A 48-year-old man with cirrhosis due to chronic hepatitis B is found to have a partially occlusive thrombus in the main portal vein on routine surveillance ultrasound. He has no history of variceal bleeding. Liver function is Child-Pugh B. Which is the most appropriate management?
- A Observation with repeat imaging in 6 months
- B Transjugular intrahepatic portosystemic shunt (TIPS)
- C Anticoagulation with low-molecular-weight heparin ✓
- D Systemic thrombolysis with alteplase
Explanation
Recent guidelines support anticoagulation for portal vein thrombosis (PVT) in cirrhotic patients, particularly when the thrombus is recent and the patient is a transplant candidate. Anticoagulation (LMWH or warfarin) achieves partial or complete recanalization in a majority of cases and reduces portal hypertension complications. TIPS can be considered for PVT but is typically reserved for cases refractory to anticoagulation or with extensive splanchnic thrombosis. Observation alone risks thrombus progression. Systemic thrombolysis is contraindicated in cirrhosis due to bleeding risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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