PMC6159162_01
Intravenous contrast-enhanced (portal venous phase) multidetector CT axial image demonstrating a swollen oedematous pancreas (red arrows) with adjacent free fluid and fat stranding. Note is made of the normal and non-opacified paraumbilical vein (yellow arrow).
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The patient proceeded to get a CT scan that demonstrated a swollen, oedematous pancreas with peripancreatic inflammatory change (Figure 1).
MRI transverse T2 weighted sequence demonstrating gallstones (red arrow), a normal calibre distal common bile duct with no internal filling defects/stones (blue arrow) and a normal non-dilated paraumbilical vein (yellow arrow).
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A subsequent magnetic resonance cholangiopancreatography (MRCP) study as an outpatient did not demonstrate choledocholithiasis (Figure 2).
MRI T2 weighted maximum intensity projection three-dimensional reformat sequence depicting a newly dilated common bile duct ( >9 mm) and a small filling defect within the lower duct above the ampulla (red arrow).
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With a working diagnosis of obstructive ductal stones, a repeat MRCP was performed, showing a 12-mm calculus impacted at the ampulla (Figure 3).
MRI T2 weighted transverse sequence again showing multiple small gallstones (red arrows). The paraumbilical vein is now significantly distended, measuring approximately 4 cm maximally (yellow arrows). Centrally, there is subtle high signal suggestive of slow flow with surrounding thrombus in varying stages of maturation and consequently of varying signal intensity. Surrounding the thrombosed vessel are significant inflammatory changes.
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There was a small central high signal indicative of flow with surrounding heterogeneous thrombus of varying degrees of maturation (Figure 4).
Intravenous contrast-enhanced (portal venous phase) multidetector CT axial image showing the thrombosed paraumbilical vein (yellow arrows), which measures 3.8 cm in maximal dimensions. No identifiable internal flow was evident either on the arterial phase or the portal venous phase.
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The newly recanalized and partially thrombosed paraumbilical vein was shown to have a maximal cross-sectional diameter of 3.8 cm (Figure 5).
Intravenous contrast-enhanced (portal venous phase) multidetector CT sagittal image showing the thrombosed paraumbilical vein (yellow arrows) with thrombus extension into a branch of the left portal vein (red arrow; contrast opacified/non-thrombosed portal vein branch is illustrated by the blue arrow).
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Thrombus extended in a retrograde fashion to involve the left portal vein, with thrombosis in branches supplying segments II, III and IV (Figure 6) with corresponding relative arterial hyperenhancement in keeping with a transient hepatic attenuation difference (THAD).