Deficiency of protein C in patients with portal vein thrombosis

Portal Vein Thrombosis (PVT) Secondary to Protein C Deficiency in a Young Male

A disorder known as portal venous thrombosis (PVT) is characterized by a partial or total obstruction of the portal vein. Although PVT is somewhat uncommon, liver illness is frequently linked to it. Cirrhosis, carcinoma of the liver, myeloproliferative neoplasms, other malignancies, the use of oral contraceptives, intestinal infections, and genetic hypercoagulable illnesses are typical risk factors. In this case report, we discuss the case of a young male patient who had PVT as a result of a protein C deficit. The patient first had abdominal distention due to ascites, and the diagnosis of portal vein thrombosis was later confirmed by a triphasic computed tomography (CT) scan and Doppler ultrasonography. Anticoagulant medications were successfully administered to treat the patient. The importance of identifying PVT in patients with hypercoagulable diseases and the efficacy of anticoagulant therapy in such circumstances are both highlighted by this case.

Hereditary protein C deficiency with portal vein thrombosis in a Chinese male: A case report

Hereditary protein C deficiency (PCD) is caused by mutation in the PC gene (PROC). The homozygous mutation form of PCD is rare. Furthermore, in Asia, cases of noncirrhotic patients with portal vein thrombosis (PVT) secondary to PCD have been rarely reported. The present study reported the case of a patient with PVT due to hereditary PCD. Of note, the mutation of PROCc.152G>A was observed in the patient of the present study. According to the current literature, there has been no previous report regarding the mutation of this gene in China. The patient suffered abdominal pain for 20 days, which was accompanied by vomiting for 2 days. Multiple ulcers and diverticula in the sigmoid colon, as well as erosive small ulcers throughout the colon, were discovered during a colonoscopy. Abdominal angiography indicated thrombosis of the portal vein and its branches. Furthermore, laboratory parameters indicated a hypercoagulable state with normal PC antigen values but decreased PC activity. The discovery of blood coagulation-related genes suggested that homozygous mutation in PC resulted in an amino acid missense mutation. Anticoagulants were prescribed after a diagnosis of type II hereditary PCD with PVT was made. After 15 days, the blood coagulation function of the patient was restored to normal and the symptoms were substantially alleviated. Hence, the present study expanded the mutation spectrum of PROC in China and reaffirmed the value of anticoagulant therapy in PCD.

A case of portal vein thrombosis caused by blunt abdominal trauma in a patient with low protein C activity

Portal vein thrombosis (PVT) is caused by several conditions including infection, malignancies, surgery, medications, and coagulation disorders. However, PVT caused by low-energy injury is very rare. A 51-year-old man visited a clinic with a 2-day history of abdominal pain following blunt abdominal trauma. Contrast-enhanced computed tomography (CT) revealed thrombosis in both the portal vein and splenic vein, and he was transferred to our hospital with a diagnosis of PVT. Anticoagulant therapy was initiated using unfractionated heparin. A repeat CT scan revealed enlargement of the thrombus, which occluded the main trunk and first right branch of the portal vein. Laboratory data before heparin administration suggested low protein C activity. Anticoagulation therapy was continued with intermittent assessment of the size of the thrombus and degree of coagulation. On day 23, enhanced CT showed marked shrinkage of the thrombus compared with that on day 8. On day 30, the patient was discharged with a therapeutic prothrombin time-international normalized ratio. Here we present a case of PVT caused by low-energy trauma of the upper abdomen in a patient with a background of low protein C activity that was successfully treated without invasive surgery.

Portal vein thrombosis with protein C-S deficiency in a non-cirrhotic patient

There are several conditions that can lead to portal vein thrombosis (PVT), including including infection, malignancies, and coagulation disorders. Anew condition of interest is protein C and S deficiencies, associated with hypercoagulation and recurrent venous thromboembolism. We report the case of a non-cirrhotic 63-year-old male diagnosed with acute superior mesenteric vein thrombosis and PVT and combined deficiencies in proteins C and S, recanalized by short-term low molecular heparin plus oral warfarin therapy.

