Portal Vein Thrombosis on Noncontrast CT

I have seen PVT enough to know that it is:

  • Frequently missed
  • Can have bad consequences of portal venous hypertension
  • Management is a bit of a conundrum for clincians and rads.
    • Who to consult?
      • Vascular surgery
      • Heme/onc
      • GI
    • When to follow-up if at all?
      • Additional studies
        • Is an abdominal doppler needed?
    • Treatment
      • Anticoagulation
        • Fraught with difficulty because of the commonly associated cirrhosis and bleeding potential due to PVH/Varices.

 


One of my former colleagues and fellowship trained body imager missed this diagnosis leading to bad sequela of PVH a year later in a young patient.

In the images below, I have windowed the CT narrowly to show the contrast between the normal attenuation arterial system and the thrombosed portal venous system.  This makes it hard to see the fat and some of the secondary findings of PVH.  The coronal images below show a more normal window, but are harder to make sense of.

axial nc pvt

I’m presuming this patient has some hypercoagulable state since the patient already has an IVC filter.

 

cor nc pvt (2)

Superlow Cardiac Output

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I can’t say I remember ever seeing this physiology at contrast injection before.  I’d say the contrast injector is doing the vast majority of pumping in this patient.

The salient points are:

  • Insane volume overload with effusions, ascites and anasarca.
  • Injected contrast barely even makes it into the RV.
  • Contrast refluxes into the azygos vein which is common.
  • What is unusual is reflux through the coronary sinus into the posterior basal segment lower lobe pulmonary veins opacifing the collapsed lung parenchyma.
  • But contrast does not stop there… There is reflux into all 3 hepatic veins and into the posterior right hepatic lobe parenchyma, the right adrenal veins, and the right renal veins producing a branching pattern that could be mistaken for excreted contrast if not for the unilaterality.
  • There is even contrast into retroperitoneal veins and lumbar veins.

In sum, cardiac output could probably be measured with a TB syringe.

Reappearing Gallbladder

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Unfortunately, this is an all too common complication of cholecystectomy. This case is unusually unfortunate because the abscess tracks all the way through the porta hepatis and appears to tunnel through the wall of the adjacent 2nd part of the duodenum. Not wanting to feel left out, the laparoscopic port sites in the anterior abdominal wall also developed abscesses (right upper quadrant and periumbilical). Incidental calcified aneurysm of one of the small mesenteric vessels can be seen anterior to the aorta.

This just goes to prove that a minor procedure is when it happens to someone else.