Background: Abdominal pain is a common primary care complaint. Portal vein thrombosis (PVT) is a rare cause of abdominal pain, typically associated with cirrhosis or thrombophilia. The following describes the presentation of PVT in a young male, the search for risk factors and underlying etiology, and the debate of anticoagulation therapy.Case: A 28-year-old male presented with periumbilical pain, post-prandial nausea, and sporadic hematemesis for 3 weeks. The diagnosis was confirmed with a triphasic liver computerized tomography after obtaining an abnormal right upper quadrant ultrasound. This unexpected finding prompted investigation for intrinsic hepatic disease and potential hypercoagulable disorders. Laboratory analysis revealed a heterozygous genotype for the prothrombin 20210G/A mutation, an identified risk factor for venous thrombosis.