What is the appropriate management for a 70-year-old woman with cirrhosis and acute portal‑vein thrombosis presenting with massive ascites, hemodynamic stability, impaired renal function, elevated INR and D‑dimer, and no spontaneous bacterial peritonitis?

Management of Acute Portal Vein Thrombosis in Cirrhosis with Massive Ascites

This patient requires immediate anticoagulation without delay, despite the elevated INR of 17, because the INR does not reflect true bleeding risk in cirrhosis and early anticoagulation is critical to prevent bowel ischemia and maximize recanalization rates. 1

Immediate Assessment (Within Hours)

Rule out intestinal ischemia urgently – this is the most life-threatening complication with 10-20% mortality and requires immediate intervention: 1

• Abdominal pain out of proportion to examination – already present in this patient
• Elevated lactate levels – must be checked immediately
• CT findings of mesenteric fat stranding, bowel wall thickening, pneumatosis intestinalis, or dilated bowel loops – review the existing CT scan for these features 1, 2
• Sepsis or hemodynamic instability – currently stable but monitor closely

The elevated D-dimer confirms thrombotic activity but does not change management – it supports the diagnosis but anticoagulation is indicated based on imaging alone. 2

The INR of 17 is NOT a contraindication to anticoagulation in cirrhosis – the INR reflects factor VII deficiency but does not predict bleeding risk because cirrhotic patients have balanced hemostasis with concurrent deficiencies in both pro- and anticoagulant factors. 1, 3, 4

Anticoagulation Strategy (Initiate Immediately)

Start low-molecular-weight heparin (LMWH) immediately as first-line therapy: 1, 2

• Enoxaparin is the preferred agent with proven efficacy in cirrhotic patients with PVT 5
• Do NOT delay anticoagulation for endoscopic variceal screening – delays beyond 2 weeks reduce recanalization rates from 87% to 44% 1, 2
• Do NOT wait to "correct" the INR – the elevated INR does not increase bleeding risk in this setting 1, 4

Avoid direct oral anticoagulants (DOACs) in this patient because:

• DOACs are only recommended for Child-Pugh class A or B cirrhosis 1
• The massive ascites, elevated creatinine (2-2.3 mg/dL), and INR of 17 suggest advanced decompensated cirrhosis (likely Child-Pugh C) 1, 4
• Renal impairment (creatinine 2-2.3) contraindicates most DOACs 4

Management of Massive Ascites

Perform large-volume paracentesis immediately to relieve symptoms and improve respiratory mechanics: 1, 6

• Remove ascites to patient comfort (likely 5-10 L given "massive ascites")
• Administer 8 g of albumin per liter of ascites removed using 20% or 25% hyperoncotic solution 1, 6
• Infuse albumin slowly over 1-2 hours after paracentesis is completed to prevent cardiac overload 6
• Do NOT use synthetic colloids (dextran, hydroxyethyl starch) – they are inferior to albumin and associated with worse outcomes 1, 6

The elevated INR does NOT require correction before paracentesis – routine measurement and correction of coagulation parameters before paracentesis is not recommended. 1

Renal Protection and Monitoring

This patient has chronic kidney disease (creatinine 2-2.3 for 6 months) and is at high risk for hepatorenal syndrome: 1, 7

• Monitor serum creatinine daily – any rise >0.3 mg/dL suggests evolving hepatorenal syndrome with 21% six-month mortality 6
• Monitor serum sodium daily – hyponatremia occurs in 17% of inadequately managed patients 6
• Avoid nephrotoxins including NSAIDs and aminoglycosides 8
• Maintain mean arterial pressure >65 mmHg – hypotension worsens renal perfusion 1, 7

Diuretic Management

Re-initiate diuretics within 1-2 days after paracentesis: 1, 6

• Spironolactone 100 mg daily (titrate up to 400 mg) plus furosemide 40 mg daily maintaining a 100:40 mg ratio 1, 6
• Without diuretics, ascites re-accumulates in 93% of cases versus 18% when spironolactone is used 6
• Contraindications to diuretics include: severe hyponatremia (<120 mmol/L), progressive renal failure, worsening encephalopathy, or severe potassium abnormalities 6

Variceal Screening and Bleeding Prophylaxis

Perform endoscopic variceal screening within 24-48 hours but do NOT delay anticoagulation: 1, 2

• Anticoagulation does not increase portal hypertensive bleeding risk (11% with versus 11% without anticoagulation) 2
• If high-risk varices are identified, initiate nonselective beta-blockers (propranolol, nadolol, or carvedilol) for primary prophylaxis 1, 2
• Variceal band ligation can be performed safely on anticoagulation 2
• Use carvedilol cautiously – maintain systolic blood pressure >90 mmHg given this patient's renal impairment and massive ascites 1

Monitoring and Surveillance

Obtain cross-sectional imaging (CT or MRI) every 3 months to assess treatment response: 1, 7

• Expected recanalization timeline is within 6 months for portal vein thrombosis 2
• Continue anticoagulation until clot resolution or liver transplantation 1, 7
• If clot progresses despite anticoagulation, consider interventional options 1, 2

Advanced Interventional Options

Consider transjugular intrahepatic portosystemic shunt (TIPS) with portal vein revascularization for this patient because: 1

• Refractory ascites is an established indication for TIPS 1
• TIPS may address both the portal vein thrombosis and the massive ascites 1
• This patient is a potential liver transplant candidate given decompensated cirrhosis, and TIPS can facilitate future transplantation 1

Catheter-directed pharmacomechanical thrombectomy should be considered if: 2

• Evidence of bowel ischemia develops despite anticoagulation
• Contraindications to anticoagulation emerge
• Extensive thrombosis threatens transplant candidacy

Liver Transplantation Evaluation

Evaluate for liver transplantation urgently given: 6

• Decompensated cirrhosis with massive ascites
• Chronic renal impairment (creatinine 2-2.3)
• Portal vein thrombosis complicating transplant candidacy
• 21% six-month mortality risk with refractory ascites 6

Critical Pitfalls to Avoid

Do NOT withhold anticoagulation due to the elevated INR – this is the most common and dangerous error; the INR does not predict bleeding risk in cirrhosis. 1, 3, 4

Do NOT delay anticoagulation for variceal screening – every week of delay reduces recanalization rates significantly. 1, 2

Do NOT use DOACs in this patient – the renal impairment and likely Child-Pugh C cirrhosis make DOACs unsafe. 1, 4

Do NOT under-dose albumin after paracentesis – inadequate albumin (less than 8 g/L) causes post-paracentesis circulatory dysfunction in 70-80% of patients. 6

Do NOT use synthetic plasma expanders – they activate the renin-angiotensin-aldosterone system more than albumin and worsen outcomes. 1, 6

Do NOT restrict fluids unless serum sodium is <125 mmol/L with clinical hypervolemia – inappropriate fluid restriction worsens renal function. 1