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Age: 49

Sex: Female

Indication: Ascites

Remote history of cholecystectomy

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Case #4


Findings

  • Near-occlusive portal vein thrombosis extending from the portosplenic confluence through the main portal vein into right and left intrahepatic portal branches
  • Some hepatopetal flow is documented in the portal vein with documented velocities of 13 cm/s in the main portal vein, 13 cm/s in the right portal vein, and 10 cm/s in the left portal vein
  • Hepatic veins are patent
  • Coarsened hepatic echotexture with nodular surface contour
  • Normal appearance of the spleen
  • Moderate volume ascites


Diagnosis

Portal vein thrombosis

Sample Report

Near-occlusive portal vein thrombosis extending from the portosplenic confluence through the main portal vein into right and left intrahepatic portal branches.

Coarsened hepatic echotexture with nodular surface contour, suggestive of cirrhosis.

Moderate volume ascites.


Discussion

  • Portal vein thrombosis (aka pylethrombosis) is a rare cause for acute abdominal pain
  • Patients at increased risk for this condition include those with hypercoagulability disorders, cirrhosis, and upper abdominal tumors
  • If thrombus results in chronic occlusion, numerous collaterals will develop resulting in cavernous transformation of the portal vein
  • Pylephlebitis is thrombophlebitis of the portal vein, which rarely occurs as a complication of gastrointestinal infections. Worry about this if you see portal vein thrombosis in patients with gastrointestinal infections, if you see portal venous gas coexisting with thrombus, or if you see abscesses adjacent to thrombosed portal vein branches
  • The most reliable discriminator between bland and tumor thrombus is the presence (tumor) or absence (bland) of postcontrast enhancement
  • Normal portal vein findings on Doppler ultrasound:
    • Flow should normally be toward the liver (hepatopetal, not hepatofugal)
    • Flow should be consistently antegrade (always above the baseline) with gentle undulations
    • Normal flow velocity: 16-40 cm/s
    • Normal diameter: < 13 mm


Images

Markedly decreased flow within the main and right portal veins on power Doppler analysis (blue arrows), consistent with near-occlusive thrombosis.

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