Portal vein thrombosis associated with COVID-19

1. Cause and Etiology

Portal vein thrombosis (PVT) is defined as the formation of a blood clot within the portal vein or its branches, which can lead to partial or complete obstruction of portal venous flow. When occurring in the setting of COVID-19, it is typically secondary to virus-induced coagulopathy and endothelial injury.

Primary cause in COVID-19: Hypercoagulable state triggered by systemic inflammatory response to SARS-CoV-2.
Contributing factors:

Direct viral invasion of endothelial cells via ACE2 receptors.
Cytokine storm (notably IL-6, TNF-α) inducing widespread inflammation.
Immobility and hospitalization.
Preexisting comorbidities (e.g., obesity, cancer, or liver disease, though not always present).

2. Pathophysiology

The pathogenesis of COVID-19-associated PVT involves Virchow’s triad:

Endothelial injury: SARS-CoV-2 infects endothelial cells, leading to dysfunction and a prothrombotic state.
Hypercoagulability: Elevated fibrinogen, D-dimer, and other prothrombotic factors due to cytokine-induced coagulation cascade activation.
Venous stasis: Due to immobility or systemic hemodynamic alterations during critical illness.

Additional mechanisms include:

Platelet activation
Neutrophil extracellular traps (NETs) formation
Downregulation of anticoagulant proteins (e.g., protein C, S, antithrombin)

3. Epidemiology

While COVID-19–associated venous thromboembolism (VTE), such as deep vein thrombosis and pulmonary embolism, is relatively common, portal vein thrombosis is rare but increasingly recognized.

Incidence: Unknown exact rate; limited to case reports and small series.
Demographics: Can occur in young and previously healthy patients.
Timing: Typically within the first 1–2 weeks of COVID-19 symptom onset, often during hospitalization or ICU stay.

4. Clinical Presentation

Symptoms of COVID-19-associated PVT may be nonspecific and may overlap with those of COVID-19:

Abdominal pain, especially in the right upper quadrant or epigastrium
Fever, though not always present
Nausea, vomiting, or diarrhea
Signs of portal hypertension in chronic cases (e.g., splenomegaly, varices)
Systemic signs of COVID-19: fever, cough, dyspnea, fatigue

In some cases, PVT is incidentally discovered on imaging for abdominal pain evaluation in a COVID-19 patient.

5. Imaging Features

Contrast-enhanced abdominal CT is the gold standard for diagnosis.

Portal venous phase reveals:

Filling defect within the portal vein (main, right, or left branches)
Expanded portal vein with low attenuation
Peripheral hepatic enhancement due to altered perfusion
Ascites if portal hypertension is present

Ultrasound with Doppler:

Absence of flow in portal vein
Echogenic thrombus within vessel lumen

MRI with MR angiography: Alternative modality if CT is contraindicated

In concurrent chest CT of COVID-19:

Ground-glass opacities (GGO)
Bilateral pleural effusions (uncommon)
Multifocal patchy consolidation

6. Treatment

The mainstay of treatment is systemic anticoagulation.

First-line therapy: Intravenous unfractionated heparin (UFH) or low molecular weight heparin (LMWH)
Transition to oral anticoagulants: e.g., warfarin or direct oral anticoagulants (DOACs) after stabilization
Duration: Typically at least 3–6 months, depending on risk factors and resolution
Thrombolysis or surgery: Rare, reserved for extensive thrombosis with bowel ischemia or failure of anticoagulation
Supportive care: Management of COVID-19 symptoms and systemic complications

7. Prognosis

Prognosis varies depending on:

Extent and location of the thrombus
Presence of bowel ischemia or infarction
Underlying comorbidities
Timeliness of diagnosis and treatment

In patients with early detection and prompt anticoagulation:

Favorable outcomes are common, including recanalization of the portal vein.
Delayed treatment or severe thrombotic burden can result in:

Portal hypertension
Intestinal ischemia
Multi-organ failure
Death

In COVID-19 patients, the coexistence of PVT may signal a severe hypercoagulable state and necessitates close monitoring for thromboembolic complications elsewhere (e.g., pulmonary embolism, DVT).

Conclusion

COVID-19-associated portal vein thrombosis is a rare but serious complication stemming from the prothrombotic effects of SARS-CoV-2 infection. Clinicians, especially radiologists and intensivists, must maintain a high index of suspicion in COVID-19 patients presenting with new-onset abdominal pain. Prompt imaging, anticoagulation, and multidisciplinary management are key to improving outcomes.

