Can We Put a Needle in the Portal Vein?

Background: Portal vein thrombosis in decompensated liver disease in the absence of a hepatic lesion on imaging is a clinical situation causing dilemma in further management. Few case reports used EUS or ultrasound to get tissue from thrombus for diagnosis.

Methods: We present two cases where there was decompensated chronic liver disease and nonenhancing portal vein thrombosis. AFP and PIVKA-II were significantly elevated and there were no lesions in liver on triphasic CT and contrast MRI. EUS-FNAB was done from D1 from the most expansile part of the thrombus avoiding damage to the collateral vessels. 22 G needle was used with single puncture, five actuations and with no fanning. On-site pathology was used during the EUS-FNAB.

Results: EUS-FNAB in both the cases showed features of hepatocellular carcinoma in onsite pathology. There were no periprocedural complications in both the cases. They were done on day care and were discharged on the same day. Based on these findings, the patients were deemed unfit for orthotopic liver transplantation and were offered immunotherapy. One of them received Atezolizumab plus Bevacizumab 2 weeks after variceal banding and 4 months later, he is in CTP-A and with follow-up triphasic CT showing no liver lesions and bland portal vein thrombosis with collaterals. The other patient did not want immunotherapy and he developed encephalopathy and multiorgan failure 1 month later resulting in death.

Conclusion: Distinguishing between tumoral and nontumoral portal vein thrombosis in the absence of a lesion in liver parenchyma is very important and EUS-FNAB is a safe and effective modality for diagnosis.

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Publication History

Article published online:
22 April 2024