Portal vein thrombosis: an unexpected finding in a 28-year-old male with abdominal pain.

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. DISCUSSION Recommendations concerning anticoagulation for PVT in the absence of cirrhosis are not clearly defined. Current literature describes the following factors as indications for anticoagulation: acute thrombus, lack of cavernous transformation, absence of esophageal varices, and mesenteric venous thrombosis. This patient had clinical indications both for and against anticoagulation. Weighing this individual's clinical circumstances, we concluded the risk of thrombus in the setting of a hypercoagulable disorder outweighed the risk of variceal bleeding. A minimum of 6 months of anticoagulation was initiated. CONCLUSION PVT is an uncommon cause of abdominal pain, and the absence of hepatic disease should raise the index of suspicion for an underlying thrombophilia. Specific recommendations for anticoagulation are not well defined, demonstrating the importance of weighing the individual risks and benefits in treatment with anticoagulation for young persons with thrombophilia.