or incidentally detected SVT. High quality evidence on the acute and long-term management is substantially lacking and the risk to benefit-ratio of anticoagulant therapy in SVT still needs to be better assessed.

Portomesenteric vein thrombosis in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is associated with a high risk of deep venous thromboembolism. However, few data are available so far on portomesenteric vein thrombosis (PMVT). The aim of this study was to describe the characteristics of PMVT in patients with IBD.

METHODS

A retrospective study was conducted at 13 GETAID (Groupe d'Etude Thérapeutique des Affections Inflammatoires du Tube Digestif) centers from January 1995 to June 2010. The following data were collected, using a standardized questionnaire: characteristics of IBD, disease status at the time of PMVT, PMVT characteristics and mode of discovery, concomitant prothrombotic disorders, anticoagulant therapy, and evolution of PMVT.

RESULTS

Fifty cases (29 men and 21 women; median age, 41 years) were identified, including 14 patients with ulcerative colitis and 36 with Crohn's disease. Thirty-one patients (62%) presented with acute PMVT. Twenty-four patients had previously undergone surgical treatment, and IBD was active in 23 cases (77%) of acute thrombosis. The discovery of PMVT was fortuitous in 40% of our cases. Among the 43 patients screened for a prothrombotic disorder, abnormalities were observed in 17 patients (40%) (mainly hyperhomocysteinemia, n = 12). Forty-four patients (88%) were treated with anticoagulants. Recanalization of the vein was significantly more successful in patients with acute thrombosis (65% versus 37%, P = 0.05).

CONCLUSIONS

PMVT can occur when IBD is inactive, and its diagnosis was fortuitous in 40% of our cases. Screening for prothrombotic disorders is essential because it is positive in more than one third of cases.

Portal vein thrombosis: a clinician-oriented and practical review

With advances in modern imaging techniques, portal vein thrombosis (PVT) is being increasingly diagnosed. It has a wide ranging clinical spectrum from being an asymptomatic state to a potentially life-threatening situation. It is not unusual to find it as an incidental finding in the abdominal imagings done for other reasons. It is commonly associated with cirrhosis and abdominal malignancies and also has a strong association with prothrombotic disorders. It is often difficult for the clinicians to decide whether PVT is acute or chronic. This poses great challenges to its management strategies that include anticoagulants, thrombolysis, and surgical options. Timely diagnosis and appropriate management have great bearings on its outcomes of morbidity and mortality. In this clinician-oriented review, we have provided a concise review of clinical aspects of PVT and discussed various management strategies while addressing the common questions that come to a physician's mind dealing with such a patient.

Pregnancy in women with portal vein thrombosis: results of a multicentric European study on maternal and fetal management and outcome

BACKGROUND & AIMS

Women of childbearing age account for approximately 25% of patients with non-cirrhotic portal vein thrombosis (PVT). We aimed at assessing maternal and fetal outcome in pregnant women with known PVT.

METHODS

We performed a retrospective analysis of the files of women with chronic PVT in three European referral centers between 1986 and 2010.

RESULTS

Forty-five pregnancies, 28 (62%) treated with low molecular weight heparin, occurred in 24 women. Nine (20%) were lost before gestation week 20. Preterm birth occurred in 38% of deliveries: there were 3 births at week 24-25, 7 at week 32-36, and 26 after week 37. A term birth with a healthy infant occurred in 58% of pregnancies. Cesarean section was used in 53% of deliveries. Two women developed HELLP syndrome. A favorable outcome happened in 64% of pregnancies. Pregnancies with an unfavorable outcome were associated with a higher platelet count at diagnosis. Bleeding from esophageal varices occurred in 3 patients during pregnancy, all without adequate primary prophylaxis. Genital or parietal bleeding occurred postpartum in 4 patients, only one being on anticoagulation therapy. Thrombotic events occurred in 2 patients, none related to lower limbs or mesenteric veins. There were no maternal deaths.

CONCLUSIONS

In pregnant PVT patients treated with anticoagulation on an individual basis, the rate of miscarriage and preterm birth appears to be increased. However, fetal and maternal outcomes are favorable for most pregnancies reaching gestation week 20. High platelet counts appear to increase the risk for unfavorable outcome. Pregnancy should not be contraindicated in stable PVT patients.

