Acute portal vein thrombosis

Case contributed by Dr Mostafa El-Feky

Presentation

Recent jaundice and abdominal pain.

Patient Data

Age: 65 years
Gender: Male
MRI

Liver

Loss of the normal signal void pattern of the intra- and extrahepatic portal vein till the porto-mesenteric confluence with diffusion restriction suggestive of recent portal vein thrombosis.

Advanced cirrhotic changes of the liver with irregular borders and volume dysmorphism.

Moderate abdominal ascites noted.

CBD stent with mild ectatic CBD about 8 mm. No intrahepatic biliary back pressure changes.

A 10 mm stone noted the cystic duct/CBD junction with mild dilatation of the cystic duct reaching 10 mm. The GB is collapsed with a thickened wall. The pancreatic duct is not dilated.

The supportive features of acute/subacute benign portal vein thrombosis are 1:

  • high signal intensity on T2
  • no evident distension of the portal vein
  • intact normal wall of the portal vein
  • diffusion restriction (mean ADC value 1.2 x 10-3 mm2/s) 2
  • occurs of top of chronic liver disease with no associated liver masses

Diffusion restriction in malignant thrombus is due to high cellularity, unlike diffusion restriction of acute/subacute thrombi which is due to decreased water molecule diffusibility through damaged cell membranes of aggregated RBCs.

There are difficulties to judge intravascular thrombus being benign or malignant based on diffusion restriction or ADC value alone, as its relatively difficult to have a representative ADC value of the thrombus and there is a large grey zone between the two entities in ADC values making it relatively unreliable. Other MRI features are helpful in overall judgment.

This study wasn't performed with contrast administration. The lack of thrombus enhancement is a benign feature. A contrast study is needed if malignant thrombus is to be excluded.

Case Discussion

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Case information

rID: 73198
Published: 22nd Jan 2020
Last edited: 24th Jan 2020
Inclusion in quiz mode: Included
Institution: Dar El Ashaa Center

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