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Valla DC. Hepatic vein thrombosis and PVT: A personal view on the contemporary development of ideas. Clin Liver Dis (Hoboken) 2024; 23:e0246. [PMID: 38988821 PMCID: PMC11236412 DOI: 10.1097/cld.0000000000000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 07/12/2024] Open
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2
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da Cruz Renó L, Tustumi F, Waisberg DR, Rocha-Santos V, Pinheiro RS, Macedo RA, Nacif LS, Ducatti L, De Martino RB, Trevisan AM, Carneiro-D’Albuquerque L, Andraus W. Venous thromboembolism in in-hospital cirrhotic patients: A systematic review. Front Med (Lausanne) 2022; 9:1027882. [PMID: 36419795 PMCID: PMC9676642 DOI: 10.3389/fmed.2022.1027882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/14/2022] [Indexed: 08/30/2023] Open
Abstract
INTRODUCTION Patients with liver cirrhosis are at a higher risk of hospitalization. The present review aimed to assess the risk of thromboembolism and its burden on hospitalized cirrhotic patients. MATERIALS AND METHODS A systematic review (PROSPERO: CRD42021256869) was conducted in PubMed, Embase, Cochrane, Lilacs, and a manual search of references. It evaluated studies that compare cirrhotic patients with venous thromboembolism (VTE) with cirrhotic patients without VTE or studies that compare cirrhotic patients with non-cirrhotic patients. No restrictions were set for the date of publication or language. The last search was conducted in June 2021. RESULTS After selection, 17 studies were included from an initial search of 5,323 articles. The chronic liver disease etiologies comprise viral, alcohol, autoimmune, NASH (non-alcoholic steatohepatitis), cryptogenic, hemochromatosis, cholestasis, and drug-related. The included studies were conflicted regarding the outcomes of VTE, pulmonary embolism, or bleeding. Patients with cirrhosis associated with VTE had prolonged length of hospital stay, and patients with cirrhosis were at higher risk of portal thrombosis. CONCLUSION In-hospital cirrhotic patients are a heterogeneous group of patients that may present both thrombosis and bleeding risk. Clinicians should take extra caution to apply both prophylactic and therapeutic anticoagulation strategies. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021256869].
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Affiliation(s)
| | - Francisco Tustumi
- Transplantation Unit, Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
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Luther J, Friedman LS. Management of Thrombocytopenia and Coagulopathy in Patients with Chronic Liver Disease Undergoing Therapeutic Endoscopic Interventions. Clin Liver Dis 2022; 26:1-12. [PMID: 34802655 DOI: 10.1016/j.cld.2021.08.002] [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] [Indexed: 02/06/2023]
Abstract
Management of coagulopathy in patients with advanced liver disease undergoing therapeutic endoscopic procedures is complex. Improvements in the understanding of hemostasis at a physiologic level have highlighted the inaccuracy of currently available clinical tests, like platelet count and prothrombin time, in estimating hemostasis in patients with cirrhosis. With identification of novel factors that contribute to bleeding risk in patients with cirrhosis, there is a dearth of clinical trial data that account for all potentially relevant factors and that examine interventions to reduce bleeding risk. Precise recommendations regarding transfusion strategies based on hemostatic test results in patients with cirrhosis are impractical.
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Affiliation(s)
- Jay Luther
- MGH Alcohol Liver Center, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lawrence S Friedman
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Medicine, Newton-Wellesley Hospital, Newton, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
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4
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You H, Zhao J, Huang C, Tian X, Li M, Zeng X. Early Initiation of Anticoagulation Improves the Long-Term Prognosis in Patients With Antiphospholipid Syndrome Associated Portal Vein Thrombosis. Front Med (Lausanne) 2021; 8:630660. [PMID: 33614687 PMCID: PMC7890015 DOI: 10.3389/fmed.2021.630660] [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: 11/18/2020] [Accepted: 01/13/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Portal vein thrombosis (PVT) is a rare and severe clinical phenotype of antiphospholipid syndrome (APS) with a poor prognosis. Anticoagulation therapy is efficient but is associated with potentially severe bleeding episodes, especially for those patients with thrombocytopenia. We conducted this case-control study to explore the clinical features and associated factors of PVT in APS patients, the re-canalization rate of the PVT after anticoagulation and investigate the beneficial effects of early initiation of anticoagulation in patients with APS associated PVT. Methods: We enrolled patients with APS associated PVT as the case group, and age-, and entry-time-matched APS patients without PVT (1:2) as the control group. We explored the associated factors of PVT in APS patients using multivariate logistic regression analysis. The re-canalization rate of the PVT after anticoagulation was analyzed using the survival analysis. Results: A total of 34 patients (8 males and 26 females) with APS-PVT were enrolled, with a median follow-up time of 3 years (1.5, 7 years). Multivariate logistic regression analysis showed that thrombocytopenia (OR 6.4, 95%CI 1.561-26.218, P = 0.01), hypersensitive c-reactive protein >3 mg/L (OR 4.57, 95%CI 1.426-14.666, P = 0.011), anti β2GPI positive (OR 5, 95%CI 1.816-13.772, P = 0.002) and aPL double-positive (OR 4.08, 95%CI 1.312-12.429, P = 0.013) were independent associated factors for PVT in APS. Survival analysis revealed that effective anticoagulation could increase re-canalization rate significantly (log-rank p = 0.001), with better prognosis (lower mortality rate, log-rank p = 0.045). Conclusions: PVT could be the first presentation of APS with insidious onset and atypical clinical symptoms and easily be misdiagnosed. For patients with APS, double aPLs positive, thrombocytopenia, and inflammation could be the associated factors of PVT. Early diagnosis and anticoagulation treatment can bring thrombus re-canalization thereby significantly improving the prognosis.
