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)