Portal Vein Thrombosis?

[pistonprovost]

Good morning could some one on here please offer me some advise as to a medical issue I seem to of developed.

Just a quick run down of events to date in order to set the scene so to speak!

Last May I suffered from extreme anaemia so much so that my haemoglobin level dropped to 79, I was self admitted to Hospital through A&E and what initially followed was blood transfusions in order to initially stabilise me.

Various tests were conducted including a CT Scan with contrast, and Liver biopsy. The result from the CT Scan was Portal Vein Thrombosis, the Liver test result was normal.

From this I was then sent for a windpipe camera inspection, it was decided by my Liver Consultant banding was required to stop any possible blood loss, this is also strange as I haven't seen any blood present in my urine or stools.

To date eight bands have been completed and now he has asked my to return for more banding, this I am not too sure about as the experience was very traumatic.

As to the Portal Vein Thrombosis he doesn't seem to be too keen to treat as he seems to only want to carry on with banding and this is leading to my question.

Surely if the Portal Vein was corrected with a stent the the overall blood pressure in my windpipe and other possible future areas would decrease?

I certainly aren't a Doctor (and never will be!) but to me it just seems sensible to correct a problem with my plumbing rather than ignore it:ugh: ?

As a footnote I am also suffering from terrible itching to the point were I itch so much it results in bleeding skin, as you can imagine it is very unsightly.



Thanks in anticipation for any replies.

[Alchemy101]

Whether caused by thrombosis (clotting) of the portal vein, or a problem with the liver itself, the likely problem as I glean it (though not everything in the story totally makes sense!) is that you have portal hypertension, and have had oesophageal varices banded.

In English

The blood drainage to the liver is special. The liver, through the portal vein system, drains mainly your guts that digest food (so that all the nutrients go to the liver for processing, an not elsewhere). It's a unique drainage system that ends with the livver. If something, like increased resistance in the liver (often caused by liver diseases) or sometimes, a blood clot in the portal vain occurs, the pressure in that portal vein system increases (it's just plumbing) called portal hypertension.

There are a few areas in your body where the portal vein system can meet the rest of your venous system (that doesn't drain through your liver). Since the rest of the venous system is low pressure, and the portal vein systemic high pressure, the blood preferentially likes to drain to the rest of your venous system. However, it's not meant to work that way, and those little connections between the portal venous system and the rest of your venous system can't handle a lot of capacity. The result, in portal hypertension, is that those little connections hugely dilate. Those connections are predominantly located at the bottom of your oesophagus (food tube to the stomach), at the belly button, at the anus. There's mainly dangerous in the oesophagus, because when they dilate, they're very fragile. If they are damaged or tear, they can bleed so much that a person dies. Banding them reduces this risk!

Now, as for the causes of portal hypertension, as discussed, the causes are varied and so are the treatments. Most portal vein thrombosis is treated with blood thinning drugs, but occasionally an operation is required.
It's very hard to stent the portal vein system for several reasons 1) the clot often involves the liver itself, where the vessels branch like branches of the tree into hundreds of thousands of little branches 2) you can't easily get into the portal vein, because it's not directly connected to the rest of your system you can't just poke a catheter up an artery or vein as you often can, say, to stent a coronary artery for heart disease 3) the stent is likely to erode the wall of the vein, and/or serve as a nidus for further clot formation.

A common procedure (mainly when the cause is from the liver) is a procedure called TIPS where an artificial bridge is made between the portal vein system and the rest of the venous system within the liver - a relatively safe place to let the pressure down. This often isn't applicable to a portal vein clot though, because the problem isn't necessarily the liver, it's in the vein. Anticoagulant (thinner) drugs and time are often enough to sort the clot out and let things get better. But the big question is 'why the clot in the first place' .Sometimes they just occur, but they are often related to other problems, some potentially nasty and some not so bad.

So working with your consultant to manage this episode AND also rule out serious causes is important :)

EDIT: a couple more things

Blood that goes in the upper end (mouth, oesophagus, stomach) is well digested by the time it gets to the other end, and doesn't look like blood at all, unless a LOT is bleeding. If a fair amount bleeds all of a sudden, it's often a black tarry bowel motion called melena. But if it really hoses it often just runs right through. A small bleed is enough to make you anaemic, but often can't be seen with the naked eye. It's called 'occult' for this reason.

And with respect to the banding - I'd do it. And if you had a bad experience (assuming that experience is related to being awake/aware or distressed) you must tell them this, and they can be more liberal with the anaesthetic. We do this procedure from time to time, and with the right sedation (midaz/fentanyl or propofol), patients rarely have any recollection of the event whatsoever.

As for the itch, could be lots of things. If anything it suggests a problem in the liver itself to me - very often a liver on the fritz causes serious itching. But there are other causes.

[pistonprovost]

Thank you very much for taking time to reply to my post in such excellent detail :ok: This is the most detailed explanation I have had since last May when the initial problem occurred.

As to clotting of my Paortal Vein all I know is I wasn't told of the exact location so this is as you say it is very hard to predict with or a more detailed explanation.

Yes you are correct and just to confirm I have portal hypertension, and have also had oesophageal varices banded, all I know is a total of eight have been completed to date and my Liver Consultant wants to carry on until in his words "they are totally eradicated"

As to my bad experience with banding the first time I was sedated I recall 400 mg's of sadation was used and the second time 300 mg's was used, you are obviously correct and I will of course ask the next time I go.

Thinking back he did mention about blood thinning for a period of time wether this is on a permanent basis or short time I wasn't informed.

Thanking again for your excellent reply and on that basis I will co operate entirely with him and work towards getting this cleared up. My only other worry is that I won't be able to get my Class 2 medical back.

[Alchemy101]

I'm not an aviation doctor so 'fraid I don't know about the whole class 2 issue, but good luck!

[Radgirl]

Pistonprovost

All I would add to the excellent response is

1 You have significant ongoing pathology and have an absolute right to a full and frank explanation. You should telephone your consultant's secretary and demand a proper consultation solely to discuss your pathology and possible treatment. Always a good idea to write down the issues in advance. We can give general guidance but these cases vary.....

2 Many patients find sedation unacceptable. In the UK sedation is normally given by non anaesthetists who are severely restricted in terms of what they can use and how much for safety reasons. When you need a further endoscopy I would demand a separate anaesthetist, and discuss with that anaesthetist whether to have sedation or a general anaesthetic. Dont let your liver specialist fob you off with 'one isnt available' - it isnt true - nor 'it is unsafe / too dangerous / you arent fit enough' - he isnt an anaesthetist and only an anaesthetist can tell you this, which I very much doubt!!!

Good luck

[pistonprovost]

Good morning and thanks again for the replies to my post, very much appreciated :ok:

I realise trying to regain my class 2 medical may be an issue but also now understand I must co operate fully with my Liver Consultant and work closely to try and eradicate this thrombosis.

On the sedation side of things rest assured Radgirl I will discuss at great length my sedation as I certainly don't want to recall the procedure!