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Affiliation(s)
- Hanxiao You
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Can Huang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Wang L, Guo X, Xu X, Xu S, Han J, Wang R, Guo Z, Yi F, Qi X. No Association of Homocysteine, Anticardiolipin Antibody, and Anti-β2 Glycoprotein I Antibody With Portal Venous System Thrombosis in Liver Cirrhosis. Clin Appl Thromb Hemost 2021; 27:10760296211010969. [PMID: 33882699 PMCID: PMC8072837 DOI: 10.1177/10760296211010969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Portal venous system thrombosis (PVST), a common complication of liver cirrhosis, is closely associated with thrombophilia. To explore the association of homocysteine (Hcy), anticardiolipin antibody (aCL), and anti-β2 glycoprotein I antibody (aβ2GPI), which are possible thrombophilic factors, with PVST in liver cirrhosis. Overall, 654 non-malignant patients (219 with and 435 without liver cirrhosis) admitted between January 2016 and June 2020 were retrospectively evaluated. Presence of PVST, degree of main portal vein (MPV) thrombosis, and clinically significant PVST were identified. Hcy level, hyperhomocysteinemia (HHcy), aCL positivity, and aβ2GPI positivity were compared according to the presence of liver cirrhosis and PVST. Positive aβ2GPI was significantly more frequent in patients with liver cirrhosis than those without, but Hcy level and proportions of HHcy and positive aCL were not significantly different between them. PVST could be evaluated in 136 cirrhotic patients. Hcy level [10.57 μmol/L (2.71-56.82) versus 9.97 μmol/L (2.05-53.44); P = 0.796] and proportions of HHcy [4/44 (9.1%) versus 13/81 (16.0%); P = 0.413] and positive aCL [1/23 (4.3%) versus 10/52 (19.2%); P = 0.185] and aβ2GPI [9/23 (39.1%) versus 21/52 (40.4%); P = 0.919] were not significantly different between cirrhotic patients with and without PVST. There was still no significant association of Hcy level, HHcy, aCL, or aβ2GPI with PVST based on Child-Pugh classification, MPV thrombosis >50%, and clinically significant PVST. Hcy, aCL, and aβ2GPI may not be associated with PVST in liver cirrhosis, suggesting that routine screening for Hcy, aCL, and aβ2GPI should be unnecessary in such patients.
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Affiliation(s)
- Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Shixue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Juqiang Han
- Institute of Hepatology, PLA Army General Hospital, Beijing, China
| | - Ran Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Zeqi Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Fangfang Yi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
- Xingshun Qi, Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang 110840, Liaoning Province, China.
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Kirkeby MH, Larsen JB, Grønbaek H, Hvas AM. Thrombophilia testing in patients with portal vein thrombosis. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:694-698. [PMID: 33026843 DOI: 10.1080/00365513.2020.1827289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Portal vein thrombosis (PVT) is a rare but severe condition. Several risk factors predispose to PVT. However, it remains unclear to which degree thrombophilia contributes to the risk of PVT and whether PVT patients should be routinely referred for thrombophilia testing. The aim of the present study was to investigate the prevalence of thrombophilia in PVT patients to clarify the relevance of thrombophilia testing in PVT patients. Clinical data and results from thrombophilia investigations were systematically obtained from all PVT patients referred to Centre for Hemophilia and Thrombosis, Aarhus University Hospital, Denmark for thrombophilia testing between 1st of January 2010 and 31st of December 2018 (n = 93). The investigated thrombophilias included factor V Leiden and prothrombin G20210A mutations, deficiency of protein S, protein C and antithrombin, antiphospholipid syndrome, and increased levels of factor VIII. The prevalence of thrombophilia was compared to healthy controls obtained from previously published data on thrombophilia distribution in cohorts of the Western European adult general population. Comparing PVT patients with healthy controls, significantly increased odds of presence of lupus anticoagulant (crude odds ratio (OR) 6.2, 95% confidence interval (CI) 1.8-20.6) were found, whereas no significantly increased odds of inherited thrombophilia were demonstrated. In conclusion, routine testing for inherited thrombophilia in PVT patients does not seem indicated. However, PVT patients should still be tested for antiphospholipid antibodies because patients meeting the criteria for antiphospholipid syndrome preferentially should receive vitamin K antagonists as anticoagulant therapy.
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Affiliation(s)
- Malene Helligsø Kirkeby
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Denmark
| | - Henning Grønbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Portal vein thrombosis prevalence and mortality among alcoholic cirrhosis in a nationwide inpatient cohort. Eur J Gastroenterol Hepatol 2020; 32:1160-1167. [PMID: 31834054 DOI: 10.1097/meg.0000000000001624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Portal vein thrombosis is commonly associated with cirrhosis. The effect of alcoholic cirrhosis on portal vein thrombosis prevalence and mortality has not been well studied. METHODS We conducted a retrospective cohort study utilizing the 2000-2014 National Inpatient Sample Database. We included patients older than 18 years with decompensated cirrhosis without a history of liver transplantation or hepatocellular carcinoma. We further identified patients with alcoholic cirrhosis vs. non-alcoholic cirrhosis. Primary outcomes included the risk and mortality of portal vein thrombosis in alcoholic cirrhosis. Secondary outcomes included trends of portal vein thrombosis prevalence and mortality in alcoholic cirrhosis, implications of portal vein thrombosis on complications in alcoholic cirrhosis vs. non-alcoholic cirrhosis, and risk of venous thromboembolism in alcoholic cirrhosis. RESULTS Among 1 892 271 patients with decompensated alcoholic cirrhosis, portal vein thrombosis prevalence was 1.3%. Alcoholic cirrhosis was associated with lower risk of portal vein thrombosis (odds ratio 0.76, P < 0.001) and venous thromboembolism (odds ratio 0.69, P < 0.001) compared to non-alcoholic cirrhosis. Portal vein thrombosis contributed to increased mortality (odds ratio 1.19, P < 0.001) in alcoholic cirrhosis. Portal vein thrombosis prevalence among alcoholic cirrhosis increased while mortality declined during the study period. CONCLUSION Thrombotic events including portal vein thrombosis and venous thromboembolism were found in less frequent association with alcoholic cirrhosis compared with non-alcoholic cirrhosis. Despite this, the higher in-hospital mortality found among portal vein thrombosis with alcoholic cirrhosis should prompt careful consideration of management.
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Zheng K, Guo X, Yi F, Wang L, Mancuso A, Qi X. No Association between Ischemic Stroke and Portal Vein Thrombosis in Liver Cirrhosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8172673. [PMID: 32714987 PMCID: PMC7352149 DOI: 10.1155/2020/8172673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/17/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS There seems to be a higher risk of ischemic stroke and portal vein thrombosis in liver cirrhosis. Both of them may be associated with hypercoagulability. We aim to explore the association between ischemic stroke and portal vein thrombosis in liver cirrhosis. Study Design and Methods. We selected patients from our prospectively established database of liver cirrhosis from December 2014 to July 2019. The difference between patients with and without stroke was compared. A 1 : 1 propensity score matching (PSM) analysis was performed to adjust the effect of age, sex, Child-Pugh score, and MELD score on our statistical results. RESULTS There were 349 cirrhotic patients in the cross-sectional study. The prevalence of stroke, ischemic stroke, hemorrhagic stroke, and portal vein thrombosis was 8.88% (31/349), 8.31% (29/349), 1.15% (4/349), and 28.65% (100/349) in liver cirrhosis, respectively. Patients with ischemic stroke were significantly older and had significantly higher proportions of alcohol abuse, smoking, and arterial hypertension and higher levels of white blood cell and low-density lipoprotein. However, statistical analyses with and without PSM did not find any significant association between ischemic stroke and portal vein thrombosis in patients with liver cirrhosis. CONCLUSION Ischemic stroke might not be associated with portal vein thrombosis in liver cirrhosis.
