Chest Pain in Vain: Spontaneous Portal Vein Thrombosis

A 53-year-old man with a patient-reported history of ultrasound-diagnosed fatty liver disease presented with sudden-onset severe chest pain and a brief loss of consciousness, followed by progressive abdominal pain and a single episode of bloody diarrhoea. Admission investigations approximately 24 hours after the chest pain episode showed a D-dimer of 14,502 µg/L and high-sensitivity troponin I below 3 ng/L. An arterial-phase computed tomography (CT) aortogram showed no aortic dissection but did not establish portal venous patency. Following specialist thoracic radiology review, the aortogram was considered satisfactory to exclude pulmonary embolism down to the segmental level, and dedicated pulmonary angiography was not performed. Portal venous-phase CT performed 72 hours after the aortogram demonstrated extensive portal, superior mesenteric, and splenic vein thrombosis, with equivocal caecal and ascending colonic changes. Symptoms improved during anticoagulation. Repeat CT three months later showed resolution of thrombosis, with all three affected veins patent. This case illustrates the importance of selecting an imaging protocol appropriate to the evolving clinical presentation. An unrevealing arterial-phase examination did not exclude portal venous thrombosis. The relationship between the thrombosis and the initial chest pain and collapse remains uncertain, as does the contribution of the patient's reported fatty liver disease.