Acute portal vein thrombosis precipitated by indomethacin in a HCV-positive elderly patient
© Mantarro et al.; licensee BioMed Central Ltd. 2012
Received: 25 April 2012
Accepted: 17 October 2012
Published: 13 November 2012
An increased risk of venous thromboembolism has been reported in patients treated with non-steroidal anti-inflammatory drugs (NSAIDs). We describe a case of acute portal vein thrombosis (PVT) in a hepatitis C virus (HCV)-positive elderly patient following administration of indomethacin.
A 79-year-old HCV-positive man was hospitalized for severe abdominal pain, nausea and vomiting, 15 days after starting indomethacin for back pain. Clinical signs and imaging evaluations disclosed a picture of PVT. Indomethacin was discontinued, and the patient was started on fondaparinux and antithrombin. He was discharged 15 days later due to improvement of his clinical conditions. Thirty days later, a follow-up ultrasound did not show appreciable signs of PVT. The time elapsing between the start of analgesic therapy and PVT onset suggests a role of indomethacin as the triggering agent. Indomethacin could have precipitated PVT by a combination of at least two detrimental mechanisms: 1) direct action on liver vascular endothelium by inhibition of prostacyclin biosynthesis; 2) damage to the intestinal mucosa, followed by inflammatory and pro-coagulant activation of portal endothelium upon exposure to bacterial endotoxins.
This case can be of interest to physicians, who should exert caution when prescribing NSAIDs for inflammatory pain in patients with background inflammatory dysfunctions of the portal vein endothelium.
KeywordsPortal vein thrombosis Indomethacin Chronic HCV infection Case report
Portal vein thrombosis (PVT) is a thrombotic obstruction of extrahepatic/intrahepatic portal venous system, associated with local and systemic risk factors [1, 2]. Local factors include: liver cirrhosis; hepatobiliary and pancreatic malignancy; abdominal inflammation, infections and surgery. Systemic risk factors encompass congenital and acquired conditions. Congenital genotypes comprise: mutations leading to antithrombin, protein C and protein S deficiency, with loss of anticoagulant activity; mutations of prothrombin and factor V Leiden genes, with gain of procoagulant activity. Other inherited risk factors include high levels of factors VIII, IX and XI, and hyperhomocysteinemia. Acquired risk factors are: myeloproliferative disorders; anti-phospholipid syndrome; chronic inflammatory diseases; obesity; oral contraceptive intake; pregnancy and post-partum period [2–6].
Signs of acute PVT include: intestinal congestion, with abdominal distension and pain; splenomegaly; ascites; diarrhea; rectal bleeding; nausea and vomiting; anorexia; fever; lactacidosis; sepsis. Chronic PVT can be asymptomatic and characterized by portal cavernoma and portal hypertension, cholestasis, splenomegaly, ascites, gastro-esophageal varices, and pancytopenia .
This report describes a case of acute PVT in a hepatitis C virus (HCV)-positive elderly patient treated with indomethacin for acute back pain.
On May 2010, a 79-year-old man was hospitalized for severe postprandial abdominal pain, nausea and vomiting. His medical history revealed a HCV-related mild non-progressive chronic hepatitis (diagnosed in 1985; Child-Pugh class A), never treated with anti-HCV therapy. He had a normal body weight (BMI: 25), and did not present any other risk factor for thrombosis, such as smoking, alcohol intake or diabetes mellitus. Furthermore, his family history was negative for bleeding or clotting disorders. Since 1996, he was under treatment with lisinopril/hydrochlorothiazide (20/12.5 mg/day) for hypertension. Fifteen days prior hospitalization, he was placed under treatment with indomethacin (100 mg/day) for back pain. After 11 days of indomethacin therapy, the patient started to complain of dyspepsia and abdominal pain, which worsened rapidly leading to his hospitalization.
