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Boccatonda A, Gentilini S, Zanata E, Simion C, Serra C, Simioni P, Piscaglia F, Campello E, Ageno W. Portal Vein Thrombosis: State-of-the-Art Review. J Clin Med 2024; 13:1517. [PMID: 38592411 PMCID: PMC10932352 DOI: 10.3390/jcm13051517] [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: 02/11/2024] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Portal vein thrombosis (PVT) is a rare disease with an estimated incidence of 2 to 4 cases per 100,000 inhabitants. The most common predisposing conditions for PVT are chronic liver diseases (cirrhosis), primary or secondary hepatobiliary malignancy, major infectious or inflammatory abdominal disease, or myeloproliferative disorders. Methods: PVT can be classified on the basis of the anatomical site, the degree of venous occlusion, and the timing and type of presentation. The main differential diagnosis of PVT, both acute and chronic, is malignant portal vein invasion, most frequently by hepatocarcinoma, or constriction (typically by pancreatic cancer or cholangiocarcinoma). Results: The management of PVT is based on anticoagulation and the treatment of predisposing conditions. The aim of anticoagulation in acute thrombosis is to prevent the extension of the clot and enable the recanalization of the vein to avoid the development of complications, such as intestinal infarction and portal hypertension. Conclusions: The treatment with anticoagulant therapy favors the reduction of portal hypertension, and this allows for a decrease in the risk of bleeding, especially in patients with esophageal varices. The anticoagulant treatment is generally recommended for at least three to six months. Prosecution of anticoagulation is advised until recanalization or lifelong if the patient has an underlying permanent pro-coagulant condition that cannot be corrected or if there is thrombosis extending to the mesenteric veins.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, Azienda Unità Sanitaria Locale (AUSL) Bologna, 40010 Bentivoglio, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Simone Gentilini
- Internal Medicine Department, IRCCS Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (S.G.); (E.Z.)
| | - Elisa Zanata
- Internal Medicine Department, IRCCS Azienda Ospedaliero-Universitaria Policlinico di Sant’Orsola, 40138 Bologna, Italy; (S.G.); (E.Z.)
| | - Chiara Simion
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy (E.C.)
| | - Carla Serra
- Interventional, Diagnostic and Therapeutic Ultrasound Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy (E.C.)
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy (E.C.)
| | - Walter Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
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Liu J, Gong H, Chen X, Tang C, Huang L. A narrative review of acute pancreatitis-induced splanchnic vein thrombosis: from pathogenesis to clinical management. Scand J Gastroenterol 2024; 59:204-212. [PMID: 37933195 DOI: 10.1080/00365521.2023.2271111] [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: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
Acute pancreatitis-induced splanchnic vein thrombosis (APISVT) is an important sequela complication of acute pancreatitis, which may cause poor prognosis, such as severe gastrointestinal hemorrhage, bowel ischemic necrosis and liver failure. However, its mechanism remains uncertain, and there is not a general consensus on the management. In this study, we reviewed the latest academic publications in APISVT, and discussed its pathogenesis, clinical presentation, adverse outcome and treatment, especially focused on the role of anticoagulant therapy. It was indicated that anticoagulation therapy can significantly elevate thrombus recanalization and reduce the incidence of complications and mortality with no increase of bleeding. Actually, as most of these studies were retrospective analyses and prospective studies included small samples, the conclusion remains controversial. Thus, well-designed randomized controlled trials are urged to verify the effectiveness and safety of anticoagulation therapy for APISVT.