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Affiliation(s)
- Kexin Zheng
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, Liaoning Province, China
- 2Postgraduate College, Jinzhou Medical University, Jinzhou, Liaoning Province, China
| | - Xiaozhong Guo
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, Liaoning Province, China
| | - Fangfang Yi
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, Liaoning Province, China
- 3Postgraduate College, Dalian Medical University, Dalian, Liaoning Province, China
| | - Le Wang
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, Liaoning Province, China
- 3Postgraduate College, Dalian Medical University, Dalian, Liaoning Province, China
| | - Andrea Mancuso
- 4Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Piazzale Leotta 4, 90100 Palermo, Italy
| | - Xingshun Qi
- 1Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, Liaoning Province, China
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Mantaka A, Augoustaki A, Kouroumalis EA, Samonakis DN. Portal vein thrombosis in cirrhosis: diagnosis, natural history, and therapeutic challenges. Ann Gastroenterol 2018; 31:315-329. [PMID: 29720857 PMCID: PMC5924854 DOI: 10.20524/aog.2018.0245] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/26/2017] [Indexed: 12/13/2022] Open
Abstract
Portal vein thrombosis (PVT) is a frequent complication in cirrhosis and its prevalence increases with disease severity. Several factors are involved in the development and progression of PVT. The challenge for the management of PVT is the precise evaluation of the bleeding risk as opposed to life-threatening extension of thrombosis. Nevertheless, the impact on the progression and outcome of liver disease is unclear. A critical evaluation of the available data discloses that treating PVT in cirrhotics is safe and effective. However, there are open issues, such as which anticoagulant could represent a safer therapeutic option, and when and for how long this treatment should be administered to cirrhotic patients with PVT.
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Affiliation(s)
- Aikaterini Mantaka
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Elias A Kouroumalis
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
| | - Dimitrios N Samonakis
- Department of Gastroenterology and Hepatology, University Hospital of Crete, Heraklion, Crete, Greece
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Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48:455-467. [PMID: 27012444 DOI: 10.1016/j.dld.2016.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.
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Ventura P, Venturelli G, Marcacci M, Fiorini M, Marchini S, Cuoghi C, Pietrangelo A. Hyperhomocysteinemia and MTHFR C677T polymorphism in patients with portal vein thrombosis complicating liver cirrhosis. Thromb Res 2016; 141:189-95. [PMID: 27065203 DOI: 10.1016/j.thromres.2016.03.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 01/04/2016] [Accepted: 03/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is serious complication of liver cirrhosis (LC), especially in the presence of hepatocellular carcinoma (HCC). The liver plays a key role in homocysteine (Hcy) metabolism: mild hyperhomocysteinemia (HHcy) has been described in LC. HHcy is a risk factor for deep vein thrombosis. Methylen-tetrahydrofolate-reductase (MTHFR) C677T polymorphism is the commonest determinant of mild HHcy and has been involved also in cancer development. AIM To investigate a possible relation between HHcy, MTHFR status, HCC and PVT in patients affected by LC. MATERIALS AND METHODS 100 patients affected by LC, 38 with (PVT group, 24 with HCC) and 62 without PVT (LC group, 14 with HCC) sex-, age-, liver disease stage and etiology-matched were assessed for thrombophilia, smoking status, plasma Hcy, MTHFRC677T polymorphism and homocysteine-related vitamin status. RESULTS A higher prevalence of HCC, HHcy and MTHFR TT status was observed in PVT group. No significant difference in vitamin status was observed between groups. Patients with HCC showed significantly higher plasma Hcy and higher prevalence of HHcy than patients without HCC. They had also higher prevalence of MTHFR TT status. In patients with TT status (n=11) and HCC, 10 had HHcy e 9 had PVT. CONCLUSIONS Mild HHcy is associated to LC may have a role in PVT development and assessment of plasma Hcy may be suggested in patients with LC (especially if complicated by HCC). Association between HCC and MTHFR TT status is intriguing, due the postulated role for this polymorphism in cancer: it may represent a possible link between HCC and PVT.
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Affiliation(s)
- Paolo Ventura
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy.
| | - Giorgia Venturelli
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Matteo Marcacci
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Massimo Fiorini
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Stefano Marchini
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Chiara Cuoghi
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Antonello Pietrangelo
- Unit of Internal Medicine 2, Department of Medical and Surgical Science for Children and Adults, University of Modena and Reggio Emilia, Italy
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Harding DJ, Perera MTPR, Chen F, Olliff S, Tripathi D. Portal vein thrombosis in cirrhosis: Controversies and latest developments. World J Gastroenterol 2015; 21:6769-84. [PMID: 26078553 PMCID: PMC4462717 DOI: 10.3748/wjg.v21.i22.6769] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/12/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is encountered in liver cirrhosis, particularly in advanced disease. It has been a feared complication of cirrhosis, attributed to significant worsening of liver disease, poorer clinical outcomes and potential inoperability at liver transplantation; also catastrophic events such as acute intestinal ischaemia. Optimal management of PVT has not yet been addressed in any consensus publication. We review current literature on PVT in cirrhosis; its prevalence, pathophysiology, diagnosis, impact on the natural history of cirrhosis and liver transplantation, and management. Studies were identified by a search strategy using MEDLINE and Google Scholar. The incidence of PVT increases with increasing severity of liver disease: less than 1% in well-compensated cirrhosis, 7.4%-16% in advanced cirrhosis. Prevalence in patients undergoing liver transplantation is 5%-16%. PVT frequently regresses instead of uniform thrombus progression. PVT is not associated with increased risk of mortality. Optimal management has not been addressed in any consensus publication. We propose areas for future research to address unresolved clinical questions.
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Qi X, De Stefano V, Su C, Bai M, Guo X, Fan D. Associations of antiphospholipid antibodies with splanchnic vein thrombosis: a systematic review with meta-analysis. Medicine (Baltimore) 2015; 94:e496. [PMID: 25634200 PMCID: PMC4602955 DOI: 10.1097/md.0000000000000496] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/11/2014] [Accepted: 01/06/2015] [Indexed: 02/07/2023] Open
Abstract
Splanchnic vein thrombosis (SVT) refers to Budd-Chiari syndrome (BCS) and portal vein system thrombosis (PVST). Current practice guidelines have recommended the routine screening for antiphospholipid antibodies (APAs) in patients with SVT. A systematic review and meta-analysis of observational studies was performed to explore the association between APAs and SVT. The PubMed, EMBASE, and ScienceDirect databases were searched for all relevant papers, in which the prevalence of positive APAs or levels of APAs should be compared between BCS or noncirrhotic PVST patients versus healthy controls, or between cirrhotic patients with portal vein thrombosis (PVT) versus those without PVT. Fourteen studies were eligible. Only 1 study evaluated the role of APAs in BCS patients and found that positive immunoglobulin (Ig) G anticardiolipin antibody (aCL) was more frequently observed in BCS patients than in healthy controls; however, the associations of other APAs with BCS were not evaluated. Positive IgG aCL was more frequently observed in noncirrhotic patients with PVST than in healthy controls; however, other APAs, such as IgM aCL, lupus anticoagulants (LAs), anti-β2-glycoprotein-I antibody (aβ2GPI), and aβ2GPI-oxidized low-density lipoprotein antibody (ox-LDL) were not associated with noncirrhotic PVST. Positive unclassified aCL was more frequently observed in cirrhotic patients with PVT than in those without PVT; however, the association of IgG aCL and IgM aCL with the development of PVT in liver cirrhosis remained inconsistent among studies. The risk of BCS and noncirrhotic PVST might be increased by positive IgG aCL but not IgM aCL, LA, aβ2GPI, or aβ2GPI ox-LDL. However, the evidence regarding APAs in BCS originated from only 1 study. The association between APAs and PVT in liver cirrhosis was unclear.
