Assess for bleeding risk – varices, concomitant antiplatelet agents etc If bleeding risk is low, start therapeutic anticoagulation with low molecular weight heparin If varices likely to be present (history of haematemesis or known cirrhosis), refer to gastroenterology to see if definitive treatment is possible (eg banding) and commence anticoagulation when safe from bleeding risk point of view If symptoms suggest or imaging confirms intestinal ischaemia, refer to surgeons. Start intravenous unfractionated heparin since interruption of the anticoagulation may be required for surgery. Monitor the heparin infusion with anti-Xa if APTT is abnormal prior to commencement because of concomitant liver disease If the thrombus extends while on adequate therapeutic anticoagulation, consideration should be given for thrombolysis. If very high bleeding risk is a contraindication for thrombolysis, surgical intervention may be sought In patients with decompensated cirrhosis and portal hypertension, consideration should be made for a transjugular intrahepatic portosystemic shunt (TIPS) procedure
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