1
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Wang JX, Lu LG, Cai XB. Endoscopic ultrasound for the diagnosis and treatment of primary hepatocellular carcinoma. J Dig Dis 2024; 25:156-162. [PMID: 38628105 DOI: 10.1111/1751-2980.13266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/07/2024] [Accepted: 03/18/2024] [Indexed: 05/04/2024]
Abstract
Chronic liver disease has emerged as a significant global concern, with primary hepatocellular carcinoma (HCC) representing a critical consequence of this disease. However, early detection of HCC remains challenging in clinical practice. Recently, there has been a growing interest in applying endoscopic ultrasound (EUS) as a diagnostic tool for gastrointestinal diseases. Nevertheless, using EUS to diagnose and treat HCC is uncommon. In this review we described the diagnostic and therapeutic applications of EUS in primary HCC and evaluated its clinical significance. The diagnostic procedures primarily involve EUS-guided fine-needle biopsy or aspiration, assessment of metastatic lymph nodes and portal vein thrombosis, portal pressure monitoring, and portal vein blood collection. Treatment mainly includes EUS-guided tumor ablation, brachytherapy, injectable chemotherapy, and managing variceal hemorrhage related to portal hypertension.
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Affiliation(s)
- Jian Xiang Wang
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lun Gen Lu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Bo Cai
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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2
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Walia D, Saraya A, Gunjan D. Vascular complications of chronic pancreatitis and its management. World J Gastrointest Surg 2023; 15:1574-1590. [PMID: 37701688 PMCID: PMC10494584 DOI: 10.4240/wjgs.v15.i8.1574] [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: 03/28/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 08/25/2023] Open
Abstract
Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.
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Affiliation(s)
- Dinesh Walia
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anoop Saraya
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deepak Gunjan
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
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3
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Odriozola A, Puente Á, Cuadrado A, Rivas C, Anton Á, González FJ, Pellón R, Fábrega E, Crespo J, Fortea JI. Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review. J Clin Med 2022; 11:6435. [PMID: 36362663 PMCID: PMC9655000 DOI: 10.3390/jcm11216435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 08/06/2023] Open
Abstract
Portal vein thrombosis constitutes the most common thrombotic event in patients with cirrhosis, with increased rates in the setting of advanced liver disease. Despite being a well-known complication of cirrhosis, the contribution of portal vein thrombosis to hepatic decompensation and overall mortality is still a matter of debate. The incorporation of direct oral anticoagulants and new radiological techniques for portal vein recanalization have expanded our therapeutic arsenal. However, the lack of large prospective observational studies and randomized trials explain the heterogenous diagnostic and therapeutic recommendations of current guidelines. This article seeks to make a comprehensive review of the pathophysiology, clinical features, diagnosis, and treatment of portal vein thrombosis in patients with cirrhosis.
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Affiliation(s)
- Aitor Odriozola
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Ángela Puente
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Coral Rivas
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Ángela Anton
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | | | - Raúl Pellón
- Radiology Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - José Ignacio Fortea
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
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4
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Bezerra S, França NJ, Mineiro F, Capela G, Duarte C, Mendes AR. Pylephlebitis — a rare complication of a fish bone migration mimicking metastatic pancreatic cancer: A case report. World J Clin Cases 2021; 9:6768-6774. [PMID: 34447823 PMCID: PMC8362519 DOI: 10.12998/wjcc.v9.i23.6768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/26/2020] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pylephlebitis is a rare condition, poorly recognized by clinicians and with few references. In this case, the clinical appearance resembled the clinical course of a pancreatic cancer and was originated by the ingestion of a fish bone, making the case more interesting and rare.
CASE SUMMARY A 79-year-old female presented to the emergency department with fever, loss of appetite and jaundice. Tenderness in the right upper quadrant was present. Inflammation marker were high. A computed tomography (CT) scan revealed gallstones and aspects compatible with acute pancreatitis. The patient was admitted to surgery ward and has her condition aggravated. A magnetic resonance revealed multifocal liver lesions. Later, a cholangiopancreatography and an endoscopic ultrasound (US) were able to diagnose the condition. Specific treatment was implemented and the patient made a complete recovery.
CONCLUSION In conclusion, this case report demonstrates for the first time the diagnosis of an unusual case of pylephlebitis complicated by the migration of a fish bone, mimicking metastatic pancreatic cancer. Clinical presentation and traditional imaging studies, such as transabdominal US and CT, remain the standard for diagnosing this condition.