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Affiliation(s)
- Xingshun Qi
- From the Department of Gastroenterology (XQ, XG), General Hospital of Shenyang Military Area, Shenyang; Xijing Hospital of Digestive Diseases (XQ, MB, DF), Fourth Military Medical University, Xi'an, China; Institute of Hematology (VDS), Catholic University, Rome, Italy; and Library of Fourth Military Medical University (CS), Xi'an, China
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Qi X, Li H, Liu X, Yao H, Han G, Hu F, Shao L, Guo X. Novel insights into the development of portal vein thrombosis in cirrhosis patients. Expert Rev Gastroenterol Hepatol 2015; 9:1421-32. [PMID: 26325361 DOI: 10.1586/17474124.2015.1083856] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The prognostic impact of portal vein thrombosis (PVT) in liver cirrhosis remains controversial among studies, primarily because the risk stratification of PVT is often lacking. A definition of clinically significant PVT should be proposed and actively improved. Moreover, the risk factors for the development of PVT in liver cirrhosis should be fully recognized to screen and identify high-risk patients. Currently, well-recognized risk factors include a reduced portal vein flow velocity, a worse liver function, splenectomy, liver transplantation, and factor V Leiden and prothrombin G20210A mutations. Novel risk factors include an increased flow volume of portosystemic collateral vessel, thrombopoietin receptor agnonists, and non-selective beta-blockers. In contrast to the traditional perspectives, the abnormalities of procoagulant and anticoagulant factors may not contribute to the development of PVT in liver cirrhosis. Further studies should explore the role of other risk factors, such as antiphospholipid antibodies, methylenetetrahydrofolate reductase C677T gene mutation, hyperhomocysteinemia, and myeloproliferative neoplasms.
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Affiliation(s)
- Xingshun Qi
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Hongyu Li
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Xu Liu
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Hui Yao
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Guohong Han
- b 2 Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Fengrong Hu
- c 3 Department of Digestive Diseases, No. 2 Hospital of Xi'an, Xi'an, 710003, China
| | - Lichun Shao
- d 4 Department of Gastroenterology, No. 463 Hospital of Chinese PLA, Shenyang, 110045, China
| | - Xiaozhong Guo
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
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Qi X, Chen H, Han G. Effect of antithrombin, protein C and protein S on portal vein thrombosis in liver cirrhosis: a meta-analysis. Am J Med Sci 2013. [PMID: 23187296 DOI: 10.1097/maj.0b013e31826485fc] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effects of antithrombin (AT), protein C (PC) and protein S (PS) on the pathogenesis of portal vein thrombosis (PVT) in liver cirrhosis remain controversial in different studies. In this study, a systematic review and meta-analysis to examine this issue were performed. METHODS PubMed database was employed to identify all studies in which AT, PC and PS concentrations were measured in both cirrhotic patients with and without PVT. A standardized mean difference (SMD) with 95% confidence interval (CI) was calculated to evaluate the effect of AT, PC and PS on PVT. Data were pooled using both fixed-effect and random-effect models. Only the pooled data using random-effect model were considered appropriate, when significant heterogeneity was observed. RESULTS Nine studies involving 160 cirrhotic patients with PVT and 428 cirrhotic patients without PVT were eligible. AT and PC concentrations were similar between PVT and non-PVT groups (AT: SMD = -0.21, 95% CI = -0.56 to 0.14, P = 0.24; PC: SMD = -0.23, 95% CI = -0.55 to 0.09, P = 0.16). But PS concentration was significantly lower in the PVT group than in the non-PVT group (SMD = -0.29, 95% CI = -0.49 to -0.08, P = 0.006). Subgroup analyses were further conducted in 4 studies in which baseline liver function was similar between cirrhotic patients with and without PVT, showing similar AT, PC and PS concentrations between the 2 groups (AT: SMD = -0.10, 95% CI = -0.36 to 0.16, P = 0.57; PC: SMD = -0.18, 95% CI = -0.62 to 0.25, P = 0.41; PS: SMD = -0.10, 95% CI = -0.59 to 0.39, P = 0.69). CONCLUSIONS AT, PC and PS concentrations might not be associated with the pathogenesis of PVT in liver cirrhosis, especially when the impact of liver function was excluded.
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Affiliation(s)
- Xingshun Qi
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Werner KT, Sando S, Carey EJ, Vargas HE, Byrne TJ, Douglas DD, Harrison ME, Rakela J, Aqel BA. Portal vein thrombosis in patients with end stage liver disease awaiting liver transplantation: outcome of anticoagulation. Dig Dis Sci 2013; 58:1776-80. [PMID: 23314858 DOI: 10.1007/s10620-012-2548-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/24/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence of portal vein thrombosis (PVT) increases with the severity of liver disease. Development of PVT is often accompanied by increased rate of morbidity and mortality and may affect patient candidacy for liver transplant. There is limited data regarding the role of anticoagulation therapy in patients with PVT and liver cirrhosis. OBJECTIVES The aims of this study were to describe the prevalence of hypercoagulable disorders in patients with liver cirrhosis and PVT, and to describe the outcome of anticoagulation in patients with liver cirrhosis and PVT. METHODS A retrospective chart review was conducted of patients with liver cirrhosis awaiting liver transplant who were diagnosed with PVT between January 2005 and November 2011. RESULTS During the study period, 537 patients were evaluated for liver transplant. Sixty-nine (13 %) patients were diagnosed with portal vein thrombosis. Chronic hepatitis C was the cause of liver disease in 24/69 (35 %) patients, and hepatocellular carcinoma was present in 39 % of patients. In 22 patients screened for hypercoagulable disorders, hypercoagulable disorder was diagnosed in one patient (5 %). Twenty-eight (28/69) patients were treated during the study period with warfarin: PVT resolved in 11/28 (39 %), no change in 5/28 (18 %), and 12/28 (43 %) patients showed partial resolution of thrombus. Eight patients received liver transplant while on anticoagulation, and operative notes confirmed patency of PV in all eight patients. CONCLUSIONS PVT is frequently seen in patients with end stage liver disease with prevalence of 13 %. Hypercoagulable disorder was detected in 5 % of the patients screened. Careful use of anticoagulation is safe and effective in patients with PVT.
