Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding

Visceral Thromboses in Pancreas Adenocarcinoma: Systematic Review

Within gastrointestinal malignancies, primary hepatocellular carcinoma and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity and speculatively improve oncologic outcomes. To perform a systematic review to study PVT, MVT, and SVT associated with PDAC, and to provide a comprehensive review. Medline/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Data Extraction and Assessment: Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English-language literature published between 2007 and 2016. Eleven articles were identified. Five case reports and 7 retrospective studies were found, with a total of 127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (n = 46), SVT in 52% (n = 65), and MVT in 13% (n = 15). Mean follow-up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in VT. All patients with nonvisceral thrombosis (eg, deep-vein thrombosis, pulmonary emboli) were therapeutically treated; in contrast, patients with VT only rarely received treatment. VT in PDAC is a frequent finding at diagnosis or during disease progression. Evidence to guide treatment choices is limited, and current management is based on inferred experience from nononcologic settings. Anticoagulation appears to be safe in VT, with most of the large studies recommending a careful assessment for patients at a high risk of bleeding.

Role of thrombophilia in splanchnic venous thrombosis in acute pancreatitis

Background:

Splanchnic venous thrombosis (SVT) is a common vascular complication of acute pancreatitis (AP). We conducted this study to prospectively investigate the frequency, risk factors, and extent of SVT in patients with AP and to evaluate the role of thrombophilia in its causation.

Methods:

Patients with AP presenting between January 2015 and June 2016 were prospectively evaluated with contrast-enhanced computed tomography (CT) for the presence of SVT. These patients underwent a detailed analysis of coagulation parameters.

Results:

We evaluated 96 patients with AP (73 male, mean age 31.85±13.34 years), of whom 26 (27.1%) had SVT. Splenic vein, portal vein, and superior mesenteric vein involvement were seen in 22 (84.6%), 11 (42.3%), and 4 (15.3%) patients, respectively. Necrotizing pancreatitis, CT severity index (CTSI) >6 and modified CTSI >6 were significantly more frequent in patients with SVT than in those without (96.2% vs. 78.6%, 76.9% vs. 47.1%, and 92.3% vs. 67.1%, respectively). Proteins C and S, and antithrombin III deficiency were found in 23.8%, 33.3% and 31.0% of patients, respectively. Anti-β2-glycoprotein I and lupus anticoagulant were positive in 4.8% and 11.9% of patients, respectively. Factor V Leiden mutation analysis was positive in 6.1% of patients. Coagulation abnormality did not differ significantly between the patients with and without SVT.

Conclusions:

SVT is more common in patients with necrotizing pancreatitis, suggesting that local inflammation plays a major role in its causation. Thrombophilia is seen in one third of patients with AP but does not seem to increase the risk of SVT.

Risk factors and outcomes of infected pancreatic necrosis: Retrospective cohort of 148 patients admitted to the ICU for acute pancreatitis

Objective

The primary objective of this article is to identify risk factors for infected pancreatic necrosis (IPN) in patients admitted to the intensive care unit (ICU) for severe acute pancreatitis. We also described outcomes of IPN.

Background

Acute pancreatitis is common and associated with multiple, potentially life-threatening complications. Over the last decade, minimally invasive procedures have been developed to treat IPN.

Methods

We retrospectively studied consecutive patients admitted for severe acute pancreatitis to the ICUs of the Nantes University Hospital in France, between 2012 and 2015. Logistic regression was used to evaluate potential associations linking IPN to baseline patient characteristics and outcomes.

Results

Of the 148 included patients, 26 (17.6%) died. IPN developed in 62 (43%) patients and consistently required radiological, endoscopic, and/or surgical intervention. By multivariate analysis, factors associated with IPN were number of organ failure (OF) (for ≥ 3: OR, 28.67 (6.23-131.96), p < 0.001) and portosplenomesenteric venous thrombosis (OR, 8.16 (3.06-21.76)).

Conclusion

IPN occurred in nearly half our ICU patients with acute pancreatitis and consistently required interventional therapy. Number of OFs and portosplenomesenteric venous thrombosis were significantly associated with IPN. Early management of OF may reduce IPN incidence, and management of portosplenomesenteric venous thrombosis should be investigated.

Bleeding from isolated gastric varices as complication of a mucinous cystic neoplasm of the pancreas: A case report

INTRODUCTION

Bleeding from isolated gastric varices, though uncommon, may be life threatening and may occur as a consequence of splenic vein thrombosis by tumoral compression and subsequent left-sided portal hypertension.

CASE OVERVIEW

We report the case of a 37-year old woman, previously diagnosed with a benign pancreatic cyst, who presented with severe gastric variceal bleeding.

DIAGNOSIS, THERAPEUTICS INTERVENTIONS, AND OUTCOMES

Abdominal ultrasound (US) and computed-tomography (CT) revealed enlargement and changed morphology of the cystic tumor located on the body of the pancreas. Left-sided portal hypertension was disclosed resulting from splenic vein occlusion. Salvage left spleno-pancreatectomy with lymphadenectomy was undertaken with an excellent postoperative outcome. Histological analysis established the diagnosis of mucinous cystic neoplasm with foci of adenocarcinoma.