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Affiliation(s)
- Sofia Bezerra
- Department of Surgery, Centro Hospitalar do Médio Tejo, Tomar 2304-909, Portugal
| | - Nuno J França
- Department of Surgery, Centro Hospitalar do Médio Tejo, Tomar 2304-909, Portugal
| | - Firmo Mineiro
- Department of Surgery, Centro Hospitalar do Médio Tejo, Tomar 2304-909, Portugal
| | - Germano Capela
- Department of Surgery, Centro Hospitalar do Médio Tejo, Tomar 2304-909, Portugal
| | - Cristina Duarte
- Department of Surgery, Centro Hospitalar do Médio Tejo, Tomar 2304-909, Portugal
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5
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Li H, Sun PM, Sun HW, Cui Y. Progress in clinical diagnosis and treatment of cavernous transformation of the portal vein. Shijie Huaren Xiaohua Zazhi 2021; 29:662-669. [DOI: 10.11569/wcjd.v29.i12.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cavernous transformation of the portal vein (CTPV) refers to the compensatory neoformation of venous collaterals around the hepatic portal after the main portal vein or its branches are blocked, in order to maintain liver blood perfusion. This disease is relatively rare, and in clinical practice, its etiology, diagnosis, and treatment are not well understood. Patients with portal hypertension-related syndromes need to receive active treatment. The main goal of treatment is to prevent upper gastrointestinal hemorrhage and hypersplenism caused by portal hypertension, and to restore hepatopetal portal blood perfusion. It is necessary to fully assess the patient's condition and understand the best indications for each treatment. On this basis, we should adopt individualized comprehensive treatment strategies. This article reviews the latest advances in the understanding of the etiology, diagnosis, classification, and treatment of CTPV.
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Affiliation(s)
- Hao Li
- Department of General Surgery, Strategic Support Force Medical Center, Beijing 100101, China
| | - Pei-Ming Sun
- Department of General Surgery, Strategic Support Force Medical Center, Beijing 100101, China
| | - Hong-Wei Sun
- Department of General Surgery, Strategic Support Force Medical Center, Beijing 100101, China
| | - Yan Cui
- Department of General Surgery, Strategic Support Force Medical Center, Beijing 100101, China
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Abstract
While portal vein thrombosis (PVT) is a frequently encountered complication in the cirrhosis population, its management can be challenging for even the most experienced clinicians. Multiple factors must be considered with regards to management, including the degree of underlying portal hypertension and liver dysfunction, risks of therapies including anticoagulation and transjugular intrahepatic portosystemic shunt placement, and extent of the thrombosis. Interpreting the available literature to determine the best treatment strategy for any individual patient can be especially challenging given the lack of prospective, randomized controlled trials and the heterogeneity of cohorts studied. This review will provide an overview of PVT in the cirrhosis population, including necessary steps in evaluation and the potential benefits and drawbacks of different treatment approaches.
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Affiliation(s)
- Matthew J Stotts
- Division of Gastroenterology and Hepatology, UVA Center for the Study of Hemostasis and Thrombosis in Liver Disease, University of Virginia, Charlottesville, Virginia
| | - Brian J Wentworth
- Division of Gastroenterology and Hepatology, UVA Center for the Study of Hemostasis and Thrombosis in Liver Disease, University of Virginia, Charlottesville, Virginia
| | - Patrick G Northup
- Division of Gastroenterology and Hepatology, UVA Center for the Study of Hemostasis and Thrombosis in Liver Disease, University of Virginia, Charlottesville, Virginia
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7
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Alzubaidi S, Patel I, Saini A, Knuttinen G, Naidu S, Kriegshuaser S, Albadawi H, Oklu R. Current concepts in portal vein thrombosis: etiology, clinical presentation and management. Abdom Radiol (NY) 2019; 44:3453-3462. [PMID: 31407054 DOI: 10.1007/s00261-019-02174-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this article is to focus on etiology, risk factors, clinical presentation and classification systems of acute and chronic PVT as well as focusing on current diagnostic and therapeutic options for the management of acute and chronic PVT. RESULTS PVT represents a serious clinical concern in cirrhotic patients and in those with specific local or systemic risk factors. The rate and extent of thrombus formation can significantly impact patient presentation and the resulting clinical outcomes. The presentation of acute PVT can range from abdominal pain to intestinal ischemia/infarction and even death, while chronic PVT can remain clinically silent. A number of imaging modalities including US, CT and MRI can be used to confirm the diagnosis. In addition to addressing underlying risk factors, AC therapy forms a cornerstone of treatment and has demonstrated efficacy in both acute and chronic settings. Proper caution should be used when initiating AC therapy in cirrhotic patients given their underlying coagulopathic status with attention now being paid to NOACs and LMWH. For patients with bowel ischemia, extensive thrombosis, contraindications or poor response to AC, or for those with co-morbidities that preclude AC, minimally invasive endovascular techniques offer alternative treatment options. CONCLUSION Familiarity with the etiology, clinical presentation and classification of PVT optimize early detection and incorporate effective therapeutic options, the management of these complex patients should be undertaken by a multidisciplinary team. Minimally invasive catheter-based therapies and endovascular portosystemic shunt creation demonstrated efficacy in the treatment of AC-resistant patients and for patients with extensive or complicated disease.
