Stage of portal vein thrombosis
Authors: Xingshun Qi, Guohong Han, Ming Bai, Daiming Fan
Journal: Journal of Hepatology (2010)

Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertensionJournal of HepatologyVol. 53Issue 4PreviewPortal hypertension is associated with the most severe complications of cirrhosis, including ascites, hepatic encephalopathy, and bleeding from gastro-esophageal varices. Despite the progress achieved over the last decades, the 6-week mortality associated with variceal bleeding is still in the order of 10–20%. Awareness of the difficulty inherent to the evaluation of diagnostic tools and the design and conduct of good clinical trials for the treatment of portal hypertension has led to the organization, since 1986, of a series of consensus meetings. Full-Text PDF Open AccessRevising consensus in portal hypertension: Report of the Baveno V Consensus Workshop on methodology of diagnosis and therapy in Portal HypertensionJournal of HepatologyVol. 54Issue 5PreviewWe read with great interest the letter by Dr. Qi et al. [1]. We do agree with them that, at times, it is difficult to make a precise diagnosis of acute and chronic portal vein thrombosis on the basis of contrast enhanced CT alone, especially if it is in the transition period and the disease is evolving. In making a proper diagnosis, one needs to take into account the natural history, including the rapidity of development of the thrombus, the appearance of symptoms, the extent of the thrombosis, and the development of complications. Full-Text PDF Open Access Similar to previous recommendations [1de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol. 2005; 43: 167-176Abstract Full Text Full Text PDF PubMed Scopus (937) Google Scholar, 2DeLeve L.D. Valla D.C. Garcia-Tsao G. Vascular disorders of the liver.Hepatology. 2009; 49: 1729-1764Crossref PubMed Scopus (649) Google Scholar, 3Sarin S.K. Sollano J.D. Chawla Y.K. Amarapurkar D. Hamid S. Hashizume M. et al.Consensus on extra-hepatic portal vein obstruction.Liver Int. 2006; 26: 512-519Crossref PubMed Scopus (187) Google Scholar], a stage-dependent therapeutic strategy of non-malignant and non-cirrhotic portal vein thrombosis (PVT) is advocated in the recent Baveno V consensus [[4]de Franchis R. Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol. 2010; 53: 762-768Abstract Full Text Full Text PDF PubMed Scopus (1097) Google Scholar]. At recent or acute stage of PVT, the predominant goals of treatment are to maximize the rate of portal vein recanalization and to prevent thrombus extension upstream into the superior mesenteric vein and its possible secondary intestinal infarction. At the old or chronic stage, the primary therapeutic objectives are shifted to the prevention and treatment of variceal bleeding and management of portal biliopathy. Despite the fact that this uniform therapeutic strategy is widely approved, no clear definition for staging of PVT has been postulated until now. Thus, the heterogeneity of the criteria might greatly preclude the standardization of the above-mentioned therapeutic strategy and the further evaluation of the outcomes. It has been widely accepted that the formation of portal cavernoma has been considered the "tipping point" between acute and chronic PVT. Once portal cavernoma is detected, the patients are regarded as having entered the chronic stage. However, this does not completely fall in line with our clinical practice. Fig. 1 demonstrates the transverse computed tomography (CT) images obtained at the hilum in one patient who was admitted to our department due to a recent onset of abdominal pain in the absence of complications of portal hypertension. Contrast-enhanced CT scans showed cavernous vessels around the thrombosed portion of the main portal vein (Fig. 1, A). This finding suggests that PVT might have been at the chronic phase according to the prior criteria. Conversely, non-enhanced CT scans showed a high intraluminal density within the portal vein (Fig. 1, panel B), which was strongly suggestive of a fresh thrombus because the protein fraction of hemoglobin in the clot resulted in the elevated CT attenuation value. From our perspective, despite the detection of portal cavernoma, this group of patients should be classified into the acute stage and treated with anticoagulation and thrombolysis to resolve abdominal symptoms and recanalize the thrombosed portal vein. Both experimental and clinical observations have indicated that the cavernous transformation could rapidly develop within a few days after the formation of fresh PVT [5Ide T. Ohno Y. Nakanuma Y. Kanematsu T. Early development of cavernomatous vasculatures in portal venous thrombosis: morphometric kinetics in rabbit model.Hepatol Res. 2003; 27: 136-142Crossref PubMed Scopus (12) Google Scholar, 6De Gaetano A.M. Lafortune M. Patriquin H. De Franco A. Aubin B. Paradis K. Cavernous transformation of the portal vein: patterns of intrahepatic and splanchnic collateral circulation detected with Doppler sonography.AJR Am J Roentgenol. 1995; 165: 1151-1155Crossref PubMed Scopus (158) Google Scholar]. Despite the fact that the compensatory mechanism of collateral circulation is very helpful to drain intestinal congested blood and maintain total hepatic blood flow [[7]Valla D.C. Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management.J Hepatol. 2000; 32: 865-871Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar], thrombus progression and extension still go on, which may result in progressive abdominal presentations in some patients with PVT. Accordingly, we postulated that the therapeutic strategy of the early period of cavernous transformation might be similar to that of the acute stage. In the end, based on our previous observations [8Han G. Qi X. He C. Yin Z. Wang J. Xia J. et al.Transjugular Intrahepatic Portosystemic Shunt for Portal Vein Thrombosis with Symptomatic Portal Hypertension in Liver Cirrhosis.J Hepatol. 2011; 54: 78-88Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 9Qi X. Han G. Wang J. Wu K. Fan D. Degree of portal vein thrombosis.Hepatology. 2010; 51: 1089-1090Crossref PubMed Scopus (26) Google Scholar], we attempted to draw an elementary schematic diagram demonstrating the possible course of portal vein thrombosis and the progression of symptoms (Fig. 2). But it should be noted that the natural history of EHPVO is a complex and dynamic process, and thus this new framework needs to be further improved in many aspects, such as clarification of the role of thrombotic recurrence and the prognostic significance of ascites. The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. We are greatly indebted to Wengang Guo and Jing Niu for their efforts regarding proper preservation of all imaging data.