Time course of laboratory parameters
Parameters (reference range)
2 months before admission
Red Blood Cell (4.5-6,00 10 6 /μl)
White Blood Cell (4.5-10,00 10 3 /μl)
Neutrophil (1.8-7.5 10 3 /μl)
Platelet (150–400 10 3 /μl)
AST (<40 U/l)
ALT (<41 U/l)
GGT (<60 U/l)
Total Bilirubin (<1.2 mEq/l)
Lactate dehydrogenase (135–225 U/l)
Prothrombin activity (80-130%)
aPTT (25.1-36.5 sec)
aPTT Ratio (0.84-1.22)
Fibrinogen (200–450 mg/dl)
D-dimer (< 0.3 mg/dl)
C-Reactive Protein (< 0.500 mg/dl)
Albumin (3.6-4.9 g/dl)
On day 4, a follow-up abdominal ultrasound confirmed previous findings and displayed diffuse small bowel distension, without colonic involvement. An upper digestive endoscopy did not reveal erosions, ulcerations, mucosal dysplasia or gastro-esophageal varices. On day 5, a virological blood screening was performed: cytomegalovirus (CMV) IgM index was negative, while IgG levels were positive, suggesting a past infection; anti-HCV antibody, anti-HCV IgM and HCV core antigen were positive; screening tests for hepatitis B virus were negative. A CT-scan of chest and abdomen, with intravenous contrast medium, revealed: massive thrombosis of portal trunk; partial thrombosis of left portal vein branch and superior mesenteric vein; mild ascites and ileal distension, with parietal thickening; mild lymphadenopathies in the hepatic hilum, celiac trunk and intercavo-aortic region; and no sign of cancer or suspected lesions. A diagnosis of PVT was then made, and a treatment with fondaparinux (7.5 mg/day) and antithrombin infusion (2000 UI) was started.
On day 7, a decrease in protein C (30%, reference range 72-146%) and protein S (30%, reference range 70-140%) was detected. However, both parameters had never been altered in past assessments. A genetic screening did not show relevant mutations. Treatments with intravenous antithrombin and oral ciprofloxacin were discontinued. On day 11, a follow-up abdominal CT scan, with contrast medium, displayed the persistence of thrombosis in portal trunk, left portal vein branch and superior mesenteric vein, with a reduction of intestinal distension and ascites. Moreover, an abdominal Doppler confirmed an almost complete PVT. Throughout the hospitalization, the patient had some episodes of red bloody stool excretion, which were ascribed to his venous stasis.
On day 15, the severity of postprandial pain decreased significantly, and the patient was discharged. After discharge, he remained on fondaparinux for 12 days, and then he was switched to warfarin with the goal of maintaining the international normalized ratio within the therapeutic range of 2–3. Thirty days later, a follow-up ultrasound did not show appreciable signs of PVT. At 2 years from discharge, several follow-up visits have shown that the patient persists on a stable mild liver disease and he has not experienced further thrombotic events.
In the present case, the time interval elapsing between the start of indomethacin treatment and the event onset suggests a role of this NSAID as the triggering agent of PVT. According to the available medical information, in this patient a prothrombotic condition has developed during the 2 months ranging from the last blood analysis, performed before his admission, and the onset of the abdominal symptoms leading to his hospitalization. Therefore, the possibility that his mild chronic hepatitis might have contributed to the occurrence of PVT cannot be ruled out, even though his clinical history and his previous records of coagulation parameters give a weak support to the hypothesis that the underlying liver disease played a predominant pathogenic role in the development of PVT. In this context, when considering the possible association of indomethacin with PVT, two possible scenarios can be proposed: 1) the patient had a subclinical prothrombotic state, and indomethacin acted as the triggering agent of an overt PVT; 2) indomethacin elicited primarily a prothrombotic state, which subsequently evolved towards PVT in the presence of a susceptible portal endothelium. Whatever the pathogenic picture, it is important to consider that the patient recovered promptly from PVT after indomethacin dechallenge and the start of adequate anticoagulant therapy. Moreover, the patient has not experienced any further thrombotic event after about a two-year follow-up from his discharge. A causality assessment of the association of indomethacin therapy with the occurrence of PVT, using the Naranjo probability scale, has scored as possible .
