Portal vein thrombosis medical therapy

Medical therapy for portal vein thrombosis include anticoagulation to maintain INR between 2 to 3. The goal of anticoagulation is to prevent extension of the clot and to allow for recanalization so that intestinal infarction and portal hypertension do not develop.

Pharmacologic therapy is recommended among patients with portal vein thrombosis without cirrhosis.^[1][2][3]

• The following factors should be considered with treartment of portal vein thrombosis:^[4][5][6]
  • Correction of the causal factors
  • Prevention of thrombosis extension
  • Achievement of portal vein patency
  • Management of complications related to portal hypertension
  • Management of complications related to portal cholangiopathy^[7]

  NOTE (1):Initiate anticougulation with heparin for 3-4 weeks then start oral vitamin K antagonist(e.g. warfarin) to maintain INR between 2 to 3.

  NOTE (2): Biliary abnormalities due to portal vein thrombosis are observed to be reversed after anti-coagulopathy therapy.

  NOTE (3): It is performed to initiate anticoagulation therapy early in course of disease.

  • Improves recanalization rates
  • Minimizes serious complication like peritonitis due to bowel necrosis
  • Decrease development of esophageal varices and complications associated with varices

• 1. Portal vein thrombosis with cirrhosis
  • NOTE: Chronic anticoagulation is generally not recommended

• 2. Portal vein thrombosis without cirrhosis
  • 2.1 Chronic portal vein thrombosis
    • 2.1.1 Chronic portal vein thrombosis with hypercoagulable state or previous history of vascular disease
      • 2.1.1.1 Long term anticoaugulation
        • Preferred regimen: Warfarin 2-5 mg PO q24h
      • 2.1.1.2 Treatment of esophageal varices
    • 2.1.2. Chronic portal vein thrombosis without hypercoagulable state or previous history of vascular disease
  • NOTE: Chronic anticoagulation is generally not recommended
    • 2.1.2.1 Treatment of esophageal varices
  • 2.2 Acute portal vein thrombosis
    • 2.1 Anticoagulant therapy
      • 2.1.1 Acute portal vein thrombosis with hypercoagulable state
        • Preferred regimen: Warfarin 2-5 mg PO q24h for long term
      • 2.2.2 Acute portal vein thrombosis without hypercoagulable state
        • Preferred regimen: Warfarin 2-5 mg PO q24h for 3-6 months
    • 2.2 Thrombolytic therapy

      • Preferred regimen: Recombinant tissue plasminogen activator (RTPA)^[8]
      • Alternate regimen(1): Urokinase^[9]
      • Alternate regimen(2): Streptokinase^[9]

    NOTE: Administration of thrombolytic therapy in acute portal vein thrombosis^[10][11][12]

    • Indirect intraarterial infusion into the superior mesenteric artery
    • Directly intoducing catheter into portal vein^[13][14][8]
      • Transhepatic
      • Transjugular

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