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Grassi G, Lenci I, Signorello A, Milana M, Baiocchi L. Gastrointestinal endoscopy in cirrhotic patient: Issues on the table. World J Gastrointest Endosc 2021; 13:210-220. [PMID: 34326942 PMCID: PMC8311468 DOI: 10.4253/wjge.v13.i7.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are fragile and present specific clinical hallmarks. When undergoing to gastrointestinal (GI) endoscopy, these subjects require an individual pre evaluation, taking into account: Level of haemostasis impairment, the individual risk of infection, the impact of sedation on hepatic encephalopathy and other factors. The overall assessment of liver function, employing common scoring systems, should be also assessed in the preprocedural phase. Beside some common general problems, regarding GI endoscopy in cirrhotic subjects, also specific issues are present for some frequent indications or procedures. For instance, despite an increased incidence of adenomas in cirrhosis, colon cancer screening remains suboptimal in subjects with this disease. Several studies in fact demonstrated liver cirrhosis as a negative factor for an adequate colon cleansing before colonoscopy. On the other hand, also the routine assessment of gastroesophageal varices during upper GI endoscopy presents some concern, since important inter-observer variability or incomplete description of endoscopic findings has been reported in some studies. In this review we discussed in details the most relevant issues that may be considered while performing general GI endoscopic practice, in patient with cirrhosis. For most of these issues there are no guidelines or clear indications. Moreover until now, few studies focused on these aspects. We believe that targeting these issues with corrective measures may be helpful to develop a tailored endoscopic approach for cirrhosis, in the future.
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Affiliation(s)
- Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
| | | | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00100, Italy
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Toyoda J, Morioka D, Horii N, Nakayama G, Oyama N, Asano F, Izumisawa Y, Miura M, Sato Y, Endo I. Treatment of acute exacerbation of liver-cirrhosis-associated portal vein thrombosis with direct-acting oral anticoagulant, edoxaban, used as an initial treatment in the early postoperative period after abdominal surgery: a case report. J Med Case Rep 2021; 15:52. [PMID: 33563326 PMCID: PMC7874483 DOI: 10.1186/s13256-020-02651-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Cirrhosis-associated portal vein thrombosis (CA-PVT) has been reportedly observed in 5–30% of cirrhotic patients. Moreover, the acute exacerbation of CA-PVT is likely to occur after certain situations, such as a status after abdominal surgery. Safety and efficacy of the direct-acting oral anticoagulant (DOAC) used for cirrhotic patients have been being confirmed. However, use of the DOAC as an initial treatment for CA-PVT appears still challenging especially in the early postoperative period after major surgery in terms of unestablished efficacy and safety in such occasion. Case presentation We herein report a case of the acute exacerbation of CA-PVT in the early postoperative period after abdominal surgery, which was successfully treated with DOAC, edoxaban used as an initial treatment. The patient was a 79-year-old Japanese male with alcoholic cirrhosis. The patient suffered choledocholithiasis and had a mural chronic CA-PVT extending from the superior mesenteric vein to the portal trunk. He underwent open cholecystectomy and choledochotomy. Early postoperative clinical course was uneventful except for abdominal distension due to ascites diagnosed on postoperative day (POD)7 when hospital discharge was planned. Contrast enhancement computed tomography (CE-CT) taken on POD 7 revealed the exacerbation of the CA-PVT. Despite recommendation for extension of hospital admission with low molecular weight heparin treatment, the patient strongly hoped to be discharged. Unwillingly, we selected DOAC, edoxaban, as an initial treatment, which was commenced the day after discharge (POD8). As a result, the remarkable improvement of the exacerbated CA-PVT was confirmed by the CE-CT taken on POD21. Any bleeding complications were not observed. Although a slight residue of the CA-PVT remains, the patient is currently doing well 4 years after surgery and is still receiving edoxaban. Any adverse effects of edoxaban have not been observed for 4 years. Conclusions A case of successful treatment of the acute exacerbation of CA-PVT with edoxaban was reported. Moreover, edoxaban has been safely administered in a cirrhotic patient for 4 years. The findings obtained from the present case suggest that DOAC can be used as an initial treatment for CA-PVT even in early postoperative period after major abdominal surgery.
