Combined Hormonal Contraceptives: The Culprit of Acute Portal Vein Thrombosis

Abstract

Oral contraceptive medications are known to increase the risk of developing blood clots. Most commonly, these thrombi are found as deep vein thrombi (DVTs) or pulmonary emboli (PEs). The incidence of portal vein thrombosis is much rarer in patients without comorbidities like liver cirrhosis, malignancies, and hematologic disorders. In this case report, we present the cause of a female's epigastric abdominal pain to stem from portal vein thrombosis while on combination oral contraceptive pills (OCPs). A 34-year-old Caucasian female with a history of hypothyroidism, obesity, and oral contraceptive use presented to the emergency room complaining of epigastric abdominal pain for two days. The pain radiated to her back, and she described it as pressure-like in nature with intermittent episodes of nausea. She reported taking norethindrone-ethinyl estradiol for contraception for several years prior. No history of blood clots in the past. Physical examination was pertinent for tenderness in the epigastric area. Vital signs were stable. A blood pregnancy test was negative. Liver enzymes were within normal limits. A complete abdominal ultrasound was unremarkable. Computerized tomography of the abdomen without contrast revealed left portal vein hyperattenuation which was suggestive for acute portal vein thrombosis (Figure 1). Serological testing performed to rule out inherited thrombophilia were negative (Table 1). The patient was subsequently started on anticoagulation and was discharged hemodynamically stable with close outpatient follow up. Portal vein thrombosis can present acutely or exist in chronic states in a broad array of underlying causes. Risk factors include: liver cirrhosis, malignancy, hematologic disorders, thrombophilia, inflammatory disease, and while on hormonal therapies. In the current literature, the most typical sites to find venous thromboembolisms while on OCPs are in the deep veins of the legs and the pulmonary vasculature. Finding a thrombus in the portal vasculature is rare when there is no associated liver disease. Other contributing factors in our patient were obesity and the presence of hypothyroidism. We believe this case report is noteworthy as it helps clinicians suspect portal vein thrombi in patients that are chronically on OCPs. This will help decrease morbidity and mortality and will help guide future management of birth control, possibly by helping form a guideline for contraceptive use in the setting of unusual thrombus locations.