P4799 - A Thrombotic Storm: Emergent PVR-TIPS & Bowel Perforation From PVT

Leah Yao, MD, Vladislav Fomin, MD, Gloria Rothenberg, ARNP, Anthony Choi, MD, Danielle Brandman, MD, MAS
New York-Presbyterian / Weill Cornell Medical Center, New York, NY

Introduction: An acute portal vein thrombosis (PVT) is a rare event among patients without a history of cirrhosis, often suggesting an underlying hypercoagulable condition. First line treatment for PVT is traditionally anticoagulation to achieve portal vein recanalization (PVR). Transjugular intrahepatic portosystemic shunt (TIPS) is typically used to treat portal hypertensive complications of cirrhosis. This case featured a young patient with portomesenteric thrombi leading to portal hypertension and bowel ischemia, urgently requiring PVR-TIPS and exploratory laparotomy.

Case Description/Methods: A 26-year-old healthy man presented with acute abdominal pain, nausea, and diarrhea after 4 months of marathon training. Labs were notable for WBC 15.04, PLT 45, D-dimer 3637. Imaging demonstrated bilateral lower lobe pulmonary embolisms, a superior mesenteric vein thrombus (SMV), and a main PVT of 7.5 cm. He was started on argatroban and transferred to the intensive care unit for mesenteric ischemia. Repeat imaging demonstrated new thrombi in the splenic vein and left hepatic vein. His course was complicated by esophageal variceal bleeding secondary to portal hypertension, requiring emergent endoscopy and banding. Once stabilized, he underwent PVR-TIPS. Interval imaging then demonstrated small bowel perforation with peritonitis, likely from prior extensive mesenteric ischemia. He required urgent exploratory laparotomy with multiple takebacks and anastomosis. Repeat imaging showed patent intrahepatic portosystemic shunt and resolution of portomesenteric thrombi. He was started on apixaban outpatient. Extensive evaluation for thrombophilia was negative, however risk factors included dehydration from training, increased platelet reactivity from amino acid supplements, and infection.

Discussion: The acuity and extent of this patient’s PVT were dramatic indications to pursue early PVR-TIPS intervention. TIPS has been previously shown to be effective for severe complications of portal hypertension in patients with idiopathic noncirrhotic portal hypertension. However, there is limited prospective literature investigating the role of TIPS in acute PVT without cirrhosis. Despite undergoing PVR-TIPS, the patient developed acute intestinal ischemia, likely a delayed complication from prior mesenteric venous outflow obstruction. This case illustrates a rare occurrence of acute PVT without cirrhosis resulting in severe portal hypertension and catastrophic complications of bowel perforation.


Disclosures:


Leah Yao, MD, Vladislav Fomin, MD, Gloria Rothenberg, ARNP, Anthony Choi, MD, Danielle Brandman, MD, MAS. P4799 - A Thrombotic Storm: Emergent PVR-TIPS & Bowel Perforation From PVT, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.