EASL Campus

A 47-year-old woman with no history of liver disease presents with progressive abdominal pain, new-onset ascites, and elevated D-dimer. Doppler ultrasound reveals absent flow in all three hepatic veins, and CT confirms complete occlusion of the hepatic veins without IVC involvement. Laboratory studies: bilirubin 1.3 mg/dL, INR 1.1, platelets 390×10⁹/L. No encephalopathy. JAK2^V617F mutation is positive. No focal liver lesions are seen. She is hemodynamically stable and has no contraindications to anticoagulation.

According to the 2025 EASL Guidelines on Vascular Diseases of the Liver, what is the most appropriate next step in management?

A. Initiate full-dose LMWH and proceed directly to TIPS because underlying MPN predicts poor response to medical therapy.

B. Start therapeutic LMWH followed by VKA, evaluate for short-segment venous stenosis, and perform percutaneous angioplasty if feasible.

C. Begin rivaroxaban and defer imaging-based intervention unless she develops hepatic decompensation.

D. List for urgent liver transplantation because complete hepatic vein occlusion predicts rapid deterioration.