CONCLUSION

Surgical treatment proved to be the election one, leading to a steady hemostasis, removal of the lesion, positive diagnosis, and resolution of the varices. Imaging follow-up of pancreatic cyst should also assess vascular patency to identify the patient at risk for gastric bleeding and to select patients who benefits from surgical resection.

Risk Prediction for Portal Vein Thrombosis in Acute Pancreatitis Using Radial Basis Function

BACKGROUND

Acute pancreatitis (AP) can induce portosplenomesenteric vein thrombosis (PVT), which may generate higher morbidity and mortality. However current diagnostic modalities for PVT are still controversial. In recent decades, artificial neural networks have been increasingly applied in medical research. The aim of this study is to predict the risk of AP-induced PVT by radial basis function (RBF) artificial neural networks (ANNs) model.

METHODS

A retrospective or consecutive study of 426 individuals with AP at our unit between January 1, 2011 and July 31, 2016 was conducted. All individuals were subjected to RBF ANNs. Variables included age, gender, red blood cell specific volume (Hct), prothrombin time (PT), fasting blood glucose, D-Dimer, concentration of serum calcium ([Ca²⁺]), triglyceride, serum amylase (AMY), acute physiology and chronic health evaluation II score, and Ranson score. All outcomes were derived after subjecting the variables to a statistical analysis.

RESULTS

In the RBF ANNs model, D-dimer, AMY, Hct, and PT were the important factors among all 11 independent variables for PVT. The normalized importance of them was 100%, 96.3%, 71.9%, and 68.2%, respectively. The predict sensitivity, specificity, and accuracy by RBF ANNs model for PVT were 76.2%, 92.0%, and 88.1%, respectively. There were significant differences between the RBF ANNs and logistic regression models in these parameters (95% CI: 110.9% [-0.4 to 15.8%]; 8.4% [-3.3 to 19.2%]; and 12.8% [1.6-20.7%], respectively). In addition, the area under receiver operating characteristic curves value for identifying thrombosis when using the RBF ANNs model was 0.892 ± 0.091 (95% CI: 0.805-0.951), demonstrating better overall performance than the logistic regression model (0.762 ± 0.073; 95% CI: 0.662-0.839).

CONCLUSIONS

The RBF ANNs model was a valuable tool in predicting the risk of PVT following AP. AMY, D-dimer, PT, and Hct were important prediction factors of approval for AP-induced PVT.

Portal Vein Thrombosis After Splenic and Pancreatic Surgery

The portal vein is formed by the confluence of the splenic and superior mesenteric veins, which drain the spleen and small intestine respectively. Occlusion of the portal vein by thrombus typically occurs in patients with cirrhosis and/or prothrombotic disorders. However, portal vein thrombosis (PVT) can also happen after determined surgeries. Moreover, PVT can have serious consequences depending on the location and extent of the thrombosis, including hepatic ischemia, intestinal ischemia, portal hypertension… In this chapter, we will review the incidence, management and prophylaxis of PVT after splenectomy, pancreas transplantation, pancreatic surgery and in the setting of acute and chronic pancreatitis.

Complications of Chronic Pancreatitis

Chronic pancreatitis is a disease that leads to irreversible changes in the pancreatic morphology and function. The loss of function can lead to diabetes mellitus and exocrine pancreatic insufficiency. The inflammation and fibrosis can also lead to other complications including a chronic abdominal pain syndrome, metabolic bone disease, and pancretic cancer. This article reviews our current understanding of the mechanisms and management of these complications of chronic pancreatitis.

Vascular Diseases of the Spleen: A Review

Vascular diseases of the spleen are relatively uncommon in the clinical practice. However, the reported incidence has been progressively increasing, probably due to advances in the imaging modalities used to detect them. This disease condition often presents with non-specific clinical manifestations, but can be associated with significant morbidity and mortality. This review article aims to provide updated clinical information on the different vascular diseases of the splenic vasculature-splenic vein thrombosis, splenic vein aneurysm, splenic artery aneurysm, splenic arteriovenous fistula, and spontaneous splenorenal shunt-in order to aid clinicians in early diagnosis and management.

Splenic Artery Embolization for the Treatment of Gastric Variceal Bleeding Secondary to Splenic Vein Thrombosis Complicated by Necrotizing Pancreatitis: Report of a Case

Splenic vein thrombosis is a relatively common finding in pancreatitis. Gastric variceal bleeding is a life-threatening complication of splenic vein thrombosis, resulting from increased blood flow to short gastric vein. Traditionally, splenectomy is considered the treatment of choice. However, surgery in necrotizing pancreatitis is dangerous, because of severe inflammation, adhesion, and bleeding tendency. In the Warshaw operation, gastric variceal bleeding is rare, even though splenic vein is resected. Because the splenic artery is also resected, blood flow to short gastric vein is not increased problematically. Herein, we report a case of gastric variceal bleeding secondary to splenic vein thrombosis complicated by necrotizing pancreatitis successfully treated with splenic artery embolization. Splenic artery embolization could be the best treatment option for gastric variceal bleeding when splenectomy is difficult such as in case associated with severe acute pancreatitis or associated with severe adhesion or in patients with high operation risk.