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Affiliation(s)
- K T Werner
- Division of Gastroenterology and Hepatology, Mayo Clinic, E Mayo Blvd. 5777, Phoenix, AZ 85054, USA
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Ferro D, Angelico F, Caldwell SH, Violi F. Bleeding and thrombosis in cirrhotic patients: what really matters? Dig Liver Dis 2012; 44:275-9. [PMID: 22119620 DOI: 10.1016/j.dld.2011.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 10/13/2011] [Accepted: 10/20/2011] [Indexed: 12/11/2022]
Abstract
Bleeding complications, particularly in the gastro-intestinal tract, may complicate the clinical course of liver cirrhosis. Coexistence of abnormal global tests exploring the platelet and clotting systems generated the hypothesis that cirrhotic patients have "coagulopathy" predisposing to bleeding complications. Using more sophisticated laboratory methods this hypothesis has been partly confuted as cirrhotic patients actually disclose an ongoing prothrombotic state in the portal and systemic circulation that could predispose to thrombosis. Recent data of the literature support this hypothesis as portal vein thrombosis and peripheral thrombosis are frequent features of cirrhosis. We reviewed the literature data to assess the prevalence of bleeding and thrombotic complication in cirrhosis and the role of clotting activation in precipitating them. Whilst it appears scarcely relevant the interplay between the so called "coagulopathy" and bleeding, the interplay between clotting activation and thrombosis seems to be relevant but needs more accurate investigation in larger study populations.
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Affiliation(s)
- Domenico Ferro
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy
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Huh JY, Yi DY, Hwang SG, Choi JJ, Kang MS. Characterization of antiphospholipid antibodies in chronic hepatitis B infection. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:36-40. [PMID: 21461302 PMCID: PMC3065625 DOI: 10.5045/kjh.2011.46.1.36] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/13/2011] [Accepted: 02/15/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many infections are associated with antiphospholipid antibodies (aPLs). The purpose of this study was to investigate the prevalence, persistence, clinical significance, and characteristics of aPLs in hepatitis B virus (HBV)-infected patients. METHODS This study included 143 patients with HBV infection and 32 healthy individuals as controls. The presence of anticardiolipin antibodies (aCL Ab), anti-β(2)-glycoprotein I antibodies (β(2)GPI Ab), and lupus anticoagulant (LA) was assessed. RESULTS The total prevalence of aPLs in HBV-infected patients was 12.6% (18 of 143). Of these 18 patients, 15 had low to medium titers of aCL Ab (10 with IgM, 4 with IgG, and 1 with both isotypes). β(2)GPI Ab and LA were detected in 3 (2.1%) and 2 (1.4%) patients with HBV infection, respectively. In follow-up specimens from 14 patients with elevated levels of aCL Ab or β(2)GPI Ab, 10 (71.4%) showed the persistent presence of aPLs. No clinical manifestations related to aPLs were identified. CONCLUSION In HBV-infected patients, the most frequently detected antiphospholipid antibodies were IgM aCL Ab, which have a weak association with the clinical manifestations of APS. Unlike the transient presence reported for other infection-associated aPLs, most aPLs were persistently detected over a 12-week period in patients with HBV infection.
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Affiliation(s)
- Ji Young Huh
- Department of Laboratory Medicine, CHA Bundang Medical Center, Seongnam, Korea
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Enestvedt BK, Enestvedt CK, Diggs B, Orloff SL. Hypercoagulability in Liver Transplant Recipients: Does Portal Vein Thrombosis Predict Post-Operative Thrombotic Complications? ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ojots.2011.11001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Ponziani FR, Zocco MA, Tortora A, Gasbarrini A. Is there a role for anticoagulants in portal vein thrombosis management in cirrhotic patients? Expert Opin Pharmacother 2010; 11:1479-87. [PMID: 20446862 DOI: 10.1517/14656561003749264] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE OF THE FIELD Portal vein thrombosis (PVT) is one of the principal complications of liver cirrhosis. The estimated prevalence is < 1% in patients with a compensated disease; this increases to 8 - 25% in candidates for liver transplantation. Many determinants may influence PVT clinical presentation and its outcome. AREAS COVERED IN THIS REVIEW We report the actual knowledge regarding management of PVT and analyze the different therapeutic approaches, focusing particularly on the use of anticoagulants and their implications in the complex clinical setting of liver cirrhosis. We also describe the possible available preemptive strategies, as an early prophylactic management based on clinical, biochemical or radiological parameters may in the future reduce PVT incidence and complications, ameliorating patients' outcome. WHAT THE READER WILL GAIN The importance of an accurate PVT diagnosis and its implications in PVT management; a description of the different available therapeutic tools, their efficacy and their possible risks in different typologies of patients; the principal elements to choose a correct individualized therapy for PVT patients. TAKE HOME MESSAGE The challenge for clinicians is the early identification of PVT, in order to prevent frightening complications, such as variceal bleeding or mesenteric infarction, and to provide the best therapeutic management.
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Affiliation(s)
- Francesca Romana Ponziani
- Catholic University of Rome, Department of Internal Medicine, Largo A. Gemelli 8, 00168 Rome, Italy.
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Amitrano L, Ames PRJ, Guardascione MA, Lopez LR, Menchise A, Brancaccio V, Iannaccone L, Balzano A. Antiphospholipid antibodies and antiphospholipid syndrome: role in portal vein thrombosis in patients with and without liver cirrhosis. Clin Appl Thromb Hemost 2010; 17:367-70. [PMID: 20530055 DOI: 10.1177/1076029610369797] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
UNLABELLED The antiphospholipid syndrome (APS) has been associated with portal vein thrombosis (PVT). This study explored the contribution of antiphospholipid antibodies (aPL) to PVT in cirrhotic and noncirrhotic patients. PATIENTS AND METHODS A total of 50 patients with liver cirrhosis and PVT, 50 patients with liver cirrhosis without PVT, 50 consecutive PVT without liver cirrhosis, and 50 controls. aPL tests: lupus anticoagulants (LAs), immunoglobulin G (IgG) anti-cardiolipin antibodies (aCL), IgG anti-beta-2-glycoprotein-I (β(2)GPI), and IgG β( 2)GPI-complexed with oxidized low-density lipoprotein antibodies (ox-LDL). RESULTS Lupus anticoagulants were negative in all patients. A titre of IgG aCL >40 IgG phospholipid units (GPL) was present in 2% of patients with liver cirrhosis and in none of the other groups. In all, 4% of patients with PVT without cirrhosis were positive for IgG β(2)GPI in the absence of any other positive aPL and labelled as primary APS. CONCLUSIONS aPL play no role in PVT associated with liver cirrhosis but can be tested in idiopathic PVT.