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8
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Intagliata NM, Caldwell SH, Tripodi A. Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology 2019; 156:1582-1599.e1. [PMID: 30771355 DOI: 10.1053/j.gastro.2019.01.265] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis unrelated to solid malignancy is common in patients with cirrhosis, but less frequently observed in patients without cirrhosis. Prompt diagnosis and management of acute symptomatic portal vein thrombosis are essential. Failure to detect and treat thromboses can result in mesenteric ischemia, chronic cavernous transformation, and complications of portal hypertension. In patients with cirrhosis, development of portal vein thrombosis is often insidious and remains undetected until its incidental detection. Management of portal vein thrombosis in patients with cirrhosis is more controversial. However, there are data to support treatment of specific patients with anticoagulation agents. We review the common and distinct features of portal vein thromboses in patients without liver tumors, with and without cirrhosis.
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Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia
| | - Armando Tripodi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
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9
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Al Saeed M, Al-Jiffry B, Younes A, Badr S, Abdel-Rahman T, Hatem M, El-Meteini M. Risk factors, pattern of presentation, methods of diagnosis, and results of treatment of acute portal vein thrombosis: A multicenter study. SAUDI JOURNAL FOR HEALTH SCIENCES 2019. [DOI: 10.4103/sjhs.sjhs_77_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Rodrigues SG, Maurer MH, Baumgartner I, De Gottardi A, Berzigotti A. Imaging and minimally invasive endovascular therapy in the management of portal vein thrombosis. Abdom Radiol (NY) 2018; 43:1931-1946. [PMID: 28983654 DOI: 10.1007/s00261-017-1335-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Thrombosis of the portal venous system, although rare in the general population, is commonly diagnosed in patients with specific underlying conditions including prothrombotic diseases, cirrhosis, hepatobiliary malignancy, and intraabdominal inflammation. Recent improvements in imaging have played a fundamental role in increased detection of portal vein thrombosis (PVT), frequently reported in asymptomatic patients as an incidental finding. Minimally invasive, endovascular therapy is a medically rational option to achieve recanalization of the portal vein as an adjunct to conservative medical management. This review focuses on the advances in imaging modalities to diagnose, stage and follow-up PVT, and gives a short overview of the available endovascular techniques in this field.
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Affiliation(s)
- Susana G Rodrigues
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, MEM F807, Murtenstrasse 35, 3010, Bern, Switzerland
| | - Martin H Maurer
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Iris Baumgartner
- Clinic for Angiology, Swiss Cardiovascular Center, Inselspital, University of Bern, Bern, Switzerland
| | - Andrea De Gottardi
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, MEM F807, Murtenstrasse 35, 3010, Bern, Switzerland
| | - Annalisa Berzigotti
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, MEM F807, Murtenstrasse 35, 3010, Bern, Switzerland.
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11
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Tan SBM, Greenslade J, Martin D, Talbot M, Loi K, Hopkins G. Portomesenteric vein thrombosis in sleeve gastrectomy: a 10-year review. Surg Obes Relat Dis 2018; 14:271-275. [DOI: 10.1016/j.soard.2017.12.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/30/2017] [Accepted: 12/08/2017] [Indexed: 12/13/2022]
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12
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Affiliation(s)
- Idan Levy
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
| | - Kenneth F Binmoeller
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
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13
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Abstract
Endoscopic ultrasound (EUS) has evolved from a purely diagnostic to an interventional modality offering minimally invasive alternatives to surgical and radiologic interventions. This has led to a rapidly growing interest in EUS-guided vascular interventions. EUS-guided portal venous access is an emerging technique which opens a new arena for interventional vascular EUS. Portal vein can be accessed under EUS guidance with high precision and low risk of complications thus expanding its application for both benign and malignant conditions. Potential applications of EUS-guided portal vein access include: fine needle aspiration of portal vein thrombus and portal venous blood sampling for circulating tumor cells for diagnosis and staging of occult and known malignancies; portal vein angiography, portal pressure measurement, and creation of endoscopic intrahepatic portosystemic shunt; portal vein embolization and targeted drug delivery. This article will review the current literature on EUS-guided portal vein access, its feasibility and safety in animal and human studies, and current diagnostic and therapeutic applications with future directions.