Predicting the clinical manifestations in necrotizing acute pancreatitis patients with splanchnic vein thrombosis

BACKGROUND

Splanchnic venous thrombosis (SVT) is a relatively rare but important complication of necrotizing acute pancreatitis (NAP). Clinical manifestations and severity of this complication in different patients vary greatly, ranging from mild abdominal discomfort even asymptomatic to lethal gastrorrhagia or hepatic failure. The aim of the present study was to develop a model to predict the clinical manifestations of SVT in NAP patients.

METHODS

This retrospective cohort study was conducted in the surgical intensive care unit (SICU) of Jinling Hospital. Patients with the presence of both pancreatic necrosis and SVT were selected for possible inclusion. Both univariate and multivariate logistic regression analyses were applied using 12 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP(C - reactive protein) levels, etc to assess potential predictors for symptomatic pancreatic splanchnic venous thrombosis (PSVT) in this cohort. A prognostic nomogram was also applied to develop an easy-to-use prediction model.

RESULTS

A total of 104 patients with necrotizing acute pancreatitis (NAP) and splanchnic vein thrombosis (SVT) from January 2012 to December 2013 were enrolled for analysis. A quarter of study subjects (26 of 104, 25%) developed variable symptomatic manifestations including variceal bleeding, persistent ascites and enteral nutrition (EN) intolerance during the disease course. In the multivariable regression model, the following factors were found to be associated with the occurrence of symptomatic SVT: Balthazar's computed tomography (CT) score (OR = 1.818; 95% CI: 1.251-2.641; P = 0.002), intra-abdominal pressure (IAP) (OR = 1.172; 95% CI: 1.001-1.251; P = 0.043 and presence of SMVT (OR = 6.946; 95% CI: 2.290-21.074; P = 0.001). A prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.842.

CONCLUSIONS

Balthazar's CT score, IAP and SMVT are predictors of symptomatic SVT in NAP patients. The nomogram we conducted can be used as an easy-to-use risk stratification tool in either clinical practice or future studies.

Puzzles in practice: splenic vein thrombosis

This report details a 58-year-old gentleman who presented to his outpatient primary care physician's clinic several times over four weeks for ongoing epigastric pain radiating into his left flank, dry heaving, and constipation. He was presumed to have gastritis at each visit and prescribed escalating doses of proton pump inhibitors. Due to the unrelenting pain, he eventually was admitted to the hospital and diagnosed with splenic vein thrombosis after computed tomography imaging of the abdomen. Our literature search revealed that pancreatic pathology is overwhelmingly the contributing factor to splenic vein thrombosis. Our patient had prominent collateral vasculature, suggesting that his splenic vein thrombosis was chronic in nature and likely the cause of his ongoing abdominal pain. Splenic vein thrombosis is an uncommon cause of abdominal pain, but one that should be included in the treating physician's differential diagnoses when abdominal pain is ongoing despite medical therapy. Although he had no evidence of initial findings on radiography, our patient was eventually diagnosed with biopsy-proven pancreatic cancer. Our case report demonstrates how patients presenting with persistent or worsening abdominal pain despite the use of proton pump inhibitors or other acid reducing agents and potential 'red flag' findings such as decreased appetite and weight loss should be worked up for other potential sources of abdominal pathology.

Chronic Pancreatitis: A Review

This is to incorporate the recent trends in chronic pancreatitis. Extensive literature search was done from Pubmed and Ovid SP. Full text articles and abstracts related to chronic pancreatitis were reviewed and the article was prepared. Chronic pancreatitis is evolving fast on its etiology and treatment areas. The main etiological factors are pointing towards genetic, alcohol, and smoking. Autoimmune has also been added as a cause. Endoscopic ultra sound (EUS) becoming the standard diagnostic procedure. Surgery is becoming the treatment of choice for pain and mechanical complications and not the endotherapy in the long-term follow-up. The numbers of surgeries are getting narrowed down. The two etiological groups of chronic pancreatitis namely alcohol + smoking and genetic getting clearer, where the later group present at an early age. Endoscopic ultrasound and imaging with secretin is diagnostic of chronic pancreatitis before the structural changes. Endotherapy is found to be inferior to surgery in long-term pain relief. Diagnostic criteria for autoimmune pancreatitis are established. Pancreaticogenic diabetes (Type3c) and its problem associated with fat malabsorption are being understood.

Necrotizing pancreatitis: A review of the interventions

Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment.

