Portal Vein Thrombosis in Polycythaemia Vera: A Case Report

Abstract

At presentation lab investigation revealed Hb(Haemoglobn) 16.5g/dl, WBC 11.0 x109/L, ESR 10 mm1st hour, Hct( Haematocrit) 0.51, Platelet 350 x109/L, serum bilirubin 1.8 g/dl, serum total protein 8.1 g/dl, and albumin 4.5g/dl.The first USG (Ultrasongogram) done on September 9, 2007 (Fig-1) showed liver with homogenous echo texture with increased periportal echogenecity and echogenic structures noted within the portal vein along with cavernous formation. Duplex scan confirmed the echogenic structure to be thrombus in the lumen of main portal trunk causing partial obliteration (Fig-2). Mean velocity within the cavernous was 30.6 cm/sec. Thrombus was still present within the portal vein after anticoagulation (Fig-3), however, cavernous velocity was increased (35.6 cm/sec). Endoscopy upper GIT showed grade I esophageal varices with duodenal erosion. Later on he was treated with warfarin 5 mg and Propranolol 20 mg Daily. Two months later a follow up Color Doppler showed re-canalization of portal vein, a normal hepatic vein flow and development of collateral vessels in hilar and peripancreatic region along with moderate splenomegaly (18.5 cm). Differential diagnoses:The diagnosis of acute EPVT was confirmed by USG. Causes of abdominal pain like appendicitis, pancreatitis, cholecystitis, cholangitis and inflammatory bowel diseases were excluded by history, examination and USG. Liver function tests including the viral markers and renal function were also normal. Amongst other causes of systemic prothrombotic states were inherited thrombophilia, MPD, so our differential diagnoses were inherited thrombophilia and MPD.Coagulation screening test were done PT( Prothrombin time) 12.4s, APTT( activated partial thromboplastin time) 35.5s, TT (Thrombin time) 12s, Fibrinogen 200mg/dl were found to be normal. ATIII (Anti-thrombin III, 118.6%) and APCR ( Activated protein C resistance, 2.45) were found negative, protein C (121.7%) and protein S (76.4%) were also normal. Ham's test, sucrose lysis test and sickle test were negative (Table-I A 26 year old youngman presented with the complaints of sudden severe abdominal pain for 4 days in August, 2007. It was dull aching in nature, associated with nausea and vomiting not accompanied by haematemesis and melaena. He was afebrile and gave no history of dark urine,headache, seizure, loss of consciousness, generalized itching or erythromelalgia.Physical examination revealed congested lower palpebral conjunctiva without facial plethora. He was non icteric. Spleen was palpable 10 cm from left costal margin in nontender soft abdomen. Ascites was absent. Initial investigations and treatment with anticoagulation was done in the dept. of Gastroenterology in collaboration with the dept of Haematology and Vascular Surgery.