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Affiliation(s)
- Lucio Amitrano
- Gastroenterology Unit, A. Cardarelli Hospital, Naples, Italy.
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Natural anticoagulants can be useful predictors of severity in chronic liver disease. Blood Coagul Fibrinolysis 2010; 21:122-7. [DOI: 10.1097/mbc.0b013e328335d03a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Tsochatzis EA, Senzolo M, Germani G, Gatt A, Burroughs AK. Systematic review: portal vein thrombosis in cirrhosis. Aliment Pharmacol Ther 2010; 31:366-74. [PMID: 19863496 DOI: 10.1111/j.1365-2036.2009.04182.x] [Citation(s) in RCA: 203] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND As current imaging techniques in cirrhosis allow detection of asymptomatic portal vein thrombosis during routine ultrasonography, more patients with cirrhosis are diagnosed with portal vein thrombosis. Although a consensus on noncirrhotic extra-hepatic portal vein thrombosis has been published, no such consensus exists for portal vein thrombosis with cirrhosis. AIM To perform a systematic review of nonmalignant portal vein thrombosis in cirrhosis in terms of prevalence, pathogenesis, diagnosis, clinical course and management. METHODS Studies were identified by a search strategy using MEDLINE and EMBASE. RESULTS Portal vein thrombosis is encountered in 10-25% of cirrhotics. In terms of pathophysiology, cirrhosis is no longer considered a hypocoagulable state; rather than a bleeding risk in cirrhosis, various clinical studies support a thrombotic potential. Clinical findings of portal vein thrombosis in cirrhosis vary from asymptomatic disease to a life-threatening condition at first presentation. Optimal management of portal vein thrombosis in cirrhosis is currently not addressed in any consensus publication. Treatment strategies most often include the use of anticoagulation, while thrombectomy and transjugular intrahepatic portosystemic shunts are considered second-line options. CONCLUSIONS Portal vein thrombosis in cirrhosis has many unresolved issues, which are often the critical problems clinicians encounter in their everyday practice. We propose a possible research agenda to address these unresolved issues.
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Affiliation(s)
- E A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre and Division of Surgery, Royal Free Hospital, Hampstead, London NW3 2QG, UK
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Zhang D, Hao J, Yang N. Protein C and D-dimer are related to portal vein thrombosis in patients with liver cirrhosis. J Gastroenterol Hepatol 2010; 25:116-21. [PMID: 19686413 DOI: 10.1111/j.1440-1746.2009.05921.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM To profile changes of coagulation, anticoagulation and fibrolytic factors associated with liver function failure and portal vein thrombosis (PVT) formation in chronic liver cirrhosis patients. METHODS A total of 116 cirrhotic patients admitted to our hospital from June 2006 to October 2008 were included in our study. All patients were classified into two groups: PVT group (31 patients), composed of patients with PVT and a control group (85 patients), including patients without PVT. Platelet, prothrombin time (PT), activated partial prothrombin time (APTT) and fibrinogen were measured. Also, plasma samples from the patients were analyzed for the levels of antithrombin III (AT-III), protein C (PC), protein S (PS), D-dimer, tissue-type plasminogen activator as well as plasminogen activator inhibitor-1. Statistical analyses were carried out to evaluate the correlation of specific variations with the disease status. RESULTS In general, the higher Child-Pugh scores, indicating the aggravation of hepatic impairment of the patients, correlated well with the prolonged PT/APTT and increased D-dimer, as well as decreased platelet, fibrinogen, PC and AT-III levels in the serum. Furthermore, we found that the PC, PS and D-dimer levels in PVT patients were 2.32 +/- 0.72 mg/L, 17.14 +/- 3.62 mg/L and 0.99 +/- 0.36 mg/L, respectively, both representing a significant difference compared with those in the control group without PVT. Logistic regression model shows that the odds ratio value of one unit of increase of PC and D-dimer were 0.48 and 15.57. CONCLUSIONS Cirrhotic patients displayed dysfunctions in the coagulation, anti-coagulation and fibrolytic systems. The development of PVT in these patients may be independently associated with the decrease of PC, PS and D-dimer. Furthermore, decreasing PC and increasing D-dimer may be risk factors inducing PVT in cirrhotic patients.
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Affiliation(s)
- Donglei Zhang
- Beijing Chaoyang Hospital Affiliate of Capital Medical University, Department of Gastroenterology, Beijing, China.
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Management of portal vein thrombosis in cirrhotic patients. Mediterr J Hematol Infect Dis 2009; 1:e2009014. [PMID: 21415954 PMCID: PMC3033127 DOI: 10.4084/mjhid.2009.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 10/24/2009] [Indexed: 12/17/2022] Open
Abstract
Portal vein thrombosis (PVT) not associated with hepatocellular carcinoma is considered a frequent complication of liver cirrhosis but, unlike PVT occurring in non-cirrhotic patients, very few data are available on its natural history and management. The reduced portal blood flow velocity is the main determinant of PVT but, as in other venous thromboses, multiple factors local and systemic, inherited or acquired often can concur with. PVT has a variety of clinical presentations ranging from asymptomatic to life-threatening diseases like gastroesophageal bleeding or acute intestinal ischemia. It is usually diagnosed by Doppler ultrasound but computed tomography and magnetic resonance imaging are useful to study the extent of thrombosis and the involvement of the abdominal organs. The risk of bleeding mainly determined by the presence of gastroesophageal varices and clotting alterations causes concern for the treatment of PVT in cirrhotic patients. To date, anticoagulant therapy seems to be indicated only in patients awaiting liver transplantation. This review focuses on the definition of the subgroups of patients with cirrhosis that might benefit from treatment of PVT and examines the pros and cons of the available treatments in terms of efficacy, monitoring and safety, providing also perspectives for future studies.
