Acute portal vein thrombosis postimage-guided liver biopsy in common variable immunodeficiency

Portal vein thrombosis (PVT) is a rare complication following percutaneous liver biopsy, with an incidence below 0.4% in large multicenter series. We report a 51-year-old male with common variable immunodeficiency (CVID), chronic liver enzyme elevation, and preoperative imaging consistent with cirrhotic morphology, who developed acute abdominal pain within minutes of ultrasound-guided liver biopsy. Notably, biopsy demonstrated only mild steatosis with portal chronic inflammation and no significant fibrosis—a discordance from imaging attributed to CVID-associated nodular regenerative hyperplasia and biopsy sampling error. Contrast-enhanced CT on the day of the procedure showed heterogeneous left lobe enhancement consistent with a transient hepatic attenuation difference (THAD) secondary to focal portal venous obstruction, with a subsegmental filling defect in segment 3 on portal venous phase imaging. Repeat CT on postprocedure day 1 demonstrated thrombus extension into the left main portal vein; MRCP excluded biliary complications and hemobilia. The patient was treated with intravenous heparin transitioned to oral apixaban, with symptomatic improvement and normalization of liver function tests. A formal hypercoagulable evaluation was not performed given the provoked clinical context and normal INR, and no postdischarge imaging was available to assess recanalization; both are acknowledged as limitations. This case illustrates the convergence of multiple risk factors—abnormal hepatic vascular architecture from CVID-related liver disease, endothelial injury from needle passage, and potential hemostatic agent migration—in the pathogenesis of postbiopsy PVT, and underscores the importance of prompt vascular imaging and anticoagulation in patients presenting with acute abdominal pain following liver biopsy.