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Case Study: A Previously Healthy 26-Year-Old Male Presenting with a Two-Day History of Dyspnea and Fatigue

COVID-19-Associated Portal Vein Thrombosis

https://doi.org/10.1259/bjrcr.20200089

Abstract

The rapid global spread as well as the mortality and morbidity associated with COVID-19 has raised increasing concern around the globe. Studies have reported that patients infected with the novel coronavirus are prone to coagulopathy. However, information on portal vein thrombosis in patients with COVID-19 is scarce. In this case report, we depict the abdominal CT findings of a 26-year-old male patient with COVID-19 who developed severe abdominal pain during hospitalization and was later diagnosed with portal vein thrombosis. We also demonstrate the chest CT findings of the same patient, which revealed bilateral pleural effusion, a less common imaging finding, and multifocal patchy consolidations. This paper emphasizes that physicians, particularly radiologists, should be aware of thromboembolic events when examining any suspected patient during the current outbreak.

History and Imaging Findings

A previously healthy 26-year-old male was admitted to our hospital with a two-day history of dyspnea and fatigue.
He denied any recent travel and reported no known contact with confirmed COVID-19 cases in the preceding months.
His medical history was unremarkable except for well-controlled asthma diagnosed four years prior.
He had no history of medication use, smoking, or alcohol consumption.
On admission, he was hemodynamically stable with a blood pressure of 115/75 mmHg and a heart rate of 88 bpm.
He was afebrile (oral temperature 37.1°C) but exhibited tachypnea with a respiratory rate of 33 breaths per minute, and his oxygen saturation was 92% on room air.
Laboratory investigations revealed a normal white blood cell count (7.2 ×10³/µl) and lymphocyte count (2800/µl), elevated C-reactive protein (CRP) at 96 mg/L, prolonged prothrombin time (PT) of 39 seconds, international normalized ratio (INR) of 1.34, and an increased D-dimer level of 0.5 mcg/ml.
Reverse transcription polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 was positive. Chest CT imaging demonstrated multifocal patchy consolidations and bilateral pleural effusions (Figure 1), consistent with COVID-19 pneumonia.

Figure 1.

Axial contrast-enhanced CT scan of the chest shows bilateral pleural effusion (*) and multifocal patchy consolidations (black arrows).

He was later admitted to the intensive care unit (ICU) due to worsening respiratory distress.
On hospital day 5, while undergoing treatment in the ICU, he developed severe pain in the right upper quadrant of the abdomen, prompting further evaluation with contrast-enhanced abdominal CT imaging.
A multiphasic CT scan—including arterial, portal venous, and equilibrium phases—was performed using a 16-slice multidetector CT scanner following intravenous administration of 80–120 mL of iodinated contrast agent.
The portal venous phase of the abdominal CT revealed evidence of portal vein thrombosis.
Additionally, intra-abdominal fluid accumulation was noted on imaging, most likely secondary to portal hypertension resulting from the thrombosis (Figure 2).

Figure 2.

Axial (a) and coronal (c) contrast-enhanced CT images of the abdomen demonstrate a clot within the portal vein (black arrows). There are altered patchy areas of hepatic parenchymal enhancement (*) that are suggestive of occlusion of small branches of the portal vein. Intraperitoneal fluid is also seen on CT images (white arrows).

14. Anticoagulation therapy was initiated immediately with a continuous intravenous infusion of heparin at 1,000 units per hour. The patient's condition gradually improved, and he was discharged on hospital day 9.

Quiz:

1. What was the chief complaint of the 26-year-old male patient upon initial presentation to the hospital?
A. High fever and diarrhea
B. Abdominal pain and jaundice
C. Shortness of breath and fatigue
D. Headache and visual disturbance

Explanation:
The patient presented with a 2-day history of shortness of breath and fatigue, which are respiratory symptoms commonly associated with COVID-19. His condition later deteriorated, necessitating intensive care treatment.

2. Which of the following was an uncommon chest CT finding associated with COVID-19 in this case?
A. Pulmonary abscess in the right lower lobe
B. Bilateral pleural effusions and multifocal patchy consolidation
C. Mediastinal lymphadenopathy
D. Pulmonary embolism

Explanation:
Chest CT revealed bilateral pleural effusions and multifocal patchy consolidation—findings that are not typical for COVID-19. While ground-glass opacities (GGO) are the hallmark of COVID-19 pneumonia, more severe cases may present with various atypical radiologic patterns.

3. What symptom developed suddenly on hospital day 5, and what was identified as the underlying cause?
A. High fever / Sepsis
B. Seizures / Cerebral thrombosis
C. Severe abdominal pain / Portal vein thrombosis
D. Tachycardia / Pulmonary embolism

Explanation:
On the fifth day of hospitalization, the patient developed sudden and severe right upper quadrant abdominal pain. Contrast-enhanced abdominal CT revealed portal vein thrombosis, which was determined to be the cause of his abdominal symptoms. This reflects a form of COVID–19–related coagulopathy.

4. What was the initial treatment performed for portal vein thrombosis in this case?
A. Surgical resection
B. Antibiotic therapy
C. Continuous intravenous heparin infusion
D. Plasma exchange therapy

Explanation:
Upon diagnosis of portal vein thrombosis, the patient was started on continuous intravenous heparin infusion at 1,000 U/h for anticoagulation. His condition improved, and he was discharged on day 9. This approach is consistent with standard treatment for COVID–19–associated thrombosis.

