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Affiliation(s)
- Melissa Martinez
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN
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Potze W, Adelmeijer J, Lisman T. Decreased in vitro anticoagulant potency of Rivaroxaban and Apixaban in plasma from patients with cirrhosis. Hepatology 2015; 61:1435-6. [PMID: 25088782 DOI: 10.1002/hep.27350] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 06/17/2014] [Accepted: 06/25/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Wilma Potze
- Surgical Research Laboratory and Section of Hepatobiliary, Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.
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Key Words
- ACLA, anti-cardiolipin antibody
- AFP, alpha feto protein
- BCS, Budd-Chiari syndrome
- CDUS, color doppler ultrasonography
- CT, computed tomography
- CTP, Child Turcotte Pugh
- EHPVO, extra hepatic portal venous obstruction
- EST, endoscopic sclerotherapy
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- IGF-1, insulin like growth factor-1
- IGFBP-3, insulin like growth factor binding protein-3
- INR, international normalized ratio
- JAK-2, Janus kinase 2
- LA, lupus anticoagulant
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MPD, myeloproliferative disorder
- MRI, magnetic resonance imaging
- MTHFR, methylenetetrahydrofolate reductase
- MVT, mesenteric vein thrombosis
- OCPs, oral contraceptive pills
- PAI-1 4G-4G, plasminogen activator inhibitor type 1- 4G/4G genotype
- PNH, paroxysmal nocturnal hemoglobinuria
- PV, portal vein
- PVT
- PVT, portal vein thrombosis
- PWUS, Pulsed Wave ultrasonography
- RFA, radio frequency ablation
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- TAFI, thrombin activatable fibrinolysis inhibitor
- TARE, Trans arterial radioembolization
- TB, tuberculosis
- TIPS, transjugular intrahepatic portosystemic shunt
- UFH, unfractionated heparin
- acute and chronic
- anticoagulation
- imaging
- prothrombotic
- rtPA, recombinant tissue plasminogen activator
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Affiliation(s)
- Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Zhou J, Yang JH. Progress in treatment of nontumoral portal vein thrombosis in liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2015; 23:735-740. [DOI: 10.11569/wcjd.v23.i5.735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is not uncommon in patients with liver cirrhosis, and it increases the risk of gastroesophageal hemorrhage. At present, pharmacological treatment is the preferred selection of management of PVT. Studies have shown that anticoagulation therapy does not increase the risk of gastrointestinal bleeding. Therefore, patients having indications should be given anticoagulation therapy as early as possible. When patients fail to respond to anticoagulation therapy, interventional therapy or surgery may be considered. This article reviews the recent knowledge about the treatment of PVT and discusses the progress in treatment of nontumoral PVT in liver cirrhosis.
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Intagliata NM, Maitland H, Northup PG, Caldwell SH. Treating thrombosis in cirrhosis patients with new oral agents: ready or not? Hepatology 2015; 61:738-9. [PMID: 24829112 DOI: 10.1002/hep.27225] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 05/13/2014] [Indexed: 12/20/2022]
Affiliation(s)
- Nicolas M Intagliata
- University of Virginia Health System, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
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Abstract
Abstract
Antithrombotic treatment of splanchnic vein thrombosis (SVT) is a clinical challenge. Depending on the site of thrombosis, patients are at risk of developing liver insufficiency, portal hypertension, or bowel infarction and may experience recurrence in both the splanchnic veins and other vein segments. To prevent recurrence, anticoagulant therapy should be started as soon as possible after diagnosis and is often continued for an indefinite period of time. However, active bleeding is not infrequent at the time of SVT diagnosis, and major risk factors for bleeding, such as esophageal varices or a low platelet count, are frequently present in these patients. In real-world clinical practice, a proportion of SVT patients are left untreated because the risks associated with anticoagulant therapy are felt to exceed its benefits. However, the majority of patients receive anticoagulant drugs, with heterogeneous timing of initiation, drug choice, and dosages. Evidence to drive treatment decisions is limited because no randomized controlled trials have been carried out in these patients. This review provides practical guidance for the use of anticoagulant drugs in patients presenting with SVT, including symptomatic as well as incidentally detected events.
