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.