Discussion

Portal Vein Thrombosis Associated with COVID-19

Patients with COVID-19 may experience a hypercoagulable state in both the arterial and venous systems, which is reflected by thrombocytopenia, elevated D-dimer levels, and prolonged prothrombin time (PT).⁴ Several mechanisms have been proposed to explain the heightened risk of coagulopathy in COVID-19 patients. These include systemic inflammation, platelet–leukocyte aggregation, and endothelial dysfunction triggered by the activation of macrophages, monocytes, endothelial cells, platelets, and lymphocytes in response to viral infection.⁴ In addition, increased levels of von Willebrand factor, activation of Toll-like receptors, and the tissue factor pathway have been implicated. Hypoxia, immobility, and disseminated intravascular coagulation (DIC) are also considered potential contributors to the hypercoagulable state seen in COVID-19.⁵

Numerous studies have reported thromboembolic complications associated with COVID-19 infection.⁶⁻⁹ In a recent study by Klok et al., the incidence of thrombotic complications in critically ill patients with COVID-19 was reported to be as high as 31%, with pulmonary embolism (PE) being the most common thrombotic event.⁵ However, to date, there has been only one published case of a patient who developed portal vein thrombosis during hospitalization without a confirmed RT-PCR diagnosis of COVID-19.¹⁰

This report describes a young male patient with COVID-19 who was diagnosed with portal vein thrombosis following the onset of acute abdominal pain. Given the absence of any known predisposing risk factors for venous thromboembolism in this case, it is plausible that the hypercoagulable vasculitic state associated with COVID-19 contributed to the development of portal vein thrombosis. Similar cases of COVID-19 patients presenting with pulmonary embolism in the absence of traditional risk factors have been documented.¹¹ ¹² Moreover, as noted by Grillet et al., male sex and the use of invasive mechanical ventilation may be associated with an increased risk of thromboembolic complications.¹³

Learning Points

Patients with confirmed COVID-19 are at increased risk of thromboembolic complications.
Coagulation parameters in hospitalized COVID-19 patients should be closely monitored.
Unless medically contraindicated, prophylactic anticoagulation should be considered for all hospitalized COVID-19 patients.
In cases of severe abdominal pain, either at presentation or during hospitalization in COVID-19 patients, abdominal imaging—particularly contrast-enhanced studies—should be strongly considered.

REFERENCES

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2. Hughes C , Nichols T , Pike M , Subbe C , Elghenzai S . Cerebral venous sinus thrombosis as a presentation of COVID-19 . Eur J Case Rep Intern Med 2020 ; 7 : 001691 . doi:10.12890/2020_001691

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6. Lodigiani C , Iapichino G , Carenzo L , Cecconi M , Ferrazzi P , Sebastian T , et al. . Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy . Thromb Res 2020 ; 191 : 9 – 14 . doi: 10.1016/j.thromres.2020.04.024

7. Llitjos J-F , Leclerc M , Chochois C , Monsallier J-M , Ramakers M , Auvray M , et al. . High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients . J Thromb Haemost 2020 ; 18 : 1743 – 6 . doi: 10.1111/jth.14869

8. Middeldorp S , Coppens M , van Haaps TF , Foppen M , Vlaar AP , Müller MCA , et al. . Incidence of venous thromboembolism in hospitalized patients with COVID-19 . J Thromb Haemost 2020 ;05 May 2020. doi: 10.1111/jth.14888

9. Bikdeli B , Madhavan MV , Jimenez D , Chuich T , Dreyfus I , Driggin E , et al. . COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review . J Am Coll Cardiol 2020 ; 75 : 2950 – 73 . doi: 10.1016/j.jacc.2020.04.031

10. de Barry O , Mekki A , Diffre C , Seror M , El Hajjam M , Carlier R-Y . Arterial and venous abdominal thrombosis in a 79-year-old woman with COVID-19 pneumonia . Radiology Case Reports 2020 ; 15 : 1054 – 7 . doi: 10.1016/j.radcr.2020.04.055

11. Polat V , Gİ B . Sudden death due to acute pulmonary embolism in a young woman with COVID-19 . J Thromb Thrombolysis 2020 ;: 1 – 3 .

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13. Grillet F , Behr J , Calame P , Aubry S , Delabrousse E . Acute pulmonary embolism associated with COVID-19 pneumonia detected by pulmonary CT angiography . Radiology 2020 ;: 201544 . doi: 10.1148/radiol.2020201544

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CASE STUDY: A Previously Healthy 26-Year-Old Male Presenting with a Two-Day History of Dyspnea and Fatigue, COVID-19-Associated Portal Vein Thrombosis