Portal vein thrombosis in children and adolescents: 20 years experience of a pediatric hepatology reference center

CONTEXT

Portal vein thrombosis refers to a total or partial obstruction of the blood flow in this vein due to a thrombus formation. It is an important cause of portal hypertension in the pediatric age group with high morbidity rates due to its main complication - the upper gastrointestinal bleeding.

OBJECTIVE

To describe a group of patients with portal vein thrombosis without associated hepatic disease of the Pediatric Hepatology Clinic of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil with emphasis on diagnosis, presentation form and clinical complications, and the treatment of portal hypertension.

METHODS

This is a descriptive study of a series of children and adolescents cases assisted from January 1990 to December 2010. The portal vein thrombosis diagnosis was established by ultrasound.

RESULTS

Of the 55 studied patients, 30 (54.5%) were male. In 29 patients (52.7%), none of the risk factors for portal vein thrombosis was observed. The predominant form of presentation was the upper gastrointestinal bleeding (52.7%). In 20 patients (36.4%), the initial manifestation was splenomegaly. During the whole following period of the study, 39 patients (70.9%) showed at least one episode of upper gastrointestinal bleeding. The mean age of patients in the first episode was 4.6 ± 3.4 years old. The endoscopic procedure carried out in the urgency or electively for search of esophageal varices showed its presence in 84.9% of the evaluated patients. The prophylactic endoscopic treatment was performed with endoscopic band ligation of varices in 31.3% of patients. Only one died due to refractory bleeding.

CONCLUSIONS

The portal vein thrombosis is one of the most important causes of upper gastrointestinal bleeding in children. In all non febrile children with splenomegaly and/or hematemesis and without hepatomegaly and with normal hepatic function tests, it should be suspect of portal vein thrombosis. Thus, an appropriate diagnostic and treatment approach is desirable in an attempt to reduce morbidity and mortality.

Abdominal thromboses of splanchnic, renal and ovarian veins

Thromboses of abdominal veins outside the iliac-caval axis are rare but clinically relevant. Early deaths after splanchnic vein thrombosis occur in 5-30% of cases. Sequelae can be liver failure or bowel infarction after splanchnic vein thrombosis, renal insufficiency after renal vein thrombosis, ovarian infarction after ovarian vein thrombosis. Local cancer or infections are rare in Budd-Chiari syndrome, and common for other sites. Inherited thrombophilia is detected in 30-50% of patients. Myeloproliferative neoplasms are the main cause of splanchnic vein thrombosis: 20-50% of patients have an overt myeloproliferative neoplasm and/or carry the molecular marker JAK2 V617F. Renal vein thrombosis is closely related to nephrotic syndrome; finally, ovarian vein thrombosis can complicate puerperium. Heparin is used for acute treatment, sometimes in conjunction with systemic or local thrombolysis. Vitamin K-antagonists are recommended for 3-6 months, and long-term in patients with Budd-Chiari syndrome, unprovoked splanchnic vein thrombosis, or renal vein thrombosis with a permanent prothrombotic state such as nephrotic syndrome.

Ph-negative chronic myeloproliferative neoplasm (primary myelofibrosis) - as one of the reasons of the budd-Chiari syndrome

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Management of hepatic vascular diseases

