How I Treat How I treat splanchnic vein thrombosis

M.A. is a 73-year-old white man who presented to our Thrombosis Center 2 days after ultrasonographic diagnosis of occlusive portal vein thrombosis (PVT). He had known liver cirrhosis secondary to chronic alcohol consumption (Child class A). The ultrasound test was ordered because the patient complained of abdominal pain during the previous 5 days. The remaining clinical history was unremarkable with the exception of arterial hypertension and recurrent episodes of hemorrhoidal bleeding. The patient was prescribed a calcium-channel blocking drug. Laboratory tests revealed an international normalized ratio of 1.3, a prothrombin time ratio of 1.4, an activated partial thromboplastin time of 35 seconds (laboratory reference range, between 25 and 40 seconds) with a ratio of 1.1, and a platelet count of 90 000/mm. Estimated glomerular filtration rate was 60 mL/minute. Upper gastrointestinal endoscopywas immediately ordered to check the presence of esophageal varices, and the patient was temporarily started on intermediate-dose low-molecular-weight heparin (LMWH) (1mg/kg once a day), pending endoscopy. Grade 1 esophageal varices and amild congestive gastropathy were detected, and treatment with LMWH was continued at the usual full therapeutic dose of 1 mg/kg twice a day. Propranolol for the primary prevention of variceal bleeding was also started. As no bleeding events occurred and as the hemoglobin level remained stable at the follow-up visit on day 10, it was decided to continue treatmentwithLMWHfor a total of 1month and then to switch the patient to warfarin, with a target therapeutic range international normalized ratio between 2 and 3, for an indefinite period of time. Complete recanalization of the thrombosis was observed at an ultrasound test performed at 3 months.