Cirrhosis
When do you need to take the INR into account before procedures in patients with cirrhosis?
When patients are on vitamin K antagonists
Why is early anticoagulation recommended for PVT?
reduces the risk of intestinal ischemia, increases the probability of portal vein recanalization
What is the first line imaging modality for BCS?
Doppler ultrasound
How do you make the diagnosis of PSVD?
Liver biopsy (with reticulin stain to rule out cirrhosis)
When and why would a liver biopsy be indicated in patients with recent or chronic PVT/portal cavernoma without known cirrhosis?
If blood tests, imaging or an elevated LSM suggests cirrhosis because if the liver biopsy shows cirrhosis, then the patient will need screening for HCC
In patients with cirrhosis and PVT, why is routine anticoagulation after TIPS generally not recommended?
Because it does not improve recanalization rates, and unnecessary anticoagulation may increase bleeding risk without proven benefit.
True or false: MASLD is an independent risk factor for PVT
True
Name two of the most common causes of PVT/primary BCS in the absence of cirrhosis
Abdominal cancer (30%), Inflammation/infection (20-20%), myeloproliferative disorders, inherited thrombophilia. (Other less common: antiphospholipid antibody, paroxysmal nocturnal hemoglobinema, Behcet, oral contraceptives, pregnancy)
Name one of the diseases that now falls under the name portosinusoidal vascular disease
Nodular regenerative hyperplasia, hepatoportal sclerosis, incomplete septal cirrhosis,or obliterative portal venopathy in the West. Non-cirrhotic portal fibrosis in India, idiopathic
portal hypertension in Japan
Name two potential clinical benefits of anticoagulation in patients with Child-Pugh B or C cirrhosis without PVT
Reduction in morbidity
Reduction in mortality
What other Medicine sub-specialty can help in the workup for PVT risk factors in patients without cirrhosis?
Hematology (myeloproliferative disorders)
Should patients with BCS be surveilled for HCC?
yes, every 6 months
What is the recommended surveillance interval for detecting portal vein thrombosis in patients with porto-sinusoidal vascular disease?
Every 6 months
In patients with cirrhosis and PVT, name two complications that may prompt consideration of TIPS rather than anticoagulation alone.
Variceal bleeding
Recurrent ascites
Name two anticoagulants that can be used for PVT.
LMWH: more effective than warfarin
Vitamin K antagonists: once daily but require monitoring
DOACs: insufficient data to compare with LMWH or VKA; contraindicated in Child-Pugh C
In non-fulminant BCS, what are the initial steps in management
Anticoagulate and treat underlying condition
True or false: Routine surveillance for hepatocellular carcinoma (HCC) is recommended in patients with PSVD.
False
What is the risk factor for PVT that needs to be ruled out in patients with cirrhosis?
HCC
What is the treatment for patients with chronic PVT/portal cavernoma without cirrhosis and refractory complications of portal hypertension?
TIPS± endovascular portal vein recanalization (the latter requires a patent intrahepatic portal branch and depends on the extent of the portal cavernoma).
What is the approach for BCS with acute liver failure
True or false: There is sufficient evidence to recommend routine anticoagulation in PSVD to prevent portal vein thrombosis
False