Association between venous thromboembolism and acute pancreatitis: An analysis from the nationwide inpatient sample

Celiac disease is associated with increased risk of deep vein thrombosis and hypotensive shock in patients admitted with acute pancreatitis

Background and Aim

Celiac disease (CD) was shown to be associated with increased risk of developing acute pancreatitis (AP). There is a paucity of literature critically analyzing the association of CD with AP outcomes. We aimed to evaluate the impact of CD on outcomes and complications of AP in recent years.

Methods

A population-based analysis was performed using the National Inpatient Sample (NIS) between 2016 and 2019. Multivariable logistic regression was conducted to identify the independent impact of CD on AP outcomes while controlling for demographics and comorbidities and all patients refined diagnosis-related groups (APR-DRG) risk of severity subclass.

Results

From 2016 to 2019, a total of 2 253 730 inpatients with AP were identified, of which 4640 (0.2%) had CD. On multivariable analysis, while controlling for demographics, comorbidities, and severity of illness, CD patients had significantly decreased odds for mortality (OR = 0.387), pseudocyst formation (OR = 0.786), sepsis (OR = 0.707), respiratory failure (OR = 0.806), acute kidney injury (AKI) (OR = 0.804), and myocardial infarction (OR = 0.217), (P < 0.05). However, CD patients were at significantly increased odds for deep vein thrombosis (DVT) (OR = 2.240) and hypotensive shock (OR = 1.718) (P < 0.05). Patients with CD had shorter lengths of stay by 0.4 days and lower total charges by $12 690.

Conclusions

Our nationwide study evaluating AP outcomes in patients with CD suggests that patients with CD admitted for AP tend to have better mortality and several other outcomes compared to non-CD patients. We also show that CD patients admitted for AP have a greater risk for DVT and hypotensive shock. Future studies are warranted to validate the revealed findings in CD patients admitted for AP.

Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk.

METHODS

The German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005-2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated.

RESULTS

Overall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0-71.0] years), 39.2 % females) were detected in Germany 2005-2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513-1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854-4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619-1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684-4.181], P < 0.001).

CONCLUSIONS

VTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.

Venous Thrombosis in Acute Pancreatitis: What to and Not to Do?

Acute pancreatitis is an acute inflammatory condition of the pancreas that has not only local but systemic effects as well. Venous thrombosis is one such complication which can give rise to thrombosis of the peripheral vasculature in the form of deep vein thrombosis, pulmonary embolism, and splanchnic vein thrombosis. The prevalence of these complications increases with the severity of the disease and adds to the adverse outcomes profile. With better imaging and awareness, more cases are being detected, although many at times it can be an incidental finding. However, it remains understudied and strangely, most of the guidelines on the management of acute pancreatitis are silent on this aspect. This review offers an overview of the incidence, pathophysiology, symptomatology, diagnostic work-up, and management of venous thrombosis that develops in AP.

Acute Pancreatitis Complicated by Thrombosis in the Right Brachiocephalic Veins and Superior Vena Cava: A Case Report

BACKGROUND

Acute pancreatitis (AP) is one of the most common digestive emergencies, and vascular complication is one of the primary reasons for death, with splanchnic venous thrombosis being the most common. Although extra-splanchnic venous thrombosis is rare, it carries the risk of life-threatening secondary pulmonary embolism.

CASE PRESENTATION

We have, herein, reported a case of AP complicated by rare brachiocephalic vein thrombosis and superior vena cava thrombosis. A 40 years old woman was diagnosed with severe AP for abdominal pain 21 days ago. The patient received symptomatic treatment, including acid suppression, enzyme suppression, lipid-lowering, fluid infusion, anti-infection, and continuous renal replacement therapy. The patient was discharged after symptomatic relief. Recently, the patient was admitted again for middle-upper abdominal pain and discomfort. On admission, her blood platelet, DDimer, fibrin degradation products (FDP), and triglyceride levels have been found to be increased; abdominal enhanced CT showed pancreatic necrosis and an accumulation of peripancreatic necrosis and fluid, while chest enhanced CT suggested thrombosis in the right brachiocephalic vein and superior vena cava. The patient, however, improved and was discharged after anticoagulation combined with insulin and trypsin inhibitors.

CONCLUSION

In diagnosing and treating AP, dynamic monitoring of D-dimer levels is necessary for the timely detection of the development of thrombotic complications.

Acute pancreatitis induces a transient hypercoagulable state in murine models

BACKGROUND/OBJECTIVES

Although understudied, risk of venous thromboembolism (VTE) appears to be increased during acute pancreatitis (AP). We aimed to further characterize a hypercoagulable state associated with AP utilizing thromboelastography (TEG), a readily available, point of care test.

METHODS

AP was induced in C57/Bl6 mice using l-arginine and caerulein. TEG was performed with citrated native samples. The maximum amplitude (MA) and coagulation index (CI), a composite marker of coagulability, were evaluated. Platelet aggregation was assessed using whole blood collagen-activated platelet impedance aggregometry. Circulating tissue factor (TF), the initiator of extrinsic coagulation, was measured with ELISA. A VTE model using IVC ligation followed by measurement of clot size and weight was evaluated. After IRB approval and consent, blood samples from patients hospitalized with a diagnosis of AP were evaluated by TEG.