In patients with severe chronic liver diseases, such as cirrhosis, PVT can occur as a complication . However, our patient had a mild HCV-related chronic hepatitis without signs of significant progression, as documented by previous liver ultrasound patterns and lack of portal hypertension and gastro-esophageal varices. Acute viral infections, including CMV, represent other possible risk factors for PVT, but, in our case, serologic evaluations were consistent with a past CMV infection . Other systemic risk factors, including congenital defects, do not appear to have played a relevant role in the occurrence of the present PVT event. Moreover, since the levels of antithrombin III, platelet count, aPTT, protein C and protein S were not altered in close proximity of PVT onset, as shown by previous follow-up assessments (Table 1), these deficiencies were likely a consequence of PVT, rather than acting as contributing factors. In support of this contention, based on information from current literature , the slight alterations of coagulation parameters, recorded at admission, can be explained by their consumption in the acute phase of thrombosis and the reduced hepatic blood flow consequent to PVT. In this light, the hypothesis of indomethacin as the triggering agent of PVT would be strengthened further.
Besides a background chronic anti-hypertensive therapy, the patient had been recently started on treatment with indomethacin at the time of his symptom presentation. We therefore performed a MEDLINE search on these drug treatments until December 2011. Key search terms were: indomethacin, non-steroidal anti-inflammatory drugs, NSAIDs, lisinopril, angiotensin-converting enzyme inhibitors, ACE-Is, hydrochlorothiazide, diuretics, portal vein thrombosis, venous thrombosis and thromboembolism. According to our literature search, cases of indomethacin-related PVT have not been previously published. Nevertheless, we were able of retrieving 4 unpublished cases of PVT in patients taking indomethacin, by exploring the US Food and Drug Administration and user community through the eHealthMe searching system . Moreover, a case–control study, on the association between the use of NSAIDs, including indomethacin, and the risk of venous thromboembolism, reported an overall incidence rate ratio of 2.51 (95% confidence interval [CI] 2.29-2.76). Of note, this study showed also that in new users (first-ever exposure to NSAIDs within 60 days before thrombotic event) the risk increased to 4.56 (95% CI 3.85-5.40) . In addition, another case–control study highlighted an increased risk of symptomatic pulmonary embolism in patients taking NSAIDs (odds ratio: 2.39, 95% CI 2.06-2.77). In this analysis, the risk was higher for traditional non-selective NSAIDs over non-users and the overall risk for NSAIDs was higher in the first 30 days of exposure (odds ratio: 4.77, 95% CI 3.92-5.81), as compared with chronic (<1 year; odds ratio: 1.83, 95% CI 1.47-2.28) or long-term use (>1 year; odds ratio: 2.14, 95% CI 1.48-3.09). This association can be partly explained by the underlying medical conditions, which may hamper the haemostatic balance . For instance, the intake of drugs inhibiting prostaglandin G2 synthase, such as acetaminophen, during pregnancy has been associated with an increased risk of preeclampsia and thromboembolic events, and this effect could be the consequence of a reduced prostacyclin production during childbearing .
The present report suggests that in patients with background inflammatory conditions of portal vein endothelium, indomethacin may precipitate thrombotic events, likely through the inhibition of endothelial prostacyclin biosynthesis and alterations of intestinal permeability. Moreover, in these patients the older age may represent an additional risk factor for NSAID related bowel damage, thereby further increasing the risk of endothelial activation and PVT. Accordingly, in these patients the option of prescribing non-NSAID analgesics might be considered when pain management is the main issue, while caution should be exerted when NSAID prescription is deemed to be unavoidable.
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Non-steroidal anti-inflammatory drugs
Portal vein thrombosis
Hepatitis C virus
Angiotensin-converting enzyme inhibitors
Human umbilical vein cells
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