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  • Review Article
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Imaging in clinical decision-making for portal vein thrombosis

Nature Reviews Gastroenterology & Hepatology volume 11, pages 308–316 (2014)Cite this article

Subjects

Key Points

  • Doppler ultrasonography is the first imaging technique to be used for portal vein thrombosis (PVT) diagnosis; it is well-tolerated, accurate and a negative examination performed by a trained operator is sufficient to rule out thrombosis

  • Following PVT diagnosis, imaging techniques should guide clinicians about the presence or absence of prothrombotic conditions such as cirrhosis, solid tumours and septic foci, and signs suggestive of malignant thrombosis

  • CT or MRI is needed to assess the number of vessels involved in thrombosis, the severity of thrombotic stenoses and to map collateral circulation, all of which have prognostic importance

  • Imaging should determine signs of chronicity to determine the age of the thrombus; existence of a portal vein remnant should also be investigated

  • Magnetic resonance cholangiography is the technique of choice to assess portal cholangiopathy in patients with PVT; grade 3 portal cholangiopathy is associated with an increased risk of biliary complications

  • Imaging should be repeated 3–6 months after the first diagnosis and every 6 months thereafter, to inform about thrombosis improvement, stability and progression; symptoms suggesting re-thrombosis should be reassessed by CT or MRI

Abstract

Thrombosis of the portal venous system is a frequent and potentially life-threatening condition that can take place in a number of different clinical settings including liver cirrhosis, hepatocellular carcinoma, other solid tumours, abdominal septic foci, acute pancreatitis, haematological malignancies and congenital or acquired prothrombotic disorders. Clinical decision-making in patients with thrombosis of the portal venous system is a particularly complex process owing to the heterogeneity of the population affected by this condition and the lack of high-quality evidence from randomized controlled trials for the use of anticoagulation therapy in these patients. This Review discusses the available data regarding how imaging can provide assistance to physicians involved in this decision-making process in different clinical settings. A flowchart illustrating how to use imaging in this setting, based on current evidence and on the experience of the Vascular Liver Diseases Group of the Hospital Clinic in Barcelona, is also presented.

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Figure 1: Diagnosis of portal vein thrombosis and its nature.
Figure 2: Extent of thrombosis, age of the thrombus and mapping of collaterals.
Figure 3: Portal cholangiopathy and follow-up of PVT.
Figure 4: Flowchart summarizing how the different imaging methods are used for diagnosing and follow-up of patients with PVT according to the consensus of the Vascular Liver Diseases Group at the Hospital Clinic in Barcelona.

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Acknowledgements

The authors are members of the Vascular Liver Diseases Group of the Hospital Clinic in Barcelona, and would like to express their gratitude to all the colleagues (clinicians, radiologists, anaesthesiologists and surgeons) that participate in the work of this multidisciplinary team. The authors thank the nursing and technical staff of the Hepatic Hemodynamic Laboratory and of the CDIC, and Ms C. Esteva for expert secretarial support. CIBERehd is funded by the Instituto de Salud Carlos III.

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Authors and Affiliations

  1. Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, CIBERehd, Hospital Clinic, c/Villarroel 170, Barcelona, 08036, Spain

    Annalisa Berzigotti & Juan-Carlos García-Pagán

  2. Centre Diagnostic per la Imatge, Hospital Clinic c/Villarroel 170, Barcelona, 08036, Spain

    Ángeles García-Criado & Anna Darnell

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  1. Annalisa Berzigotti
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A. Berzigotti contributed to all aspects in the generation of this article. Á. García-Criado and A. Darnell contributed equally to researching data for the article, discussion of content and reviewing/editing the manuscript before submission. J.-C. García-Pagán substantially contributed to the discussion of content and reviewed/edited the manuscript before submission.

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Correspondence to Annalisa Berzigotti.

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Berzigotti, A., García-Criado, Á., Darnell, A. et al. Imaging in clinical decision-making for portal vein thrombosis. Nat Rev Gastroenterol Hepatol 11, 308–316 (2014). https://doi.org/10.1038/nrgastro.2013.258

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