Necrotizing pancreatitis: diagnosis, imaging, and intervention

Acute necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis in and around the pancreas and is associated with high rates of morbidity and mortality. Although acute interstitial edematous pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory test findings, the diagnosis and severity assessment of acute necrotizing pancreatitis are based in large part on imaging findings. On the basis of the revised Atlanta classification system of 2012, necrotizing pancreatitis is subdivided anatomically into parenchymal, peripancreatic, and combined subtypes, and temporally into clinical early (within 1 week of onset) and late (>1 week after onset) phases. Associated collections are categorized as "acute necrotic" or "walled off" and can be sterile or infected. Imaging, primarily computed tomography and magnetic resonance imaging, plays an essential role in the diagnosis of necrotizing pancreatitis and the identification of complications, including infection, bowel and biliary obstruction, hemorrhage, pseudoaneurysm formation, and venous thrombosis. Imaging is also used to help triage patients and guide both temporizing and definitive management. A "step-up" method for the management of necrotizing pancreatitis that makes use of imaging-guided percutaneous catheter drainage of fluid collections prior to endoscopic or surgical necrosectomy has been shown to improve clinical outcomes. The authors present an algorithmic approach to the care of patients with necrotizing pancreatitis and review the use of imaging and interventional techniques in the diagnosis and management of this pathologic condition.

Surgical Management of Chronic Pancreatitis

Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.

Repeated pancreatitis-induced splenic vein thrombosis leads to intractable gastric variceal bleeding: A case report and review

Gastric varices (GV) are one of the most common complications for patients with portal hypertension. Currently, histoacryl injection is recommended as the initial treatment for bleeding of GV, and this injection has been confirmed to be highly effective for most patients in many studies. However, this treatment might be ineffective for some types of GV, such as splenic vein thrombosis-related localized portal hypertension (also called left-sided, sinistral, or regional portal hypertension). Herein, we report a case of repeated pancreatitis-induced complete splenic vein thrombosis that led to intractable gastric variceal bleeding, which was treated by splenectomy. We present detailed radiological and pathological data and blood rheology analysis (the splenic artery - after a short gastric vein or stomach vein - gastric coronary vein - portal vein). The pathophysiology can be explained by the abnormal direction of blood flow in this patient. To our knowledge, this is the first reported case for which detailed pathology and blood rheology data are available.

Portal venous system thrombosis complicating acute pancreatitis

Acute pancreatitis (AP) is an acute inflammatory disease of the pancreas characterized by local or systemic complications. Portal venous system thrombosis (PVT) is a relatively rare complication, which is often an incidental finding on contrast-enhanced computed tomography (CECT) performed to assess symptoms or local complications. If clinicians focus on AP while ignoring PVT, it may have serious clinical consequences. Previous studies on PVT complicating pancreatitis focused principally on chronic pancreatitis (CP) patients. Only a few single-center studies have been reported in foreign countries, and there are rare studies in China. For PVT complicating AP, there is still controversy over whether to implement anticoagulation therapy or not, suggesting the lack of a standardized treatment. This paper aims to explore the characteristics and treatment of PVT complicating AP and reviews the literature with an aim to raise awareness of this complication.

Pancreatic cancer and thromboembolic disease, 150 years after Trousseau

The connection between pancreatic cancer and venous thrombosis has been discussed for almost 150 years. The exact pathophysiological mechanisms are still partly understood, but it is known that pancreatic cancer induces a prothrombotic and hypercoagulable state and genetic events involved in neoplastic transformation (e.g., KRAS, c-MET, p53), procoagulant factors [e.g., tissue factor (TF), platelet factor 4 (PF4), plasminogen activator inhibitor type 1 (PAI-1)], mucin production (e.g., through activation of P- and L-selectin) and pro-inflammatory factors [e.g., cytokines, cyclooxygenase-2 (COX-2)] may be implicated. Also pancreatitis, both acute and chronic, is associated with increased risk of venous thrombosis, but in this circumstance a direct inflammatory process may be more important. This article discusses the incidence, treatment and outcome of venous thromboembolism (VTE) complicating pancreatic disease, with special emphasis on new knowledge obtained during the last fifteen years.

Prevalence of Splanchnic Vein Thrombosis in Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies

Splanchnic vein thrombosis (SVT) may be negatively associated with the prognosis of pancreatitis. We performed a systematic review and meta-analysis of literatures to explore the prevalence of SVT in pancreatitis. All observational studies regarding the prevalence of SVT in pancreatitis were identified via PubMed and EMBASE databases. The prevalence of SVT was pooled in the total of patients with pancreatitis. And it was also pooled in the subgroup analyses according to the stage and causes of pancreatitis, location of SVT, and regions where the studies were performed. After the review of 714 studies, 44 studies fulfilled the inclusion criteria. Meta-analyses showed a pooled prevalence of SVT of 13.6% in pancreatitis. According to the stage of pancreatitis, the pooled prevalence of SVT was 16.6% and 11.6% in patients with acute and chronic pancreatitis, respectively. According to the causes of pancreatitis, the pooled prevalence of SVT was 12.2% and 14.6% in patients with hereditary and autoimmune pancreatitis. According to the location of SVT, the pooled prevalence of portal vein, splenic vein, and mesenteric vein thrombosis was 6.2%, 11.2%, and 2.7% in pancreatitis. The prevalence of SVT in pancreatitis was 16.9%, 11.5%, and 8.5% in Europe, America, and Asia, respectively.