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Affiliation(s)
- Junya Toyoda
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Daisuke Morioka
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan. .,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan.
| | - Nobutoshi Horii
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Gakuryu Nakayama
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Norio Oyama
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Fumio Asano
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yusuke Izumisawa
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masaru Miura
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan
| | - Yoshiki Sato
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamadacho, Naka-ku, Yokohama, 231-0036, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Serper M, Weinberg EM, Cohen JB, Reese PP, Taddei TH, Kaplan DE. Mortality and Hepatic Decompensation in Patients With Cirrhosis and Atrial Fibrillation Treated With Anticoagulation. Hepatology 2021; 73:219-232. [PMID: 32267547 PMCID: PMC7541418 DOI: 10.1002/hep.31264] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/10/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Outcomes with anticoagulation (AC) are understudied in advanced liver disease. We investigated effects of AC with warfarin and direct oral anticoagulants (DOACs) on all-cause mortality and hepatic decompensation as well as ischemic stroke, major adverse cardiovascular events, splanchnic vein thrombosis, and bleeding in a cohort with cirrhosis and atrial fibrillation (AF). APPROACH AND RESULTS This was a retrospective, longitudinal study using national data of U.S. veterans with cirrhosis at 128 medical centers, including patients with cirrhosis with incident AF, from January 1, 2012 to December 31, 2017 followed through December 31, 2018. To assess the effects of AC on outcomes, we applied propensity score (PS) matching and marginal structural models (MSMs) to account for confounding by indication and time-dependent confounding. The final cohort included 2,694 veterans with cirrhosis with AF (n = 1,694 and n = 704 in the warfarin and DOAC cohorts after PS matching, respectively) with a median of 4.6 years of follow-up. All-cause mortality was lower with warfarin versus no AC (PS matched: hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.55-0.76; MSM models: HR, 0.54; 95% CI, 0.40-0.73) and DOACs versus no AC (PS matched: HR, 0.68; 95% CI, 0.50-0.93; MSM models: HR, 0.50; 95% CI, 0.31-0.81). In MSM models, warfarin (HR, 0.29; 95% CI, 0.09-0.90) and DOACs (HR, 0.23; 95% CI, 0.07-0.79) were associated with reduced ischemic stroke. In secondary analyses, bleeding was lower with DOACs compared to warfarin (HR, 0.49; 95% CI, 0.26-0.94). CONCLUSIONS Warfarin and DOACs were associated with reduced all-cause mortality. Warfarin was associated with more bleeding compared to no AC. DOACs had a lower incidence of bleeding compared to warfarin in exploratory analyses. Future studies should prospectively investigate these observed associations.
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Affiliation(s)
- Marina Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ethan M. Weinberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Jordana B. Cohen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA,Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA,Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut CT,Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
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Rogalski P, Rogalska-Plonska M, Wroblewski E, Kostecka-Roslen I, Dabrowska M, Swidnicka-Siergiejko A, Wasielica-Berger J, Cydzik M, Hirnle T, Flisiak R, Dabrowski A. Laboratory evidence for hypercoagulability in cirrhotic patients with history of variceal bleeding. Thromb Res 2019; 178:41-46. [PMID: 30959281 DOI: 10.1016/j.thromres.2019.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/01/2019] [Accepted: 03/31/2019] [Indexed: 12/18/2022]
Abstract
AIM We aimed to assess the relationship between procoagulant imbalance and the occurrence of variceal bleeding in patients with liver cirrhosis. METHODS We compared the results of chromogenic assay for the functional evaluation of the Protein C anticoagulant pathway (ThromboPath®), thromboelastometry and the levels of factor VII, VIII, and antithrombin in two groups of cirrhotic patients: Group 1 (n = 25) - patients with moderate or large esophageal or gastric varices, who had never experienced acute gastrointestinal bleeding and Group 2 (n = 24) - patients with a history of variceal bleeding. RESULTS Despite the differences in MELD score and the results of basic laboratory tests indicating more severe cirrhosis and suggesting a greater risk of bleeding in Group 2, the results of thromboelastometry did not differ significantly between groups. The ThromboPath® test results [ThP B: 67.8 ± 13.4 versus 59.09 ± 12.4%, p = 0.023] and factor VII level [69.04 ± 24.16 vs 53.54 ± 25.06, p = 0.032] confirmed greater plasma procoagulant activity in Group 1 compared to Group 2. However, there were no statistically significant differences in thrombin generation after activation of the protein C. Plasma of patients in Group 2 was more resistant to anticoagulation with protein C compared to Group 1 (PICI%: 65.58 ± 7.24 versus 55.64 ± 13.07%, p = 0.001). CONCLUSION The results of our study confirm the lack of influence of coagulation disorders on the occurrence of variceal bleeding. Moreover, the results of ThromboPath® assay indicate hypercoagulability in patients with a history of variceal bleeding and more severe liver cirrhosis, compared to patients who have never bled.
