Approach to the Critical Patient

Immediate priorities

Hemodynamic instability recognition

Ischemia identification

Airway and GI bleeding

Monitoring and targets

Initial monitoring bundle

Consults and escalation

Mandatory consultation triggers

History

Presenting symptoms

Abdominal pain

Associated symptoms

Risk factors

Local and inflammatory causes

Systemic prothrombotic states

Liver disease

Timeline and exposures

Acuity determination

Medication and exposure history

Alarm features

Red flag symptoms requiring urgent evaluation

Physical Exam

Vital signs

Hemodynamic profile

Abdominal examination

Inspection and palpation

Signs of portal hypertension

Stigmata of chronic liver disease

Hepatic skin signs

Clues to MPN

Myeloproliferative signs

Rectal examination

Stool assessment

Differential Diagnosis

Life-threatening mimics

Mesenteric arterial ischemia

Budd-Chiari syndrome

Variceal hemorrhage

Abdominal emergencies

Acute pancreatitis

Pylephlebitis (septic PVT)

Acute appendicitis, diverticulitis

Hepatic and biliary

Hepatocellular carcinoma with tumor thrombus

Biliary obstruction (portal biliopathy)

Hepatic abscess

Laboratory Tests

Essential initial labs

Complete blood count with differential

Coagulation studies

Comprehensive metabolic panel

Ischemia and infection markers

Serum lactate

Blood cultures (2 sets)

C-reactive protein and procalcitonin

Thrombophilia workup

JAK2 V617F mutation

CALR mutation

Extended thrombophilia panel

Flow cytometry for PNH

Liver-specific tests

Child-Turcotte-Pugh (CTP) score components

MELD-Na score

Diagnostic Tests

Scoring Systems

Yerdel classification of PVT in cirrhosis

AGA/AASLD severity framework

Baveno VII consensus criteria

MRI

MRI abdomen with and without contrast

CT

CT abdomen and pelvis with IV contrast

Ultrasound

Doppler ultrasound of portal vasculature

Endoscopic ultrasound (EUS)

Disposition

Admission criteria

Mandatory admission indications

Discharge criteria

Safe discharge parameters

Transfer criteria

Transfer triggers

Treatment

Anticoagulation — LMWH

Enoxaparin (LMWH) — first-line for acute PVT

Anticoagulation — DOACs

Direct oral anticoagulants

Anticoagulation — Warfarin (VKA)

Vitamin K antagonist

Anticoagulation duration

Duration framework

Management of pylephlebitis

Septic portal vein thrombosis

Portal hypertension and variceal bleeding

Variceal hemorrhage management

Interventional procedures

Transjugular intrahepatic portosystemic shunt (TIPS)

Catheter-directed thrombolysis/thrombectomy

Special Populations

Pregnancy

PVT in pregnancy

Geriatric

PVT in older adults (age >65 years)

Pediatrics

PVT in children

Background

Epidemiology

Prevalence and incidence

Demographics

Pathophysiology

Virchow's triad applied to PVT

Consequences of PVT

Therapeutic Considerations

Anticoagulation decision framework

Bleeding risk in cirrhosis

TIPS role

Patient Discharge Instructions

copy discharge instructions

Portal Vein Thrombosis — Discharge Instructions

References

Guidelines and key sources

ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation

AASLD Practice Guidance: Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding

AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis

Portal Vein Thrombosis: Diagnosis, Management, and Endpoints for Future Clinical Studies

Portal Vein Obstruction: Epidemiology, Pathogenesis, Natural History, Prognosis and Treatment

Diagnostic Performance of Ultrasound, CT and MRI in Portal Vein Thrombosis

Contemporary Management of Portal Vein Thromboses in Patients With and Without Cirrhosis

Anticoagulation and TIPS for Management of Portal Vein Thrombosis in Cirrhosis

NCCN Guidelines: Cancer-Associated Venous Thromboembolic Disease

Portal Vein Thrombosis: State-of-the-Art Review