Isolated Splenic Vein Thrombosis: 8-Year-Old Boy with Massive Upper Gastrointestinal Bleeding and Hypersplenism

We present an 8-year-old boy who was referred to our center with the complaint of upper gastrointestinal bleeding and was diagnosed with hypersplenism and progressive esophageal varices. Performing a computerized tomography (CT) scan, we discovered a suspicious finding in the venography phase in favor of thrombosis in the splenic vein. Once complementary examinations were done and due to recurrent bleeding and band ligation failure, the patient underwent splenectomy. And during the one-year follow-up obvious improvement of the esophageal varices was observed in endoscopy.

Splenic Arterial Embolization in the Treatment of Severe Portal Hypertension Due to Pancreatic Diseases: The Primary Experience in 14 Patients

Objective

This retrospective study reports our experience using splenic arterial particle embolization and coil embolization for the treatment of sinistral portal hypertension (SPH) in patients with and without gastric bleeding.

Methods

From August 2009 to May 2012, 14 patients with SPH due to pancreatic disease were diagnosed and treated with splenic arterial embolization. Two different embolization strategies were applied; either combined distal splenic bed particle embolization and proximal splenic artery coil embolization in the same procedure for acute hemorrhage (1-step) or interval staged distal embolization and proximal embolization in the stable patient (2-step). The patients were clinically followed.

Results

In 14 patients, splenic arterial embolization was successful. The one-step method was performed in three patients suffering from massive gastric bleeding, and the bleeding was relieved after embolization. The two-step method was used in 11 patients, who had chronic gastric variceal bleeding or gastric varices only. The gastric varices disappeared in the enhanced CT scan and the patients had no gastric bleeding during follow-up.

Conclusions

Splenic arterial embolization, particularly the two-step method, proved feasible and effective for the treatment of SPH patients with gastric varices or gastric variceal bleeding.

Acute pancreatitis

Acute pancreatitis, an inflammatory disorder of the pancreas, is the leading cause of admission to hospital for gastrointestinal disorders in the USA and many other countries. Gallstones and alcohol misuse are long-established risk factors, but several new causes have emerged that, together with new aspects of pathophysiology, improve understanding of the disorder. As incidence (and admission rates) of acute pancreatitis increase, so does the demand for effective management. We review how to manage patients with acute pancreatitis, paying attention to diagnosis, differential diagnosis, complications, prognostic factors, treatment, and prevention of second attacks, and the possible transition from acute to chronic pancreatitis.

Consensus guidelines on severe acute pancreatitis

This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.

Spleen-preserving proximal splenic-left intrahepatic portal shunt for the treatment of extrahepatic portal hypertension in children

PURPOSE

The Rex shunt has been employed successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of the internal jugular vein. The authors describe a novel adaptation of spleen-preserving spleno-Rex bypass, successfully carried out in children with extrahepatic portal hypertension.

METHODS

The mean age of the four patients (1 boy, 3 girls) was 46 months at the time of operation. All children had a history of upper gastrointestinal bleeding, and suffered from splenomegaly and hypersplenism. Spleen-preserving proximal splenic-left intrahepatic portal shunt was performed in all patients. The splenic artery and vein were ligated at the splenic hilum, and the splenic vein was completely separated from the bed of the pancreas to its junction with the inferior mesenteric vein. The freed splenic vein was anastomosed to left portal vein. The short gastric and left gastroepiploic vessels were kept intact to supply and drain the spleen. All patients were followed-up for 7-33 months (median: 21.5 months).

RESULTS

The spleen-preserving spleno-Rex bypass was successfully performed in all 4 patients. The median operative time was 225 min (range: 215-260 min). One patient received blood transfusion, and the postoperative length of hospital stay varied from 4 to 6 days (median: 4.5 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized and the biochemistry tests were within normal range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the proximal splenic-portal shunt in each patient. The size of the spleen decreased and there was no recurrence of variceal bleeding.

CONCLUSIONS

The spleen-preserving spleno-Rex bypass is a viable option to treat EHPVO in children.

Risk factors and outcome of splanchnic venous thrombosis in patients with necrotizing acute pancreatitis

BACKGROUND

Splanchnic venous thrombosis (SVT) is considered a rare but important complication in patients with acute pancreatitis (AP) and literatures regarding this topic were sparse. The aim of the present study was to investigate the risk factors of SVT in necrotizing acute pancreatitis (NAP) and assess the prognosis of these patients.

METHODS

Both univariate and multivariate logistic regression analyses were applied using 15 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP (C - reactive protein) levels, etc to explore potential risk factors for the development of SVT in NAP patients. Moreover, clinical outcome measures such as mortality, organ failure and length of hospital and ICU stay were also compared between NAP patients with or without SVT.