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14
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Săftoiu A, Vilmann P. EUS targeting of vascular thrombosis: Risky business? Gastrointest Endosc 2017; 86:156-160. [PMID: 28610855 DOI: 10.1016/j.gie.2016.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/21/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Adrian Săftoiu
- Endoscopy Department, GastroUnit, Copenhagen University Hospital, Herlev, Denmark; Gastroenterology Department, Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy, Craiova, Romania
| | - Peter Vilmann
- Endoscopy Department, GastroUnit, Copenhagen University Hospital, Herlev, Denmark
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15
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Rustagi T, Gleeson FC, Chari ST, Abu Dayyeh BK, Farnell MB, Iyer PG, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Truty MJ, Vege SS, Wang KK, Levy MJ. Remote malignant intravascular thrombi: EUS-guided FNA diagnosis and impact on cancer staging. Gastrointest Endosc 2017; 86:150-155. [PMID: 27773725 DOI: 10.1016/j.gie.2016.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Malignant vascular invasion usually results from gross direct infiltration from a primary tumor and impacts cancer staging, prognosis, and therapy. However, patients may also develop a remote malignant thrombi (RMT), defined as a malignant intravascular thrombus located remote and noncontiguous to the primary tumor. Our aim was to compare EUS, CT, and magnetic resonance imaging (MRI) findings of RMT and to explore the potential impact on cancer staging. METHODS Patients with RMT were identified from a prospectively maintained EUS database. Retrospective chart review was performed to obtain EUS, CT/MRI, clinical, and outcome data. RESULTS A median of 3 FNAs (range, 1-8) was obtained from RMT in 17 patients (60 ± 14.1 years, 56% men) between April 2003 and August 2016, with the finding of malignant cytology in 12 patients (70.6%; 10 positive, 2 suspicious). CT/MRI detected the RMT in 5 patients (29.4%), 4 of whom had positive or suspicious EUS-FNA cytology. Among the 8 newly diagnosed pancreatic adenocarcinoma (PaC) patients, CT did not detect the RMT in 5 (63%), of whom 3 patients had positive or suspicious intravascular EUS-FNA cytology. For newly diagnosed PaC patients (n = 8), the EUS-FNA diagnosis of a biopsy specimen-proven RMT upstaged 3 patients (37.5%) and converted 2 patients (25%) from CT resectable to unresectable disease. No adverse events were reported. The mean follow-up was 18.9 ± 27.7 months. CONCLUSIONS Our study demonstrates the ability and potential safety of intravascular FNA to detect radiographically occult RMT, which substantially impacts cancer staging and resectability.
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Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Randall K Pearson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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Khan AS, Eloubeidi MA, Khashab MA. Endoscopic management of choledocholithiasis and cholelithiasis in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2016; 10:861-8. [PMID: 26799755 DOI: 10.1586/17474124.2016.1145544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treatment of choledocholithiasis and cholelithiasis in patients with cirrhosis often requires diagnostic and therapeutic endoscopy such as endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). Patients with underlying cirrhosis may have coagulopathy, hepatic encephalopathy, ascites and other comorbidities associated with cirrhosis that can make endoscopic therapy challenging and can be associated with a higher risk of adverse events. Given the unique derangements of physiologic parameters associated with cirrhosis this population requires a truly multifaceted and multidisciplinary understanding between therapeutic endoscopists, hepatologists and anesthesiologists. For therapeutic endoscopists, it is critical to be aware of the specific issues unique to this population of patients to optimize outcomes and avoid adverse events. The epidemiology of gallstone disease, the diagnostic and therapeutic approach to patients with varying degree of hepatic dysfunction, and a review of the available literature in this area are presented.
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Affiliation(s)
- Ali S Khan
- a Digestive and Liver Diseases , Columbia University Medical Center , New York , NY , USA
| | | | - Mouen A Khashab
- c Division of Gastroenterology and Hepatology , The Johns Hopkins University , Baltimore , MD , USA
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17
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Imaging Diagnosis of Splanchnic Venous Thrombosis. Gastroenterol Res Pract 2015; 2015:101029. [PMID: 26600801 PMCID: PMC4620257 DOI: 10.1155/2015/101029] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/22/2015] [Indexed: 12/15/2022] Open
Abstract
Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.
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18
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Abstract
Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.