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Zocco MA, Di Stasio E, De Cristofaro R, Novi M, Ainora ME, Ponziani F, Riccardi L, Lancellotti S, Santoliquido A, Flore R, Pompili M, Rapaccini GL, Tondi P, Gasbarrini GB, Landolfi R, Gasbarrini A. Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol 2009; 51:682-9. [PMID: 19464747 DOI: 10.1016/j.jhep.2009.03.013] [Citation(s) in RCA: 328] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 02/19/2009] [Accepted: 03/17/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Prognostic scores currently used in cirrhotic patients do not include thrombotic risk factors (TRFs). Predicting factors of portal vein thrombosis (PVT) development are still unknown. We wanted to describe TRFs as a function of liver disease severity using the MELD score and assess the role of local and systemic TRFs as predictors of PVT development in cirrhotic patients. METHODS One hundred consecutive patients with liver cirrhosis were included in the study. TRFs, D-dimers, MELD score, portal vein patency and flow velocity were evaluated in all subjects at baseline and every 6 months thereafter. Variables able to predict PVT development within 1 year were identified by means of multiple logistic regression. RESULTS The plasma levels of protein C and antithrombin were lower and the concentration of D-dimers was higher in patients with advanced disease. Plasma levels of antithrombin, protein C and protein S resulted significantly lower in PVT group at univariate analysis, but reduced portal vein flow velocity was the only variable independently associated with PVT development. CONCLUSIONS Lower concentrations of natural coagulation inhibitors are frequently detected in patients with liver cirrhosis. A reduced portal flow velocity seems to be the most important predictive variable for PVT development in patients with cirrhosis.
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Affiliation(s)
- Maria Assunta Zocco
- Department of Internal Medicine, Catholic University of Rome, Gemelli Hospital, Largo A. Gemelli 8, 00168 Rome, Italy.
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Weber A, Krebs S, Lenhardt C, Wagenpfeil S, Schmid RM, Schulte-Frohlinde E. Correlation of routinely used coagulation parameters and presence of portal vein thrombosis in patients with liver cirrhosis. Hepatol Res 2009; 39:882-7. [PMID: 19619258 DOI: 10.1111/j.1872-034x.2009.00531.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Portal vein thrombosis (PVT) is a serious complication in patients with liver cirrhosis. In patients with advanced stages of liver cirrhosis plasmatic coagulation and platelet count are often reduced. However, patients with normal coagulation status might carry a high risk for developing PVT. A correlation between coagulation status used in clinical routine and the incidence of PVT in patients with liver cirrhosis has been evaluated in the present retrospective analysis. METHODS 88 patients with liver cirrhosis were identified by screening a database. Of these patients, 23 suffered from PVT. Patients were classified according to the Child-Pugh classification. Patients were subdivided into early stages (Child A) and advanced stages (Child B/C) of liver cirrhosis. RESULTS In patients with Child-Pugh A cirrhosis, there was no difference in activated partial thromboplastin time (apTT), international normalized ratio (INR), and platelet count between the PVT (n = 7) and the control group (n = 35). In contrast, the median apTT and INR were significantly lower in patients with Child B/C cirrhosis and PVT (n = 16) in comparison with patients without PVT (37 s vs 43 s [P = 0.017] and 1.25 vs 1.40 [P = 0.022]), respectively. Platelet count did not differ significantly in patients with advanced liver cirrhosis and PVT from those without PVT. CONCLUSION Patients with advanced liver cirrhosis and PVT displayed lower apTT and INR compared with those without PVT. Therefore, patients with advanced liver cirrhosis and almost normal coagulation parameters might be at particular risk of developing PVT. The results suggest that regular monitoring using Doppler-ultrasound should be carried out in these patients, especially when liver transplantation is intended.
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Affiliation(s)
- Andreas Weber
- II. Medical Department, Technical University Munich, Munich, Germany
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Abstract
AIM: To determine risk factors of portal vein thrombosis (PVT) in liver cirrhosis patients.
METHODS: Ninety patients diagnosed as hepatitis or non-alcoholic liver cirrhosis from 2006 to 2007 in our hospital were reviewed, including 23 liver cirrhosis cases with PVT in thrombosis group and 67 without PVT in the control group. A coagulation method was used to measure prothrombin time (PT), activated partial prothrombin time (APTT) and fibrinogen (Fib); hair color substrate was used to detect antithrombin-Ⅲ (AT-Ⅲ); ELISA was used to detect protein C (PC), protein S (PS), d-dimer, t-PA and PAI-1. Using an analyzer and following manufacturer instructions, a series of hemostatic indexes were performed on 90 LC patients with and without PVT. SPSS software was used for statistic analysis.
RESULTS: Logistic regression model showed that the increased d-dimer was a risk factor (OR = 13.236, 95% CI: 2.345-74.721) and the increased PC and AT-Ⅲ were the protective factors in PVT development (OR = 0.242, 95% CI: 0.08-0.727; OR = 0.917, 95% CI: 0.841-0.999). No differences were found in gender, Child-Pugh scores and APTT et al.
CONCLUSION: The increased d-dimer was the risk factor for liver cirrhosis patients with PVT while PC and AT-Ⅲ were the protective factors.
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Abstract
Portal vein thrombosis (PVT) is observed in 10-20% of patients with liver cirrhosis, which is responsible for 20% of all PVT cases. The main pathogenic factor of PVT in cirrhosis is the obstacle to portal flow, but acquired and inherited clotting abnormalities may play a role. The formation of collateral veins allows many patients to remain asymptomatic and prevents the onset of clinical complications also in patients with totally occlusive PVT. Gastrointestinal bleeding, thrombosis of superior mesenteric vein and refractory ascites are typical manifestations of PVT. Instrumental diagnosis can be obtained by colour-doppler ultrasonography. Future studies should verify whether asymptomatic PVT worsens liver failure, or if its life-threatening complications reduce survival in patients with cirrhosis. Moreover, randomized controlled trials should clarify the potential effectiveness of anticoagulant therapy in the treatment of PVT.
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Affiliation(s)
- Filippo Luca Fimognari
- Division of Internal Medicine, ASL Roma G, Leopoldo Parodi-Delfino Hospital, Colleferro, Rome, Italy.
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Impact of neutrophil apoptosis on haemostatic activation in chronic liver disease patients. Blood Coagul Fibrinolysis 2008; 19:535-42. [PMID: 18685437 DOI: 10.1097/mbc.0b013e3283079e15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent studies suggest the impact of apoptosis on the mechanisms leading to hypercoagulability. We aimed to clarify the potential role of neutrophil apoptosis in neutropenia and hypercoagulable state encountered in chronic liver disease patients. This study was conducted on 15 normal controls and 45 patients with chronic liver disease classified according to modified Child Pugh classification into, Child A, B and C groups (15 cases each). Haemostatic parameters studied include, prothrombin time, partial thromboplastin time, tissue factor, protein C antigen, protein S antigen, and markers of haemostatic activation [prothrombin fragment 1+2 (F1+2), thrombus precursor protein (TpP) and D-dimer]. Flowcytometric study was done for quantitative assay of neutrophil apoptotic subpopulations to detect the percentage of early and late apoptotic, and necrotic neutrophils using Annexin V-FITC/propidium iodide dye. Semiquantitative assay of apoptotic neutrophils showing DNA fragmentation was performed on neutrophil culture using terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labelling test. In addition to enzyme-linked immunosorbent assay for soluble Fas (APO-1/CD95) in culture supernatant. The results revealed a rise in the neutrophil apoptotic and necrotic markers with progression of the disease, and they were inversely correlated with the absolute neutrophil count. The apoptotic neutrophil cells showed a significant positive correlation with several haemostatic parameters (tissue factor, prothrombin fragment 1+2, thrombus precursor protein and D-dimer). Regression analysis proved that apoptotic parameters are independent determinants of prothrombotic markers, which further incriminate the apoptotic mechanisms in the hypercoagulable state encountered in this clinical setting.