Thromboelastographic evaluation of coagulation in patients with extrahepatic portal vein thrombosis and non-cirrhotic portal fibrosis: a pilot study

BACKGROUND AND AIMS

Non-cirrhotic portal hypertension due to extrahepatic portal vein thrombosis (EHO) and non-cirrhotic portal fibrosis (NCPF) is a major cause of upper gastrointestinal hemorrhage in India. Hypercoagulability has been proposed to explain the thrombosis in the portal vein in EHO and intrahepatic portal vein radicals in NCPF. However, some authors have reported hypocoagulability in these patients. Thromboelastography (TEG), which gives a dynamic assessment of coagulation, has potential for evaluating coagulation in these patients but has not been used so far. It was the aim of this study to evaluate the coagulation status in patients of EHO and NCPF using TEG.

METHODS

Thirty patients with EHO and 19 patients with NCPF were studied. TEG was done in all patients. R (reaction time), K (constant), alpha (angle), MA (maximal amplitude), A 60 (width of tracing after 60 min) were recorded and TEG index calculated and compared to controls.

RESULTS

Seven patients (23.3%) in the EHO group and eight (42.1%) in the NCPF group had severe thrombocytopenia (platlets, < 50 000 cells/dL). TEG showed significantly shorter R, higher MA and larger A in both EHO and NCPF compared to controls (P < 0.01). Thrombocytopenia normalized A but R continued to be significantly shorter in EHO and NCPF. Overt hypercoagulability (TEG index, > +2.5) was seen in two patients with EHO and one patient with NCPF.

CONCLUSION

A latent hypercoagulable state exists in patients with EHO and NCPF which is partially masked by the thrombocytopenia secondary to splenomegaly and hypersplenism.

Mesenteric venous thrombosis due to protein C deficiency

Protein C deficiency is a known underlying risk factor for thromboembolic disease. Most commonly it presents as thrombophlebitis, deep venous thrombosis or pulmonary embolism. Less common presentations are becoming increasingly recognized now that assays for protein C are more widely available. We present two cases of mesenteric venous thrombosis who were found to have protein C deficiency.

Study of portal vein thrombosis in patients with idiopathic portal hypertension in Japan

BACKGROUND/AIMS

The aim of this study was to elucidate the incidence and clinical manifestations of portal vein thrombosis (PVT) in patients with idiopathic portal hypertension (IPH) in Japan during long-term follow-up.

PATIENTS AND METHODS

Twenty-two patients with IPH were examined for PVT by sonography during a follow-up of 12+/-6 years. Clinical manifestations and patient outcome related to PVT were studied. Seventy patients with liver cirrhosis were examined by sonography as an incidence control of thrombosis.

RESULTS

Nine IPH patients had portal thrombosis (9/22, 41%), a higher incidence than in liver cirrhosis patients (7/70, 10%). Those with thrombosis showed ascites, marked hypersplenism, and low serum albumin. Four patients with thrombosis died. Patients without thrombosis showed less clinical problems after long-term follow-up. Plasma antithrombin III and protein C activity decreased in almost half of the patients. However, there were no differences in these parameters between patients with and without thrombosis.

CONCLUSIONS

In Japan, IPH patients had a high incidence of portal thrombosis, a significant factor for poor prognosis. Whether the management of PVT contributes to an improvement of a clinical course of IPH or not should be clarified in further study.

Surgical restoration of portal flow corrects procoagulant and anticoagulant deficiencies associated with extrahepatic portal vein thrombosis

Extrahepatic portal vein thrombosis (EHPVT) is associated with abnormal circulating procoagulants and anticoagulants. Eleven children with EHPVT and abnormal coagulation factors underwent a mesenterico-left portal vein bypass to restore portal flow. Coagulation factors had returned to normal by one year. The data suggest that portal venous flow is essential for maintaining normal coagulation.

Drug therapies for mesenteric vascular disease

Mesenteric vascular disease has been increasingly diagnosed in the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population and increasing number of critically ill patients, and to a greater clinical recognition of the condition. While surgical revascularization and resection has long been the standard of treatment, medical management also plays an important role. Early diagnosis before irreversible bowel damage, which may occur within 6 to 8 hours after insult, is the goal of successful medical treatment without surgical intervention. Even in the presence or irreversible bowel ischemia, perioperative medical treatment may reduce the progression of further ischemia, and bowel resection may be limited. This article outlines the appropriate medical management of ischemic disorders of the intestine, with an emphasis on the drug treatments presently used in clinical practice and those being studied in the laboratory.