RESULTS

According to the statistical results, only intra-abdominal pressure (IAP) was proved to be an independent risk factor for SVT (OR, 1.283; 95% CI, 1.091-1.509,P=0.003). In addition, Balthazar's CT score and occurrence of IPN (infected pancreatic necrosis) also reached statistical significance (P=0.040 and 0.047, respectively), but the 95% confidence interval shown in the multivariate logistic regression suggested that the observed ORs are not significant (1.326;95% CI 0.984-1.787 and 2.61;95 CI 0.972-7.352, respectively), which indicates weaker association between the two parameters and SVT. Regarding the clinical outcomes, patients with SVT showed higher mortality, longer hospital and intensive care unit duration, higher rates of a variety of complications and more utilization of invasive interventions.

CONCLUSIONS

IAP is an independent risk factor for the development of SVT in patients with NAP, while Balthazar's CT score and occurrence of IPN are also associated with SVT, although not as strong as IAP. Moreover, occurrence of SVT relates with extremely poor prognosis in NAP patients, evidenced by increased mortality, morbidity and need for invasive interventions.

Left-sided portal hypertension: Successful management by laparoscopic splenectomy following splenic artery embolization

INTRODUCTION

Left-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.

PRESENTATION OF CASE

A 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.

DISCUSSION

The advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.

CONCLUSION

Splenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.

Management of bleeding gastric varices in patients with sinistral portal hypertension

BACKGROUND AND AIM

Sinistral portal hypertension (SPH) is a rare cause of upper gastrointestinal hemorrhage. Besides splenectomy, there is no consensus on the role of sclerotherapy and splenic embolization for bleeding gastric varices (GVs). This retrospective study summarizes our experience in managing GV bleeding from SPH in patients with pancreatic diseases.

METHODS

Patients with pancreatic diseases who had bleeding GVs from SPH in two tertiary hospitals were reviewed from January 2001 to December 2011. The etiology, clinical manifestations, diagnostic and therapeutic modalities were analyzed.

RESULTS

Twenty-one patients (15.2 %) complicating bleeding GVs among 139 patients with SPH secondary to pancreatic diseases were enrolled. The etiologies were acute pancreatitis in one patient, chronic pancreatitis in seven patients, and pancreatic tumors in 13 patients. Emergent endoscopic sclerotherapy was initially performed in five patients, and succeeded in two patients, while one patient died of massive hemorrhage. Initial transcatheter artery embolization using Gianturco coils was successfully performed in six patients. Splenectomy combined with other surgical procedures was undertaken for 15 patients. The patients undergoing artery embolization or splencetomy achieved hemostasis. The survivors had no recurrent bleeding during a median 72-month follow-up period.

CONCLUSIONS

The incidence of bleeding GVs from SPH is relatively rare. Splenic artery embolization could be selected as a first-line choice for bleeding SPH, especially for patients in poor conditions, and sclerotherapy may not be preferentially recommended. Further studies are required to evaluate the optimum treatment algorithm for bleeding GVs from SPH.

Endoscopic Color Doppler Ultrasonographic Evaluation of Gastric Varices Secondary to Left-Sided Portal Hypertension

Gastric varices that arise secondary to the splenic vein occlusion can result in gastrointestinal hemorrhaging. Endoscopic color Doppler ultrasonography (ECDUS) was performed in 16 patients with gastric varices secondary to splenic vein occlusion. This study retrospectively evaluated the role of ECDUS in the diagnosis of gastric varices secondary to splenic vein occlusion. Thirteen patients had co-existing pancreatic diseases: 8 with chronic pancreatitis, 4 with cancer of the pancreatic body or tail and 1 with severe acute pancreatitis. Of the remaining 3 patients, 1 had myeloproliferative disease, 1 had advanced gastric cancer, and the third had splenic vein occlusion due to an obscure cause. The endoscopic findings of gastric varices were: variceal form (F) classified as enlarged tortuous (F2) in 12 cases and large, coil-shaped (F3) in 4 cases, and positive for erosion or red color sign of the variceal surface in 4 cases and negative in 12 cases. ECDUS color flow images of gastric variceal flow clearly depicted a round fundal region at the center, with varices expanding to the curvatura ventriculi major of the gastric body in all 16 cases. The velocities of F3 type gastric varices were significantly higher than those of the F2 type. The wall thickness of varices positive for erosion or red color sign was significantly less than the negative cases. I conclude that ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion at the round fundal region at the center, with varices expanding to the curvatura ventriculi major of the gastric body.

Gastric and ectopic varices

Although often considered together, gastric and ectopic varices represent complications of a heterogeneous group of underlying diseases. Commonly, these are known to arise in patients with cirrhosis secondary to portal hypertension; however, they also arise in patients with noncirrhotic portal hypertension, most often secondary to venous thrombosis of the portal venous system. One of the key initial assessments is to define the underlying condition leading to the formation of these portal-collateral pathways to guide management. In the authors' experience, these patients can be grouped into distinct although sometimes overlapping conditions, which can provide a helpful conceptual basis of management.