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Abstract
BACKGROUND The liver is the site for synthesis of the vast majority of proteins that play a central role in maintaining hemostasis, by participating in the regulation of coagulation and fibrinolysis. AIM To summarize the available data on the impact of coagulation disorders in patients with chronic liver disease. RESULTS Hepatocellular damage in patients with severe liver disease can lead to abnormalities in the production and function of coagulation and fibrinolytic factors, disrupting the balance between coagulation and anticoagulation systems. CONCLUSIONS Hemostatic abnormalities (eg. impaired synthesis of clotting factors, heightened fibrinolysis, disseminated intravascular coagulation, thrombocytopenia, and platelet dysfunction) can increase the risk of bleeding in cirrhotic patients.
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Affiliation(s)
- M Peck-Radosavljevic
- Department of Gastroenterology and Hepatology, Medizinische Universität & AKH Wien, Vienna, Austria.
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Pulini S, D'Amico E, Basilico R, Mereu M, Bacci F, Spadano A, Fioritoni G. Portal venous thrombosis in a young patient with idiopathic myelofibrosis and intrahepatic extramedullary hematopoiesis: a difficult diagnosis, prognosis and management. Leukemia 2007; 21:2373-5. [PMID: 17581614 DOI: 10.1038/sj.leu.2404789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
End stage liver disease results in a complex and variably severe failure of hemostasis that predisposes to abnormal bleeding. The diverse spectrum of hemostatic defects includes impaired synthesis of clotting factors, excessive fibrinolysis, disseminated intravascular coagulation, thrombocytopenia, and platelet dysfunction. Hemostasis screening tests are used to assess disease severity and monitor the response to therapy. Correction of hemostatic defects is required in patients who are actively bleeding or require invasive procedures. Fresh frozen plasma, cryoprecipitate, and platelet transfusion remain the mainstays of therapy until larger trials confirm the safety and efficacy of recombinant factor VIIa in this population.
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Affiliation(s)
- Jody L Kujovich
- Division of Hematology and Medical Oncology, Mail Code: L-586, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR 97239-3098, USA.
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Al Ghumlas AK, Abdel Gader AGM, Al Faleh FZ. Haemostatic abnormalities in liver disease: could some haemostatic tests be useful as liver function tests? Blood Coagul Fibrinolysis 2005; 16:329-35. [PMID: 15970716 DOI: 10.1097/01.mbc.0000174080.54871.6b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The liver plays a central role in haemostasis, being the site of synthesis of most of the clotting factors, coagulation inhibitors and fibrinolytic parameters, in addition to its clearance of activated clotting and fibrinolytic factors. Nonetheless, no haemostatic test(s) is included among the routine liver function tests and this study aims to probe this possibility. The liver disease group (n=258) included acute hepatitis (n=25), chronic viral hepatitis (n=128), hepatitis B (HB) carriers (n=25), liver cirrhosis (n=67), and hepatocellular carcinoma (HCC) (n=13). The prothrombin time was significantly prolonged in acute hepatitis, liver cirrhosis and HCC. However, the reptilase time was prolonged in all the groups except in HB carriers, while the thrombin time was prolonged only in the HCC group. Antithrombin III and protein C levels exhibited significant reduction in acute hepatitis, liver cirrhosis and HCC. On the other hand, protein S levels (total and free) were reduced significantly in all the patients groups, including HB carriers when compared with healthy controls. Derangement of haemostatic tests is a common feature in liver disease, being most significant in acute hepatitis, liver cirrhosis and hepatocellular carcinoma. The most sensitive markers of hepatocyte malfunction are protein S (total and free) and the reptilase time as they were abnormal, in the mildest liver affections, when other biochemical tests as well as other haemostatic tests were normal. Further studies are needed to see whether these two tests qualify for inclusion among the routine liver function tests.
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Affiliation(s)
- Abeer K Al Ghumlas
- The Coagulation Laboratory, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia
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Amitrano L, Guardascione MA, Brancaccio V, Margaglione M, Manguso F, Iannaccone L, Grandone E, Balzano A. Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. J Hepatol 2004; 40:736-41. [PMID: 15094219 DOI: 10.1016/j.jhep.2004.01.001] [Citation(s) in RCA: 361] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2003] [Revised: 12/27/2003] [Accepted: 01/07/2004] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Portal vein thrombosis in patients with liver cirrhosis is usually associated to hepatocellular carcinoma. Clinical presentation of non-neoplastic portal vein thrombosis (PVT) in cirrhotic patients has not been specifically studied and risk factors of PVT in this group of patients are still poorly understood. METHODS We studied all patients with PVT and liver cirrhosis admitted to our Unit from January 1998 to December 2002. They were paired (by gender, age and Child-Pugh score) to a group of cirrhotic patients without PVT and screened for acquired and inherited thrombophilic risk factors. These factors together with the site of thrombosis and the severity of the liver disease were correlated to the clinical presentation of PVT. RESULTS Out of a total of 701 cirrhotic patients admitted to our hospital and routinely screened with Doppler ultrasound, 79 (11.2%) were found to have PVT. Of these, 34 (43%) were asymptomatic and 45 (57%) were symptomatic (31 presented with portal hypertensive bleed and 14 with abdominal pain, 10 of whom had intestinal infarction). Mesenteric vein involvement was never asymptomatic and lead to intestinal ischemia or infarction. Most patients were in class Child-Pugh B and C. Among thrombophilic risk factors studied only the mutation 20210 of the prothrombin gene resulted independently associated to PVT. CONCLUSIONS Portal vein thrombosis may be completely asymptomatic in patients with liver cirrhosis; however in more than half of cases presents with life-threatening complications such as gastrointestinal haemorrhage and intestinal infarction. Cirrhotic patients with PVT usually have an advanced liver disease and the presence of the mutation 20210 of the prothrombin gene increases more than fivefold the risk of PVT.
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Affiliation(s)
- Lucio Amitrano
- Gastroenterology Unit, A. Cardarelli Hospital, Naples, Italy.
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Romero-Gömez M, Gutierrez-Tous R, Delgado-Mije D. Anticoagulation therapy for recent portal vein thrombosis in a patient with liver cirrhosis suffering from variceal rebleeding. Gastroenterology 2002; 122:2095. [PMID: 12055619 DOI: 10.1053/gast.2002.34024] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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