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Key Words
- ACLA, anti-cardiolipin antibody
- AFP, alpha feto protein
- BCS, Budd-Chiari syndrome
- CDUS, color doppler ultrasonography
- CT, computed tomography
- CTP, Child Turcotte Pugh
- EHPVO, extra hepatic portal venous obstruction
- EST, endoscopic sclerotherapy
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- IGF-1, insulin like growth factor-1
- IGFBP-3, insulin like growth factor binding protein-3
- INR, international normalized ratio
- JAK-2, Janus kinase 2
- LA, lupus anticoagulant
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MPD, myeloproliferative disorder
- MRI, magnetic resonance imaging
- MTHFR, methylenetetrahydrofolate reductase
- MVT, mesenteric vein thrombosis
- OCPs, oral contraceptive pills
- PAI-1 4G-4G, plasminogen activator inhibitor type 1- 4G/4G genotype
- PNH, paroxysmal nocturnal hemoglobinuria
- PV, portal vein
- PVT
- PVT, portal vein thrombosis
- PWUS, Pulsed Wave ultrasonography
- RFA, radio frequency ablation
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- TAFI, thrombin activatable fibrinolysis inhibitor
- TARE, Trans arterial radioembolization
- TB, tuberculosis
- TIPS, transjugular intrahepatic portosystemic shunt
- UFH, unfractionated heparin
- acute and chronic
- anticoagulation
- imaging
- prothrombotic
- rtPA, recombinant tissue plasminogen activator
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Affiliation(s)
- Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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19
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Abstract
Portal vein thrombosis (PVT) is the blockage or narrowing of the portal vein by a thrombus. It is relatively rare and has been linked with the presence of an underlying liver disease or prothrombotic disorders. We present a case of a young male who presented with vague abdominal symptoms for approximately one week. Imaging revealed the presence of multiple nonocclusive thrombi involving the right portal vein, the splenic vein, and the left renal vein, as well as complete occlusion of the left portal vein and the superior mesenteric vein. We discuss pathogenesis, clinical presentation, and management of both acute and chronic thrombosis. The presence of PVT should be considered as a clue for prothrombotic disorders, liver disease, and other local and general factors that must be carefully investigated. It is hoped that this case report will help increase awareness of the complexity associated with portal vein thrombosis among the medical community.
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20
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Kumar A, Sharma P, Arora A. Review article: portal vein obstruction--epidemiology, pathogenesis, natural history, prognosis and treatment. Aliment Pharmacol Ther 2015; 41:276-92. [PMID: 25475582 DOI: 10.1111/apt.13019] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/17/2014] [Accepted: 10/20/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal vein obstruction may be due to portal vein thrombosis (PVT) or its sequale, the portal cavernoma. PVT is a common complication in liver cirrhosis, however, it may also occur as a primary vascular disorder, in absence of any liver disease. AIM To review the current knowledge on nomenclature, etiology, pathophysiology, clinical presentation, diagnostic workup and management of adult patients with obstruction in the portal vein, either as a primary vascular disease in adults, or as a complication of liver cirrhosis. METHODS A structured search in PubMed was performed using defined keywords (portal vein obstruction, extra-hepatic portal vein obstruction, PVT and portal cavernoma), including full text articles and abstracts in English language. RESULTS Several causes, operating both at local and systemic level, might play an important role in the pathogenesis of PVT. Frequently, more than one risk factor could be identified; however, occasionally no single factor is discernible. Diagnosis of portal vein obstruction depends on clinical presentation, imaging and laboratory investigations. Prompt treatment greatly affects the patient's outcome. CONCLUSIONS Portal vein obstruction occurring either due to thrombosis in the portal vein or due to the portal cavernoma, can contribute to significant morbidity and mortality in patients with or without cirrhosis. In recent years our understanding of etio-pathogenesis of portal vein obstruction has evolved tremendously, which has led to significant improvement in treatment outcomes. There are still areas where more studies are needed to better clarify the management issues of portal vein obstruction.
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Affiliation(s)
- A Kumar
- Department of Gastroenterology & Hepatology, Ganga Ram Institute for Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, New Delhi, India
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21
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Marouf F, Giallourakis CC, Baer L, Hanau MS, Holbert BC. Case records of the Massachusetts General Hospital. Case 33-2013. A 40-year-old woman with abdominal pain, weight loss, and anxiety about cancer. N Engl J Med 2013; 369:1639-47. [PMID: 24152264 DOI: 10.1056/nejmcpc1215968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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22
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Handa P, Crowther M, Douketis JD. Portal vein thrombosis: a clinician-oriented and practical review. Clin Appl Thromb Hemost 2013; 20:498-506. [PMID: 23364162 DOI: 10.1177/1076029612473515] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
With advances in modern imaging techniques, portal vein thrombosis (PVT) is being increasingly diagnosed. It has a wide ranging clinical spectrum from being an asymptomatic state to a potentially life-threatening situation. It is not unusual to find it as an incidental finding in the abdominal imagings done for other reasons. It is commonly associated with cirrhosis and abdominal malignancies and also has a strong association with prothrombotic disorders. It is often difficult for the clinicians to decide whether PVT is acute or chronic. This poses great challenges to its management strategies that include anticoagulants, thrombolysis, and surgical options. Timely diagnosis and appropriate management have great bearings on its outcomes of morbidity and mortality. In this clinician-oriented review, we have provided a concise review of clinical aspects of PVT and discussed various management strategies while addressing the common questions that come to a physician's mind dealing with such a patient.