Portosplenomesenteric venous thrombosis in patients with acute pancreatitis is associated with pancreatic necrosis and usually has a benign course

BACKGROUND & AIMS

Although there are some data on prevalence of portosplenomesenteric venous thrombosis (PSMVT) in patients with acute pancreatitis (AP), the progression of PSMVT in patients who have and have not received anticoagulants has not been studied systematically. We evaluated the prevalence and natural history of PSMVT in a well-defined cohort of individuals with AP.

METHODS

In a retrospective study, we analyzed data from the University of Pittsburgh Medical Center on 162 patients with a sentinel attack of AP from 2003-2010. Data were collected on patient demographics, clinical presentation, etiology, clinical course, and outcomes. One hundred twenty-two patients underwent contrast-enhanced computed tomography; the scans were reviewed to identify thromboses and/or narrowing of splanchnic veins (splenic, superior mesenteric, and portal).

RESULTS

PSMVT was detected in 22 patients overall (14%; 18% among patients who underwent contrast-enhanced computed tomography). Median time to detection of PSMVT was 17 days (interquartile range, 11-40 days). PSMVT formed most frequently in the splenic vein (19 of 22, 86%), followed by portal (8 of 22, 36%) and superior mesenteric (6/22, 27%) veins. Development of PSMVT was associated with presence (21 of 22, 95%), location, and extent of pancreatic necrosis. Fifty-three percent of patients (21 of 40) with necrosis developed PSMVT. Anticoagulants were administered infrequently (6 of 22, 27%) and always for indications unrelated to PSMVT. Most patients with PSMVT developed collateral veins (19 of 22, 86%), and 27% (6 of 22) were found to have varices during endoscopic evaluation, but clot resolution was infrequent (2 of 22, 9%). No patient developed complications directly related to PSMVT.

CONCLUSIONS

PSMVT develops in about half of patients with necrotizing AP and is rare in the absence of necrosis. Despite infrequent administration of anticoagulants, complications directly related to PSMVT are rare.

Portal venous thrombosis after distal pancreatectomy: clinical outcomes

AIM

Outcomes of patients developing portal vein (PV) thrombosis (PVT) after distal pancreatectomy (DP) are unknown. The goal of this study was to identify risk factors for PVT and describe the long-term outcomes in these patients.

METHODS

Patients undergoing DP without repair or reconstruction of the PV between 2001 and 2011 were included. Patients that showed evidence of PVT on pre-operative imaging were excluded from the study. Location and extent of thrombosis was determined by post-operative computed tomography or ultrasound imaging in all patients. Evidence of systemic thrombosis (if present) in addition to PVT was also documented.

RESULTS

In the study period, 991 patients underwent DP and 21 (2.1%) patients were diagnosed with PVT. Pancreatic neoplasm was the most frequent indication for operation (n = 11). Thrombus occurred in the main PV in 15 and the right branch of the PV in 8 patients. Complete PV occlusion occurred in nine patients with a median time to diagnosis of 16 days (range 5-85 days). Seventeen patients were anticoagulated for a median duration of 6 months (range 3.3-36 months) after the diagnosis of PVT. Over a median follow-up of 22 months, resolution of PVT occurred in seven patients. Predictors of non-resolution of PVT included anesthesia time >180 min (p = 0.025), DM type II (p = 0.03), BMI >30 Kg/m(2) (p = 0.03), occlusive PVT (p < 0.001), or thrombus in a sectoral branch (p = 0.02). Anticoagulation therapy did not influence the frequency of thrombus resolution and was complicated by gastrointestinal hemorrhage in four patients. There was no mortality as a direct result of PVT or anticoagulation.

CONCLUSION

PVT after distal pancreatectomy is a rare complication. Serious complications as a direct result of PVT in this setting are uncommon and are not dependent on thrombus resolution. Although anticoagulation does not appear to influence the rate of PVT resolution in this small retrospective series, we support the use of anticoagulation until larger, controlled studies define clear advantages or disadvantages.

Gastric variceal bleeding due to pancreatitis-induced splenic vein thrombosis

Obscure gastrointestinal bleeding is a common clinical scenario. In the upper gastrointestinal tract, gastric varices can be frequently overlooked on endoscopy, particularly if not suspected or volume depleted. We report a case of suspected gastrointestinal bleeding in a patient with a childhood history of pancreatitis, who also experienced severe epigastric pain while in hospital. After transfer to an academic medical centre, the presence of gastric varices was identified and presumed to be due to splenic vein thrombosis. Pancreatitis is the most common cause of splenic vein thrombosis and accords with the patient's history, even though it occurred many years previously. This case highlights the importance of recognising pancreatitis-induced splenic vein thrombosis as a possible aetiology for upper gastrointestinal bleeding.