Portal vein thrombosis after hematopoietic cell transplantation: frequency, treatment and outcome

Patients who develop veno-occlusive disease (VOD) of the liver may have low plasma levels of the natural anticoagulants protein C and antithrombin III, but large vessel thromboses are not commonly reported in these patients. We reviewed the records of 1847 consecutive patients for evidence of portal vein thrombosis. Eight patients (0.4%) developed portal vein thrombosis (PVT) at a median of day +28 (range 3-58). All patients had clinical evidence of VOD with ascites, a median total serum bilirubin 11.9 mg/dl, and median weight gain from baseline of 7.9%. Median plasma levels of antithrombin III and protein C were low (36% and 21%, respectively). Four patients with PVT died of severe VOD and multi-organ failure, but PVT did not contribute to death. We conclude that PVT is a rare complication of hematopoietic cell transplant and is associated with hepatic VOD. We speculate that PVT resulted from diminished portal venous flow (related to hepatic sinusoidal obstruction to blood flow) and a hypercoagulable state (related to low circulating antithrombin III and protein C levels). Prognosis depended on the severity of the underlying VOD and not PVT per se, suggesting that treatments directed solely toward dissolution of portal vein thrombi should be used with caution in this setting.

Pathology and pathogenesis of idiopathic portal hypertension with an emphasis on the liver

Idiopathic portal hypertension (IPH) is characterized by a long-standing presinusoidal portal hypertension of unknown etiology in adults. Some unidentified agent(s) affect(s) the intrahepatic small portal veins or portal tracts. Immunological disturbance, thromboembolism, infectious etiology and/or increased fibrogenesis in portal tracts are suspected as being candidates for the primary agent(s). During the long clinical course of IPH, several pathological changes may occur, including subcapsular parenchymal atrophy, atrophy of the liver, portal and parenchymal fibrosis, and portal venous phlebosclerosis and thrombosis. The last-named of these lesions is mostly found in patients with a history of splenectomy. Subcapsular parenchymal and hepatic atrophy may result from a hepatocellular dropout via apoptosis or necrosis because of intrahepatic hemodynamic disturbances, particularly chronic portal venous blood insufficiency. Pericellular fibrosis and thin fibrous septa are also frequently found and associated with activated perisinusoidal cells positive for smooth muscle actin. At the same time, vague nodular hyperplasia of hepatocytes not surrounded by fibrous septa is not infrequently seen. It may resemble nodular regenerative hyperplasia, partial nodular transformation, or focal nodular hyperplasia. However, liver cirrhosis does not occur even at the terminal stage. Taking these findings into consideration, a new staging of IPH with a combination of hepatic parenchymal atrophy and portal venous thrombosis was proposed: non-atrophic liver without subcapsular parenchymal atrophy (stage I), non-atrophic liver with subcapsular parenchymal atrophy (stage II), atrophic liver with subcapsular parenchymal atrophy (stage III), and portal venous occlusive thrombosis (stage IV). IPH livers are likely to progress from stage I to stage III. Stage IV, which occurs relatively late, has a poor prognosis. This staging is applicable to clinical and autopsy cases without any histological data.

Mesenteric venous thrombosis: a diagnosis not to be missed!

Mesenteric venous thrombosis (MVT), an uncommon but important clinical entity, is one possible cause of ischemia or infarction of the small intestine. Diagnosis of this condition is sometimes difficult and treatment is often delayed because patients usually present with nonspecific abdominal symptoms. The hallmark is pain that is out of proportion to the physical findings. We report two cases of MVT, where the patients initially presented with vague abdominal symptoms. Diagnosis was made on the basis of computed tomography of the abdomen showing thrombus within the superior mesenteric vein. A search for a precipitating condition revealed no evidence of a hypercoagulable state, myeloproliferative disorder, or malignancy. These cases illustrate well the nonspecific clinical presentation of MVT. A high index of suspicion, recognition of known risk factors, or a previous history of venous thrombosis coupled with a history of nonspecific abdominal symptoms should alert clinicians to the possibility of MVT. Early diagnosis and prompt anticoagulation are the mainstay of therapy unless there are signs of peritonitis that necessitate surgical resection of the infarcted bowel.

Coagulation abnormalities in idiopathic portal venous thrombosis

BACKGROUND

Portal vein thrombosis, usually idiopathic, is the cause of portal hypertension in 46% of Indian patients, who present with a variceal bleed. The presence of lupus anticoagulant (LA) and antithrombin III deficiency have been reported to be associated with an increased tendency to venous thrombosis.

METHODS AND RESULTS

We studied 30 patients with portal venous thrombosis diagnosed by ultrasound. Two patients were positive for a lupus anticoagulant and both had very prolonged partial thromboplastin time with kaolin. None of the patients had antithrombin III deficiency.