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Affiliation(s)
- Pankaj Handa
- Department of Medicine, McMaster University and St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University and St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - James D Douketis
- Department of Medicine, McMaster University and St Joseph's Healthcare, Hamilton, Ontario, Canada
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23
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Usefulness of endoscopic ultrasonography in hepatology. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 25:621-5. [PMID: 22059170 DOI: 10.1155/2011/367643] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Endoscopic ultrasonography (EUS) is used to evaluate patients with hepatobiliary diseases. The technique is useful for the diagnosis of esogastric varices in selected cases of portal hypertension, and to evaluate the pathogenic role and prognostic value of the collateral circulation in patients with this condition. When coupled with the Doppler technique, EUS can be used to guide injection sclerotherapy and to verify the obliteration of varices (particularly fundal varices) after endoscopic treatment. Hemodynamic changes induced in the collateral circulation by vasoactive drugs can also be measured with Doppler-EUS. Fine-needle aspiration under EUS guidance is useful in the diagnosis of focal liver lesions and perihepatic adenopathy, and in the evaluation of biliary tract diseases. New indications can be developed in the future after adequate experimental validation.
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Abstract
AIM Many researchers consider portal thrombosis (PT) as a contraindication to transjugular intrahepatic portosystemic shunt (TIPS). The aim of this retrospective study was to compare the feasibility and long-term prognosis of TIPS in cirrhotic patients, with and without, complete PT. PATIENTS AND METHODS Four hundred and thirty-six consecutive cirrhotic patients with portal hypertension were referred for TIPS, between 1990 and 2004. These patients were divided into two groups according to their portal patency. PT+: 34 patients with complete PT with cavernoma (19) or without (15) cavernoma versus PT-: 402 patients with normal portal patency (308) and partial PT (94). Epidemiological data were compared using the chi and Student's t-tests, and comparative evolution was made from actuarial data using the log-rank test. RESULTS PT+ patients were more frequently women with viral hepatitis, and TIPS was performed more often for bleeding indications. The TIPS success rate was significantly lower in the PT+ group (79%) than in the PT- group (99.5%) (P<10). Presence of a cavernoma decreased the success rate to 63%. TIPS was always feasible in cases of recent PT and portal cavernoma with an accessible intrahepatic patent portal branch. Early and late outcome and complications were not significantly different between the two groups. CONCLUSION Complete PT does not modify TIPS' long-term outcome. Rather than a contraindication, PT should be considered as an indication for TIPS in cirrhotic patients with accessible intrahepatic portal vein. Further randomized studies should be planned in cirrhotic patients with recent PT to better qualify TIPS and anticoagulation indications, respectively.
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Ng CH, Lai L, Lok KH, Li KK, Szeto ML. Choledochal varices bleeding: A case report. World J Gastrointest Endosc 2010; 2:190-2. [PMID: 21160747 PMCID: PMC2999127 DOI: 10.4253/wjge.v2.i5.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 03/23/2010] [Accepted: 03/30/2010] [Indexed: 02/05/2023] Open
Abstract
Choledochal varices are a rare cause of hemobilia associated with chronic portal vein thrombosis. We present a case of chronic portal vein thrombosis complicated with bleeding from choledochal varices. The presentation, clinical manifestations and management are described.
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Affiliation(s)
- Chi Ho Ng
- Chi Ho Ng, Lawrence Lai, Ka Ho Lok, Kin Kong Li, Ming Leung Szeto, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, China
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Parikh S, Shah R, Kapoor P. Portal vein thrombosis. Am J Med 2010; 123:111-9. [PMID: 20103016 DOI: 10.1016/j.amjmed.2009.05.023] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 04/23/2009] [Accepted: 05/18/2009] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis is a condition not infrequently encountered by clinicians. It results from a combination of local and systemic prothrombotic risk factors. The presentation of acute thrombosis varies widely from an asymptomatic state to presence of life-threatening intestinal ischemia and infarction. In the chronic stage, patients typically present with variceal bleeding or other complications of portal hypertension. Abdominal ultrasound color Doppler imaging has a 98% negative predictive value, and is considered the imaging modality of choice in diagnosing portal vein thrombosis. Controlled clinical trials to assist with clinical decision-making are lacking in both acute and chronic portal vein thrombosis. Oral anticoagulant therapy is initiated if the risks of bleeding are low, but long-term anticoagulation is generally not recommended in patients with concomitant hepatic cirrhosis. The roles of invasive therapeutic approaches such as thrombolysis and transjugular intrahepatic portosystemic shunt continue to evolve. This review conflates dissenting views into a rational approach of managing patients with portal vein thrombosis for the general internist.