Acute pancreatitis associated left-sided portal hypertension with severe gastrointestinal bleeding treated by transcatheter splenic artery embolization: a case report and literature review

Left-sided portal hypertension (LSPH) followed by acute pancreatitis is a rare condition with most patients being asymptomatic. In cases where gastrointestinal (GI) bleeding is present, however, the condition is more complicated and the mortality is very high because of the difficulty in diagnosing and selecting optimal treatment. A successfully treated case with severe GI bleeding by transcatheter splenic artery embolization is reported in this article. The patient exhibited severe uncontrollable GI bleeding and was confirmed as gastric varices secondary to LSPH by enhanced computed tomography (CT) scan and CT-angiography. After embolization, the bleeding stopped and stabilized for the entire follow-up period without any severe complications. In conclusion, embolization of the splenic artery is a simple, safe, and effective method of controlling gastric variceal bleeding caused by LSPH in acute pancreatitis.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis (CP). For CP-related, uncomplicated, pancreatic pseudocysts (PPC), endoscopy is the first-choice therapeutic option. Recent advances have focused on endosonography-guided PPC transmural drainage, which tends to replace the conventional, duodenoscope-based coma immediately approach. Ancillary material is being tested to facilitate the endosonography-guided procedure. In this review, the most adequate techniques depending on PPC characteristics are presented along with supporting evidence. For CP-related biliary obstructions, endoscopy and surgery are valid therapeutic options. Patient co-morbidities (e.g., portal cavernoma) and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option. Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures. In endoscopy, the gold standard technique consists of placing simultaneous, multiple, side-by-side, plastic stents for a one-year period. Fully covered self-expandable metal stents are challenging this method and have provided 50% mid-term success.

Splanchnic vein thrombosis in acute pancreatitis: a single-center experience

OBJECTIVES

This study aimed to estimate outcomes of splanchnic vein thrombosis (SVT) in hospitalized patients with acute pancreatitis (AP).

METHODS

This was a retrospective study (January 1996 to December 2006) via chart review.

RESULTS

Over 10 years, 1.8% (45/2454) of patients with AP with a mean (SD) age of 58 (15) years were diagnosed with SVT. Splenic vein thrombosis was the most common form of SVT (30/45 patients, 67%). Seventeen patients were anticoagulated with heparin, when the SVT was diagnosed in the acute stage followed by oral anticoagulation (AC). The thrombosis that was most commonly anticoagulated was portal vein thrombosis in 11 (65%) of 17 patients. Of 17 patients in the AC group, 2 (12%) showed recanalization as compared with 3 (11%) of 28 patients in the non-AC group (P > 0.05). The mortality was 3 (7%) of 45 (2 from the AC group versus 1 in the non-AC group, P > 0.05). Two of these died of multiorgan failure, and the other, from septic shock. None of the deaths were due to bleeding complications.

CONCLUSIONS

Splanchnic vein thrombosis occurred in 1.8% patients of AP. The use of AC was reasonably safe with no fatal bleeding complications. However, there was no significant difference in the recanalization rates in those with and without AC.

Splenic artery embolization for the treatment of bleeding gastric varices secondary to splenic vein thrombosis

Splenic vein thrombosis can lead to gastric varices. Subsequent upper gastrointestinal bleeding may ensue related to the change in venous outflow to the portal system. Vascular surgeons are infrequently asked to assist in the management of this entity. However, with many vascular surgeons providing diverse endovascular-based interventions, understanding catheter-based solutions is imperative. This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.

Splanchnic venous thrombosis and pancreatitis

Pancreatitis is an inflammatory process with local and systemic manifestations. One such local manifestation is thrombosis in splanchnic venous circulation, predominantly of the splenic vein. The literature on this important complication is very sparse. This review offers an overview of mechanism of thrombosis, its pathophysiology, diagnosis, and management in the setting of acute as well as chronic pancreatitis.

Clinical management of patients with acute pancreatitis

Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.

Chronic Pancreatitis Associated with Chylous Ascites Simulating Liver Cirrhosis

Purpose. Ascites, esophageal varicose veins, and acute digestive bleeding are unusual in the clinical presentation of chronic pancreatitis; however, these symptoms are frequently observed in patients with liver cirrhosis. Moreover, it is unlikely to observe chylous ascites in both presentations. Method. We report a patient who presented with chronic pancreatitis with splenic vein thrombosis, necrosis of the pancreatic neck and tail, esophageal varicose veins with previous bleeding, and chylous ascites. After partial pancreatectomy, his treatment was based on low-fat oral diet with medium-chain triglycerides with remarkable resolution of the chylous ascites. After 3 years, he presented with decompensated chronic pancreatitis and underwent plexus alcoholization and biliary-enteric deviation with an unremarkable postoperative course. Conclusion. Ascites is rarely associated with chronic pancreatitis, and chylous ascites is even rarer. The treatment of atraumatic chylous ascites is based on resolution of the obstructive causes and should include drainage and a low-fat diet with medium-chain triglycerides.