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Jones C, Levy Y, Tong AW. Elevated serum erythropoietin in a patient with polycythaemia vera presenting with Budd-Chiari syndrome. BMJ Case Rep 2014; 2014:bcr-2014-205663. [PMID: 25452296 DOI: 10.1136/bcr-2014-205663] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Polycythaemia vera (PV) is a clonal disorder of bone marrow stem cells characterised by erythrocytosis. Diagnosis of PV requires exclusion of secondary causes of polycythaemia. It has been held that an elevated erythropoietin (Epo) level strongly indicates secondary erythrocytosis and excludes PV diagnosis, to the extent that the reduced serum Epo level is currently listed as a minor criterion in the WHO classification scheme for PV. However, patients with PV who co-present with Budd-Chiari syndrome have been documented with elevated serum Epo levels. For these patients, identification of the Janus kinase 2 (JAK2) V617F point mutation along with the transient nature of the Epo elevation provides certainty of PV diagnosis, as illustrated by the proband. In this case report, the patient's positive response to cytoreductive therapy (hydroxyurea 500 mg daily) and phlebotomy (750 mL over three phlebotomies) further supports validity of PV diagnosis with elevated Epo. The patient remains on rivaroxaban (Xarelto) for treatment of her portal vein thrombosis.
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Affiliation(s)
- Catherine Jones
- Department of Hematology/Oncology, Baylor Charles A Sammons Cancer Center, Dallas, Texas, USA
| | - Yair Levy
- Department of Hematology/Oncology, Baylor Charles A Sammons Cancer Center, Dallas, Texas, USA
| | - Alex W Tong
- Department of Clinical Oncology Research, Baylor Charles A Sammons Cancer Center, Dallas, Texas, USA
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Lisman T. Low molecular weight heparin in management and prevention of portal vein thrombosis. Thromb Res 2014; 134:761-2. [PMID: 25179517 DOI: 10.1016/j.thromres.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/10/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Kawanaka H, Akahoshi T, Itoh S, Iguchi T, Harimoto N, Uchiyama H, Yoshizumi T, Shirabe K, Takenaka K, Maehara Y. Optimizing risk stratification in portal vein thrombosis after splenectomy and its primary prophylaxis with antithrombin III concentrates and danaparoid sodium in liver cirrhosis with portal hypertension. J Am Coll Surg 2014; 219:865-74. [PMID: 25256370 DOI: 10.1016/j.jamcollsurg.2014.07.939] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Revised: 07/21/2014] [Accepted: 07/30/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Decreased antithrombin III (ATIII) activity and large splenic vein diameter (SVD) are risk factors for portal vein thrombosis (PVT) after splenectomy in liver cirrhosis with portal hypertension. Antithrombin III concentrates can prevent PVT. This study was designed to stratify risks for PVT after splenectomy in cirrhotic patients and to develop prophylactic protocols for PVT. STUDY DESIGN In 53 patients (testing cohort), the cutoff level of preoperative ATIII activity (≤60%) was evaluated for administration of ATIII concentrates. Antithrombin III activity and SVD were re-evaluated as criteria for prophylaxis of PVT. In 57 patients (validation cohort), the risk stratification of PVT and prophylactic protocols were validated. RESULTS In the testing cohort, 10 (19%) of 53 patients had PVT. Risk level of PVT was stratified and prophylactic protocols were developed. Patients at low risk (ATIII activity ≥70% and SVD <10 mm) were not treated; those at high risk (ATIII activity <70% or SVD ≥10 mm) received ATIII concentrates (1,500 U/day) for 3 days; and those at highest risk (SVD ≥15 mm) received ATIII concentrates for 3 days, followed by danaparoid sodium (2,500 U/day) for 14 days and warfarin. In the validation cohort, 0 of 14 low-risk and 2 of 32 high-risk patients had PVT. Although 8 of 11 patients at highest risk had temporary PVT, it disappeared within 3 months postoperatively. Finally, only 2 (3.5%) of 57 patients had PVT. CONCLUSIONS Risk stratification of PVT after splenectomy and prophylaxis with ATIII concentrates and danaparoid sodium dramatically reduced the incidence of PVT.
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Affiliation(s)
- Hirofumi Kawanaka
- Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Tomohiko Akahoshi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohiro Iguchi
- Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Takenaka
- Department of Surgery, Fukuoka City Hospital, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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