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Affiliation(s)
- Sameer Parikh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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27
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Ponziani FR, Zocco MA, Campanale C, Rinninella E, Tortora A, Maurizio LD, Bombardieri G, Cristofaro RD, Gaetano AMD, Landolfi R, Gasbarrini A. Portal vein thrombosis: Insight into physiopathology, diagnosis, and treatment. World J Gastroenterol 2010; 16:143-55. [PMID: 20066733 PMCID: PMC2806552 DOI: 10.3748/wjg.v16.i2.143] [Citation(s) in RCA: 186] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is a relatively common complication in patients with liver cirrhosis, but might also occur in absence of an overt liver disease. Several causes, either local or systemic, might play an important role in PVT pathogenesis. Frequently, more than one risk factor could be identified; however, occasionally no single factor is discernable. Clinical examination, laboratory investigations, and imaging are helpful to provide a quick diagnosis, as prompt treatment might greatly affect a patient’s outcome. In this review, we analyze the physiopathological mechanisms of PVT development, together with the hemodynamic and functional alterations related to this condition. Moreover, we describe the principal factors most frequently involved in PVT development and the recent knowledge concerning diagnostic and therapeutic procedures. Finally, we analyze the implications of PVT in the setting of liver transplantation and its possible influence on patients’ future prognoses.
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28
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Abstract
BACKGROUND Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty. AIM To provide an update on the modern management of portal vein thrombosis. Information on portal vein thrombosis in patients with and without cirrhosis and hepatocellular carcinoma is also updated. METHODS A pubmed search was performed to identify the literature using search items portal vein thrombosis-aetiology and treatment and portal vein thrombosis in cirrhosis and hepatocellular carcinoma. RESULTS Portal vein thrombosis occurs because of local inflammatory conditions in the abdomen and prothrombotic factors. Acute portal vein thrombosis is usually symptomatic when associated with cirrhosis and/or superior mesenteric vein thrombosis. Anticoagulation should be given for 3-6 months if detected early. If prothrombotic factors are identified, anticoagulation should be given lifelong. Chronic portal vein thrombosis usually presents with well tolerated upper gastrointestinal bleed. It is diagnosed by imaging, which demonstrates a portal cavernoma in place of a portal vein. Anticoagulation does not have a definite role, but bleeds can be treated with endotherapy or shunt surgery. Rarely liver transplantation may be considered. CONCLUSION Role of anticoagulation in chronic portal vein thrombosis needs to be further studied.
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Affiliation(s)
- Y Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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29
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Brugge WR. EUS is an important new tool for accessing the portal vein. Gastrointest Endosc 2008; 67:343-4. [PMID: 18226700 DOI: 10.1016/j.gie.2007.10.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 10/04/2007] [Indexed: 12/20/2022]
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DeWitt J, LeBlanc J, McHenry L, McGreevy K, Sherman S. Endoscopic ultrasound-guided fine-needle aspiration of ascites. Clin Gastroenterol Hepatol 2007; 5:609-15. [PMID: 17336593 DOI: 10.1016/j.cgh.2006.11.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aim of this study is to report a large single-center experience with endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of ascites. METHODS Consecutive patients at our institution in whom EUS-guided paracentesis was performed between January 1997 and July 2005 were identified retrospectively. All procedures were performed by or under the supervision of 1 of 5 experienced endosonographers with available on-site cytopathology. RESULTS Sixty consecutive patients (33 men; mean age, 67 y) were identified. Previously attempted percutaneous paracentesis was unsuccessful in 3 of 6 patients. Ascites confirmed by EUS FNA was visible in 28 of 54 (52%) computerized tomography, 3 of 11 (27%) transabdominal ultrasound, and 4 of 8 (50%) magnetic resonance imaging examinations before EUS. Transgastric (n = 55) or transduodenal (n = 5) EUS-guided paracentesis (mean, 8.9; range, 1-40 mL) revealed malignancy in 16 (27%) from primary pancreatic (n = 9), gastric (n = 2), urothelial (n = 1), esophageal (n = 1), gallbladder (n = 1), bile duct (n = 1) cancer, and lymphoma (n = 1). The cytology from 2 patients was atypical (1 suspicious for malignancy and 1 considered reactive) and the remaining 42 were benign. Potential complications occurred in 2 of 60 (3%) patients with self-limited fever. Of the 8 of 60 (13%) patients who underwent subsequent surgery, 3 had metastatic pancreatic adenocarcinoma (n = 2) and metastatic small intestinal carcinoid (n = 1) to the peritoneum after negative EUS-FNA cytology. CONCLUSIONS EUS frequently identifies ascites missed by other imaging studies. EUS-guided paracentesis may identify malignancy in a subset of patients. Negative ascitic fluid cytology from EUS FNA does not exclude possible peritoneal carcinomatosis.