Thrombosis of the portal vein in a miniature schnauzer

A miniature schnauzer with a history of apathy, anorexia and jaundice was presented to the Utrecht University Clinic for Companion Animals. Abnormal laboratory findings included highly increased levels of total bile acids and alkaline phosphatase, and hyponatraemia. Abdominal ultrasonography revealed that the right side of the liver was enlarged and the left side was small, together with a thrombus in the portal vein. Biopsies from the right side of the liver demonstrated subacute to chronic active hepatitis, for which the dog was treated with prednisolone (1 mg/kg/day for four weeks). No improvement was observed and the owner requested euthanasia. At necropsy the left lobes of the liver were found to be small and firm, while the right lobes were large and soft. There were two thrombi in the portal vein. Microscopic examination revealed chronic active hepatitis and cirrhosis.

Protein C, protein S and antithrombin III in children with portal vein obstruction

BACKGROUND/AIMS

Portal vein obstruction is the most common single cause of portal hypertension in children and its cause is unknown in most instances. The aim of the present study was to evaluate the incidence of protein C, protein S and antithrombin III deficiencies and to screen for possible genetic deficiencies of these proteins.

METHODS

A prospective study was undertaken in 20 consecutive children with portal vein obstruction, their parents and 20 matched healthy children.

RESULTS

Children with portal vein obstruction displayed a reduction in protein C (p<0.05), protein S (p<0.0001), and antithrombin III (p<0.001) activities as compared with controls. Protein C and protein S activities were below 60% in nine and eleven of the children with portal vein obstruction, respectively, and antithrombin III activities were below or equal to 85% in ten of them. Repeated assay of protein C activity in seven children following a surgical portosystemic shunt showed a decrease as compared with preoperative values. Protein C, protein S and antithrombin III were normal in all parents, except two mothers in whom the levels of protein S activity and protein S antigen were found to be either below or at the lower limit of the normal range.

CONCLUSIONS

These results indicate that protein C, protein S and/or antithrombin III deficiencies are frequently found in children with portal vein obstruction but are not likely to be of genetic origin in most cases.

Surgical management of extrahepatic portal hypertension and variceal bleeding

Variceal bleeding remains an important complication in extrahepatic portal vein thrombosis (EPVT). As for portal hypertension due to other etiologies, an elective treatment to decrease the risk of subsequent rebleeding is warranted. The results of the Sugiura-Futagawa procedure (SP) in 38 patients with variceal bleeding secondary to EPVT are reported: 20 women and 18 men, with a mean age of 28 +/- 2 years (SEM). Thirty-seven patients were classified as Child-Pugh class A, and one patient as class B. In terms of diagnosis, 45% of patients had idiopathic EPVT, and 18% had associated hypercoagulability disorders; 52% of patients had associated splenic vein thrombosis. The SP was completed in two surgical stages in 18 patients and in one surgical stage in 14; 6 patients had only the abdominal stage. One patient had mild postoperative encephalopathy, and three patients rebled at long-term follow-up study. There were two operative deaths. Actuarial survival was 70% at 64 months. It is concluded that the SP is an excellent alternative for patients with variceal bleeding secondary to EPVT.

A 15-year experience of injection sclerotherapy in adult patients with extrahepatic portal venous obstruction

OBJECTIVE

The authors report a 15-year experience with injection sclerotherapy in the management of adult and teenage patients with esophageal varices due to extrahepatic portal venous obstruction (EHPVO).

SUMMARY BACKGROUND DATA

Extrahepatic portal venous obstruction is an uncommon cause of esophageal varices and is associated with normal liver function. Effective control of variceal bleeding is the major factor influencing survival. The results of surgery have been unsatisfactory, and therefore, more conservative management policies have been adopted.

METHODS

Fifty-five patients with proven EHPVO underwent repeated injection sclerotherapy via either a modified rigid esophagoscope under general anaesthesia or a fiber-optic endoscope under light sedation, using ethanolamine oleate as the sclerosant.

RESULTS

Esophageal varices were eradicated in 44 patients after a median number 6 injections (range 1-17) over a mean of 12.5 months (range 1-48). The mean follow-up was 6.8 years (range 1.1-14.6 years). Eleven patients were admitted on eighteen occasions with bleeding from esophageal varices before eradication and there were seven bleeding episodes in six patients from recurrent varices after initial eradication. Complications related to sclerotherapy included injection site leak (6), stenosis (11) and mucosal ulceration (32) during 362 injection sclerotherapy episodes. Four patients died during the study period.