Primary damage to hepatic vessels is rare. (i) Hepatic arterial disorders, related mostly to iatrogenic injury and occasionally to systemic diseases, lead to ischemic cholangiopathy. (ii) Hepatic vein or inferior vena cava thrombosis, causing primary Budd-Chiari syndrome, is related typically to a combination of underlying prothrombotic conditions, particularly myeloproliferative neoplasms, factor V Leiden, and oral contraceptive use. The outcome of Budd-Chiari syndrome has markedly improved with anticoagulation therapy and, when needed, angioplasty, stenting, TIPS, or liver transplantation. (iii) Extrahepatic portal vein thrombosis is related to local causes (advanced cirrhosis, surgery, malignant or inflammatory conditions), or general prothrombotic conditions (mostly myeloproliferative neoplasms or factor II gene mutation), often in combination. Anticoagulation at the early stage prevents thrombus extension and, in 40% of the cases, allows for recanalization. At the late stage, gastrointestinal bleeding related to portal hypertension can be prevented in the same way as in cirrhosis. (iv) Sinusoidal obstruction syndrome (or venoocclusive disease), caused by agents toxic to bone marrow progenitors and to sinusoidal endothelial cells, induces portal hypertension and liver dysfunction. Decreasing the intensity of myeloablative regimens reduces the incidence of sinusoidal toxicity. (v) Obstruction of intrahepatic portal veins (obliterative portal venopathy) can be associated with autoimmune diseases, prothrombotic conditions, or HIV infection. The disease can eventually be complicated with end-stage liver disease. Extrahepatic portal vein obstruction is common. Anticoagulation should be considered. (vi) Nodular regenerative hyperplasia is induced by the uneven perfusion due to obstructed sinusoids, or portal or hepatic venules. It causes pure portal hypertension.

Computed tomography findings in portal vein aneurysm of dogs

In this retrospective study, the appearances of extrahepatic and intrahepatic portal vein aneurysms (PVAs) in dogs were evaluated using multidetector computed tomography (CT). Data from 3060 dogs that underwent abdominal CT were reviewed for focal portal vein dilatation. PVAs were detected in 15/3060 (0.49%) dogs. The bodyweights of dogs with PVAs were significantly higher than the bodyweights of dogs without aneurysms (P=0.0001). Male sex was also significantly associated with PVAs (OR=6.23). Boxers were predisposed to the development of PVA (OR=11.88). Extrahepatic PVAs were always located in the portal vein at the level of the gastroduodenal vein insertion and were saccular in 10/15 dogs and fusiform in 5/15 dogs. One dog had an additional intrahepatic aneurysm of the umbilical part of the left intrahepatic portal branch. No dogs had clinical signs related to the PVA(s), although one dog developed a portal vein thrombosis in the site of the aneurysm.

Causes of adult splanchnic vein thrombosis in the mediterranean area

The term splanchnic vein thrombosis encompasses Budd-Chiari syndrome (BCS), extrahepatic portal vein obstruction (EHPVO), and mesenteric vein thrombosis.

Risk factors can be local or systemic. A local precipitating factor is rare in BCS, while it is common in patients with portal vein thrombosis. Chronic myeloproliferative neoplasms (MPN) are the leading systemic cause of splanchnic vein thrombosis, and are diagnosed in half BCS patients and one-third of EHPVO patients; the somatic mutation JAK2 V617F is detectable in a large majority of patients with overt MPN, and up to 40% of patients without overt MPN. Inherited thrombophilia is present in at least one-third of patients, and the factor V Leiden or the prothrombin G20210A mutations are the most common mutations found in BCS or EHPVO patients, respectively. Multiple factors are present in approximately one-third of patients with BCS and two- thirds of patients with portal vein thrombosis.

In a few patient series from the Southern Mediterranean area the high prevalence of MPN and thrombophilia as underlying cause of BCS is confirmed, although the data should be considered preliminary. Peculiar risk factors present in the area are Behçet’s disease and hydatidosis; moreover, membraneous webs, typically found in Asian patients, are present in a significant portion of cases.

Vascular disorders of the liver: recommendations from the Italian Association for the Study of the Liver (AISF) ad hoc committee

This review summarizes the document elaborated by the Italian Association for the Study of the Liver (AISF) ad hoc committee "Vascular disorders of the liver" on the primary circulatory liver diseases, which include Budd-Chiari syndrome, obstruction of the hepatic portion of the inferior vena cava, portal vein thrombosis, sinusoidal obstruction syndrome (veno-occlusive disease) and hereditary hemorrhagic telangiectasia. A characteristic of the primary circulatory liver diseases is that portal hypertension usually precedes liver dysfunction. Significant overlap exists amongst the diseases and risk factors that predispose patients to the primary circulatory liver diseases, though the pathogenesis of individual diseases varies. Management of the different vascular disorders is very peculiar and often multidisciplinary and patients should be referred to a tertiary referral centre for optimal care.