RESULTS

Mice with AP displayed a significant increase in MA and CI, consistent with hypercoagulability. Hypercoagulability peaked at 24 h after induction of pancreatitis, then returned to baseline by 72 h. AP resulted in significantly increased platelet aggregation and elevated circulating TF. Increased clot formation with AP was observed in an in vivo model of deep vein thrombosis. In a proof of concept, correlative study, over two thirds of patients with AP demonstrated an elevated MA and CI compared to the normal range, consistent with hypercoagulability.

CONCLUSIONS

Murine acute pancreatitis results in a transient hypercoagulable state that can be assessed by TEG. Correlative evidence for hypercoagulability was also demonstrated in human pancreatitis. Further study to correlate coagulation measures to incidence of VTE in AP is warranted.

Chemoprophylaxis to Prevent Deep Venous Thrombosis in Patients Hospitalized for Pancreatitis: Beneficial or Harmful?

Introduction: Vascular complications in pancreatitis generally occur in the form of hemorrhage or thrombosis. Pancreatitis resulting in splanchnic thrombosis has been well studied, but the cause of this correlation has not been studied in the current era of increasing anticoagulant use for deep venous thrombosis (DVT) prophylaxis. Hemorrhagic pancreatitis and peri-pancreatic bleeding are also known phenomena encountered in relation to pancreatitis, but these risks are not well established in the setting of chemical prophylaxis for DVT.

Objectives: Our objective was to identify whether chemical DVT prophylaxis in pancreatitis harms the patient by increasing the risk of hemorrhagic conversion of pancreatitis or peri-pancreatic hemorrhage or if it is beneficial by preventing splanchnic venous thrombosis in the abdominal vasculature that surrounds the pancreas.

Methods: We undertook a retrospective chart review with approval from the Institutional Review Board on patients who were hospitalized for or developed pancreatitis during their hospital stay from April 2014 to July 2015. We reviewed the charts for imaging suggestive of venous thrombosis or the development of intra-abdominal hemorrhage at admission during hospitalization and within 30 days after hospitalization. We also reviewed the methods of DVT prophylaxis to identify any correlation with the risk of hemorrhage or thrombosis. A bedside index of severity in acute pancreatitis score was used within 24 hours of admission to calculate the severity of the patients’ pancreatitis. The data collected were analyzed for descriptive statistics, correlation using Pearson’s coefficient, and multivariate regression analysis using Microsoft Excel and SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.

Results: This study included 389 patients who met the inclusion criteria. Of these, 74.6% of patients received chemical prophylaxis, mostly low molecular weight heparin, and 18.5% of patients were not on chemical or mechanical means of DVT prophylaxis. Only 12 patients (3%) had complications related to thrombosis and hemorrhage. Seven patients had splanchnic venous thrombosis, one had a hemorrhagic conversion of pancreatitis, three had a peri-pancreatic hemorrhage, and one had both the hemorrhagic conversion of pancreatitis and peri-pancreatic hemorrhage. Ten patients out of 12 patients had complications before admission, and nine of the 12 patients were on chemical prophylaxis. Pearson’s coefficient showed no statistically significant correlation between the incidence of complications and the use of chemical DVT prophylaxis. Multivariate analysis showed no specific variable that increased the risk of complications.

Conclusions: Our study showed that chemoprophylaxis for DVT in patients hospitalized for acute pancreatitis is neither harmful by causing hemorrhagic conversion of pancreatitis, peri-pancreatic hemorrhage nor beneficial by preventing splanchnic venous thrombosis.

Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study

OBJECTIVES

Studies on the incidence of venous thromboembolism (VTE) in acute pancreatitis (AP) are scarce. We conducted a large database study to evaluate this relationship.

METHODS

Data were extracted from a large electronic health record (Explorys; IBM Watson Health, Armonk, NY). We identified patients with AP in 2018 and 2019, analyzing VTE incidence at 30 days after diagnosis of AP. Univariate and multivariate analyses were performed to identify risk factors associated with VTE.

RESULTS

A total of 25,620 cases of acute necrotizing pancreatitis (ANP) and 155,800 cases of acute nonnecrotizing pancreatitis (ANNP) were identified. The incidence of VTE was 7.1% for ANP, compared with 2.8% in ANNP (P < 0.001). On multivariate analysis, ANP conferred significantly greater odds of VTE (adjusted odds ratio, 2.78; 95% confidence interval, 2.73-2.84; P < 0.001), independent of other variables. In those with ANP, the presence of VTE was associated with a significantly higher mortality (23.5% vs 15.9%, P < 0.001).

CONCLUSIONS

Acute necrotizing pancreatitis carries near 2.5-fold risk of VTE, and a 3-fold risk of PE, compared with those with ANNP. Venous thromboembolism development in ANP is associated with higher mortality.

Falling Through the Cracks: The Need to Include Acute Pancreatitis in Risk Assessment Models for Acute Deep Venous Thrombosis

Acute pancreatitis is an inflammatory condition caused by an insult to the pancreas. Pancreatitis is associated with local and systemic complications such as splenic vein thrombosis and systemic inflammatory response syndromes (SIRS), respectively. Pancreatitis increases the risk of deep vein thrombosis (DVT) through a combination of increased production of pro-inflammatory cytokines and systemic vascular injury. However, DVT and pulmonary embolism remain under-recognized and underappreciated complications of acute pancreatitis as they fall through the cracks in the commonly used venous thromboembolism (VTE) risk assessment model. We therefore propose that VTE prophylaxis needs to be considered by all clinicians when admitting and evaluating patients with acute pancreatitis and that acute pancreatitis needs to be included on the various VTE risk assessment calculators as it is a significant risk factor for the development of VTE.