Flush the clog?

A very intellectually stimulating discussion of a 52 yo M with alcohol overuse hx, with a new presentation of abdominal pain with distension over a course of 3 weeks which on further evaluation was found to be ascites with portal hypertension and subtle signs of cirrhosis.

Abdominal US with doppler revealed thrombosis of the main and right portal veins and further imaging confirmed the presence of multifocal hepatocellular carcinoma.

Take home points:

– while assessing new onset ascites in a patient with potential cirrhosis, think of it broadly as Portal HTN (expanding your differential)

– etiology of portal HTN can be divided into pre-sinusoidal, sinusoidal and post-sinusoidal causes

– watch out for involvement of superior mesenteric vein as that can result on ischemia of the gut

– decision of anti-coagulation is dependent on; acute vs chronic clot and presence/absence of varices. Duration of treatment is reliant on the underlying cause for the thrombosis.

Reference paper. Important to differentiate it from Budd-Chiari syndrome.