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Affiliation(s)
- John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
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31
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Storch I, Gomez C, Contreras F, Schiff E, Ribeiro A. Hepatocellular carcinoma (HCC) with portal vein invasion, masquerading as pancreatic mass, diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Dig Dis Sci 2007; 52:789-91. [PMID: 17268833 DOI: 10.1007/s10620-006-9325-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2005] [Accepted: 03/22/2006] [Indexed: 02/06/2023]
Affiliation(s)
- Ian Storch
- Sylvester Cancer Center, Division of Gastroenterology, Division of Hepatology, University of Miami School of Medicine, P.O. Box 016960, Miami, Florida 33101, USA
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Condat B, Valla D. Nonmalignant portal vein thrombosis in adults. NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2006; 3:505-15. [PMID: 16951667 DOI: 10.1038/ncpgasthep0577] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2005] [Accepted: 06/28/2006] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) consists of two different entities: acute PVT and chronic PVT. Acute PVT usually presents as abdominal pain. When the thrombus extends to the mesenteric venous arches, intestinal infarction can occur. Chronic PVT is usually recognized after a fortuitous diagnosis of hypersplenism or portal hypertension, or when there are biliary symptoms related to portal cholangiopathy. Local risk factors for PVT, such as an abdominal inflammatory focus, can be identified in 30% of patients with acute PVT; 70% of patients with acute and chronic PVT have a general risk factor for PVT, most commonly myeloproliferative disease. Early initiation of anticoagulation therapy for acute PVT is associated with complete and partial success in 50% and 40% of patients, respectively. A minimum of 6 months' anticoagulation therapy is recommended for the treatment of acute PVT. For patients with either form of PVT, permanent anticoagulation therapy should be considered if they have a permanent risk factor. In patients with large varices, beta-adrenergic blockade or endoscopic therapy seems to prevent bleeding as a result of portal hypertension, even in patients on anticoagulation therapy. In patients with jaundice or recurrent biliary symptoms caused by cholangiopathy, insertion of a biliary endoprosthesis is the first treatment option. Overall, the long-term outcome for patients with PVT is good, but is jeopardized by cholangiopathy and transformation of underlying myeloproliferative disease into myelofibrosis or acute leukemia.
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Affiliation(s)
- Bertrand Condat
- Service d'Hépatologie, Hôpital Beaujon, 100 Boulevard du Général-Leclerc, 92118 Clichy Cedex, France
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33
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Wildi SM, Wallace MB, Hunter B, Noone TC, Hoffman BJ. EUS diagnosis of an unusual case of pylephlebitis mimicking metastatic pancreatic cancer. Dig Dis Sci 2005; 50:2255-8. [PMID: 16416171 DOI: 10.1007/s10620-005-3044-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2004] [Accepted: 12/13/2004] [Indexed: 12/09/2022]
Affiliation(s)
- Stephan M Wildi
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Abstract
Endoscopic ultrasonography and endoscopic ultrasonography-guided fine needle aspiration are well-established techniques, encompassing a variety of diagnostic and therapeutic applications. Along with traditional indications that constitute everyday clinical practice in all endoscopic ultrasonography centres, new indications are emerging that resemble the continuing research carried on in this field. Some of these are innovative applications, developed by highly experienced endosonographers and with a putative role for clinical practice in the near future. Others are merely experimental applications, carried out on in animal models or in highly selected groups of patients, opening up new fascinating areas of research but not for imminent introduction in clinical practice. The purpose of this review, after summarising the present indications of endoscopic ultrasonography, is to focus on the future applications and try to establish their possible advent, either in the near or in the far future.
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Affiliation(s)
- P Fusaroli
- University of Bologna, Imola, AUSL, Castel S. Pietro Terme Hospital (BO), Viale Oriani 1, Castel S. Pietro Terme, Bologna 1-40024, Italy
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35
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Webster GJM, Burroughs AK, Riordan SM. Review article: portal vein thrombosis -- new insights into aetiology and management. Aliment Pharmacol Ther 2005; 21:1-9. [PMID: 15644039 DOI: 10.1111/j.1365-2036.2004.02301.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Portal vein thrombosis may occur in the presence or absence of underlying liver disease, and a combination of local and systemic factors are increasingly recognized to be important in its development. Acute and chronic portal vein thrombosis have traditionally been considered separately, although a clear clinical distinction may be difficult. Gastrooesophageal varices are an important complication of portal vein thrombosis, but they follow a different natural history to those with portal hypertension related to cirrhosis. Consensus on optimal treatment continues to be hampered by a lack of randomized trials, but recent studies demonstrate the efficacy of thrombolytic therapy in acute thrombosis, and the apparent safety and benefit of anticoagulation in patients with chronic portal vein thrombosis.
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Affiliation(s)
- G J M Webster
- Department of Gastroenterology, University College London Hospitals NHS Trust, London, UK.
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