MOFFITT GI REPORT PEARLS 12/21/16: Portal Vein Thrombosis and Acalculous Cholecystitis!

Hi Everyone! Thanks to Gladys for presenting the case of a middle-aged man with cirrhosis presenting with abdominal pain and found to have a portal vein thrombosis and possible acalculous cholecystitis!

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Top Pearls:

  1. Portal vein thrombosis is common in decompensated cirrhosis and is divided into acute vs. chronic.
  2. Acaculous cholecystitis is a high mortality condition occurring in ICU patients that should be treated with broad spectrum antibiotics and prompt cholecystostomy/cholecystectomy.

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For those who want more info:

See these previous pearls from all three sites on portal vein thrombosis in cirrhotic and non-cirrhotic patients:

VA: https://ucsfmed.wordpress.com/2016/02/03/va-report-pearls-portal-vein-thrombosis/

ZSFG (back when it was called SFGH!): https://ucsfmed.wordpress.com/2015/07/21/sfgh-report-pearls-acute-portal-vein-thrombosis/

Moffitt: https://ucsfmed.wordpress.com/2014/11/06/portal-of-knowledge-to-portal-vein-thrombosis/

 

Portal vein thrombosis take-home points:

  • Common in decompensated cirrhosis (8-25%), rare in compensated cirrhosis (<1%).
  • Divide PVT into acute and chronic.
  • Complications: Intestinal ischemia, acute pylephlebitis, portal HTN, cholangiopathy
  • Anticoagulation generally recommended for acute PVT, but need to weigh risks/benefits.
  • For chronic PVT, anticoagulation decision is case-by-case, weighing bleeding/thrombotic risk.
  • Duration of anticoagulation is shorter if risk factors are transient, otherwise indefinite.

 

Acalculous cholecystitis:

  • 10% of acute cholecystitis cases
  • High mortality: 70% without tx, 30% with tx
  • Usually in hospitalized ICU patients
  • Consider if unexplained fever, leukocytosis, or vague abdominal pain
  • Complications: gallbladder necrosis, gangrene, perforation, septic shock, peritonitis
  • Ultrasound and blood cultures are indicated
  • Broad spectrum abx covering E. coli, Enterococcus, Klebsiella, Pseudomonas, Proteus, and Bacteroides (broad gram neg and anaerobic coverage e.g. zosyn)
  • Prompt cholecystostomy or cholecystectomy, should improve rapidly within 24 hours

Evernote: https://www.evernote.com/shard/s272/sh/88d84c17-8753-40db-a645-ad3e28e4fcbd/6413658d50c3ffc27b8c7a8a42b9a94e

Have a great day everyone!

SamMy

 

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