CONCLUSIONS

Injection scelotherapy is the treatment of choice in most patients with EHPVO.

Idiopathic acute portal vein thrombosis: a case report

There are few reported cases of acute portal vein thrombosis presenting as an acute abdomen in adolescent age group. Most published series concern chronic extrahepatic portal vein thrombosis. Acute portal vein thrombosis is rare, but can develop into serious complications. Hence, prompt diagnosis and heparinization can prevent the development of lethal complications such as venous gangrene of the bowel and portal hypertension.

Intraperitoneal haemorrhage from anterior abdominal wall varices

Patients with oesophageal varices frequently present with gastrointestinal haemorrhage but bleeding from varices at other sites is rare. We present a patient with hepatitis C-induced cirrhosis and partial portal vein occlusion who developed spontaneous haemorrhage from anterior abdominal wall varices into the rectus abdominus muscle and peritoneal cavity.

Portal vein thrombosis: imaging features and associated etiologies

Thrombosis of the portal vein and its splanchnic tributaries is often unsuspected clinically and may be recognized only after imaging studies of the abdomen are performed for other reasons. Radiologists should be aware of the clinical situations that predispose a patient to portal or mesenteric vein thrombosis and should also be able to recognize the sequelae of chronic thrombosis. Different modalities can be used to image the patient with portal vein thrombosis; each has its strengths and drawbacks. This paper discusses the conditions that predispose to portal and mesenteric vein thrombosis, differentiating intrahepatic portal vein occlusion secondary to liver disease from extrahepatic portal vein occlusion associated with a normal liver. The imaging features of portal vein thrombosis, its associated causes and sequelae will be reviewed as demonstrated on computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), angiography, and plain film.

Multiple venous thromboses and membranous obstruction of inferior vena cava in association with hereditary protein C deficiency: a case report

A forty year old male presented with multiple dilated venous channels over the whole body involving both inferior and superior vena caval territories, along with features of chronic liver disease and portal hypertension. On investigation, he was found to have membranous obstruction of the inferior vena cava (MOIVC) as well as obstruction of both brachiocephalic and right subclavian veins and 'hereditary protein C deficiency'. He was managed successfully by percutaneous transluminal balloon angioplasty for the inferior vena cava (IVC) obstruction and was doing well on follow-up.

Systemic diseases affecting the mesenteric circulation

The mesenteric circulation is acutely sensitive to processes that affect the entire body. Such systemic diseases and syndromes are reviewed with particular emphasis on the mechanisms by which they influence the mesenteric vasculature and blood flow.

Duodenal varicose veins

Duodenal varices (DV) are rare. We present a review of published cases with emphasis on the management and outcome, as illustrated by our own cases, which reflects the experience reported in the literature. The diagnosis of DV must be considered in patients with gastrointestinal bleeding. Two-thirds of all reported cases have portal venous hypertension caused by hepatic cirrhosis. In the remaining one-third prehepatic portal hypertension as a consequence of either a compromised portal venous circulation (caused by perivenous tumor or inflammation) or a primary haematological disease is the underlying cause. Previously, duodenoscopy has often failed to detect and correctly interpret DV, and was similarly unsuccessful in our case. This case report demonstrates the problems and shortcomings in the management of DV and documents a hither to unreported cause. Treatment depends on the severity of bleeding. When conservative measures cannot control the haemorrhage, emergency laparotomy may be indicated. The type of surgery should be chosen according to the aetiology, site and extent of the bleeding DV. Among 112 reported cases of DV, information on outcome exists for only 35 patients who presented with haemorrhage. The aetiology was liver cirrhosis in 26 of these patients, 10 of whom had a fatal outcome, and prehepatic portal hypertension in the remaining 9, 1 of whom had a fatal outcome.

Acute Budd-Chiari syndrome with hepatic failure and obstruction of the inferior vena cava as presenting manifestations of hereditary protein C deficiency

The protein C system is essential in limiting the activation of coagulation in vivo. We report on a 29 year old woman with Budd-Chiari syndrome and occlusion of the inferior vena cava who presented with acute liver failure. She was successfully treated with an emergency mesoatrial shunt. Eight months after surgery, she has no ascites and normal liver function. She had a low concentration of plasma protein C on admission to hospital and during the follow up. Protein C deficiency subsequently was found in her father and two sisters, who were asymptomatic. Hereditary protein C deficiency should be considered in patients with Budd-Chiari syndrome.