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland.
| | - Magdalena Rogalska-Plonska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Ines Kostecka-Roslen
- Department of Hematological Diagnostics, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Milena Dabrowska
- Department of Hematological Diagnostics, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Agnieszka Swidnicka-Siergiejko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Justyna Wasielica-Berger
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Mariusz Cydzik
- Department of Cardiosurgery, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Tomasz Hirnle
- Department of Cardiosurgery, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej - Curie 24a, 15-276 Bialystok, Poland
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Intagliata NM, Henry ZH, Maitland H, Shah NL, Argo CK, Northup PG, Caldwell SH. Direct Oral Anticoagulants in Cirrhosis Patients Pose Similar Risks of Bleeding When Compared to Traditional Anticoagulation. Dig Dis Sci 2016; 61:1721-7. [PMID: 26725062 DOI: 10.1007/s10620-015-4012-2] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Direct oral anticoagulants (DOAC) are important new anticoagulant therapies that are not well studied in patients with chronic liver disease. The aim of this study was to compare rates of bleeding in cirrhosis patients treated with DOAC (factor Xa inhibitors: rivaroxaban and apixaban) to those in cirrhosis patients treated with traditional anticoagulation (warfarin and low molecular weight heparin). METHODS We identified a total of 39 patients with cirrhosis who received anticoagulation therapy over a 3-year period (20 DOAC and 19 traditional anticoagulation) from a research database. Medical records were reviewed to obtain clinical data to compare between the groups. RESULTS Clinical characteristics between the two groups were similar. There were three documented bleeding events in the traditional anticoagulation group and four bleeding events in the DOAC group (p = 0.9). There were two major bleeding events in the traditional anticoagulation group and one major bleeding event in the DOAC group. There were no documented reports of drug-induced liver injury during this study period. Among all patients, no significant predictors of bleeding were identified using univariate regression and Cox proportional hazard modeling. CONCLUSIONS This is the first clinical study evaluating the use of DOAC in patients with cirrhosis. DOAC display similar safety characteristics when compared to traditional anticoagulation in patients with cirrhosis and are potentially attractive agents for anticoagulation therapy. Larger studies are now needed to better understand the safety and efficacy of these agents in cirrhosis.
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Affiliation(s)
- N M Intagliata
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA.
| | - Z H Henry
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - H Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, PO Box 800716, Charlottesville, VA, 22908, USA
| | - N L Shah
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - C K Argo
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - P G Northup
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
| | - S H Caldwell
- Coagulation in Liver Disease Study Group, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, 22908, USA
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Abstract
As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.
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Kavanagh C, Shaw S, Webster CRL. Coagulation in hepatobiliary disease. J Vet Emerg Crit Care (San Antonio) 2012; 21:589-604. [PMID: 22316251 DOI: 10.1111/j.1476-4431.2011.00691.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To review the pathogenesis and clinical consequences of coagulation abnormalities accompanying hepatobiliary disorders and to highlight the need for further studies to characterize these derangements and their treatment options in small animal patients. DATA SOURCES Veterinary and human medical literature: original research articles, scientific reviews, consensus statements, and recent texts. SUMMARY The liver plays an important role in the production and clearance of many components of coagulation. A wide range of hemostatic derangements can occur in patients with hepatobiliary disease including alterations in platelet number and function, coagulation factor levels, anticoagulants, vascular endothelial function, and fibrinolysis. As these hemostatic alterations include both pro- and anticoagulation pathways, the net result is often a rebalanced hemostatic system that can be easily disrupted by concurrent conditions resulting in either clinical bleeding or thrombosis. Conventional coagulation tests are inadequate at identifying the spectrum of coagulation alterations occurring in patients with hepatobiliary disease, but their evaluation is necessary to assess bleeding risk and provide prognostic information. A paucity of information exists regarding the treatment of the coagulation derangements in small animals with hepatobiliary disease. Extrapolation from human studies provides some information about potential treatment options, but further studies are warranted in this area to elucidate the best management for coagulation abnormalities in dogs and cats with hepatobiliary disease. CONCLUSION Hepatobiliary disease can have profound effects on coagulation function leading to hypercoagulable or hypocoagulable states. Overall coagulation status with hepatobiliary disease depends on both the type and severity of disease and the presence of associated complications.
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Affiliation(s)
- Carrie Kavanagh
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536, USA
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Thabut D, Rudler M, Rousseau G, Poynard T. Recombinant activated factor VII in chronic liver diseases: should we be afraid of thromboembolic events? J Hepatol 2011; 55:483-5. [PMID: 21349297 DOI: 10.1016/j.jhep.2011.01.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 01/14/2011] [Accepted: 01/16/2011] [Indexed: 01/08/2023]
Affiliation(s)
- Dominique Thabut
- Université Pierre et Marie Curie, Service d'hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière (AP-HP), Paris, France.
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