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Affiliation(s)
- Jiaping Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Hui Gong
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohua Chen
- Central Department of Transportation, West China Hospital, Sichuan University, Chengdu, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Libin Huang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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Ingviya T, Wasuwanich P, Scheimann AO, Felix G, Laengvejkal P, Vasilescu A, Imteyaz H, Seaberg EC, Karnsakul W. Clinical Predictors of Morbidity and Mortality in Hospitalized Pediatric Patients With Ascites. J Pediatr Gastroenterol Nutr 2021; 73:86-92. [PMID: 33633084 DOI: 10.1097/mpg.0000000000003104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Ascites is a pathologic buildup of fluid in the peritoneal cavity. Knowledge is lacking in clinical outcome in pediatric patients with ascites. We aim to identify and assess clinical variables, associated with morbidity and mortality in pediatric patients who are hospitalized with ascites. METHODS A retrospective cohort study was performed on patients ages 0 to 21 hospitalized at Johns Hopkins Hospital between 1983 and 2010 with an ICD-9 discharge diagnosis of ascites (789.5, 789.51, 789.59). A total of 518 pediatric patients were studied, all with a diagnosis of ascites during hospitalization. Study outcomes included hospital length of stay (LOS) as a proxy for morbidity and death at hospital discharge for mortality. Variables analyzed included demographic data, ascites etiology and grade, comorbidities, and laboratory markers. Variables were analyzed by log-linear regression and competing risk model. RESULTS Among the 3 age groups (0-5, 6-12, and 13-21), the 0 to 5 age group experienced significantly increased LOS (P < 0.001) and mortality (P = 0.027). Ascites etiology of veno-occlusive disease (VOD) and the presence of hydrothorax or thrombocytopenia was also significantly associated with increased LOS. Ascites with the etiology of congestive hepatopathy and the presence of grade 3 ascites, hepatic encephalopathy, hepatorenal syndrome, hydrothorax, hyponatremia, and thrombocytopenia were associated with increased mortality. Additionally, black pediatric patients have an increased risk of mortality (P = 0.027). Other factors including sex, leukopenia, portal vein thrombosis, and splenomegaly were not associated with LOS or mortality. CONCLUSIONS Morbidity and mortality in pediatric patients hospitalized with ascites are associated with specific demographic and clinical factors. Further studies are required to apply this knowledge to predict the clinical outcomes.
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Affiliation(s)
- Thammasin Ingviya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Medical Data Center for Research and Innovation
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Paul Wasuwanich
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN
| | - Ann O Scheimann
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Grace Felix
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pavis Laengvejkal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Vasilescu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hejab Imteyaz
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric C Seaberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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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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Hanafy AS, Abd-Elsalam S, Dawoud MM. Randomized controlled trial of rivaroxaban versus warfarin in the management of acute non-neoplastic portal vein thrombosis. Vascul Pharmacol 2019; 113:86-91. [PMID: 29886103 DOI: 10.1016/j.vph.2018.05.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/09/2018] [Accepted: 05/09/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Anticoagulation therapy is the main line of treatment for acute portal vein thrombosis (PVT) in the absence of cirrhosis. However, the use of this therapy in cirrhotic PVT is still with doubtful evidence. We aimed to evaluate the efficacy and safety of rivaroxaban compared to warfarin for the management of acute non-neoplastic PVT in Hepatitis C virus (HCV)-related compensated cirrhosis. METHODS Out of 578 patients with chronic HCV infection, 80 patients with acute PVT who had undergone splenectomy due to hypersplenism and 4 patients with acute PVT due to portal pyemia were selected. The patients were randomly assigned (1:1) to the study group (n = 40), in which the patients received rivaroxaban 10 mg/12 h, or the control group (n = 40), in which the patients received warfarin. RESULTS In the rivaroxaban group, the resolution of PVT was achieved in 34 patients (85%) within 2.6 ± 0.4 months and delayed, partial recanalization after 6.7 ± 1.2 months (n = 6.15%). Complications such as major bleeding, abnormal liver functions, death, or recurrence did not occur during treatment, and patients in this group showed improved short-term survival rate (20.4 ± 2.2 months) compared to the survival rate in the control group (10.6 ± 1.8 months) in which warfarin achieved complete resolution in 45% of patients. Complications such as severe upper GI tract bleeding (43.3%), hepatic decompensation (22.5%), progression to mesenteric ischemia (12.5%), recurrence (10%), and death (20%) were observed in the control group. The duration until complete resolution of thrombus correlated with age, the extent of the thrombus, creatinine level, and MELD score. The recurrence after complete resolution of thrombus correlated with age, the extent of the thrombus, thrombogenic gene polymorphism, and the use of warfarin. CONCLUSION Rivaroxaban was effective and safe in acute HCV-related non-neoplastic PVT with improved short-term survival rate; ClinicalTrials.gov Identifier: NCT03201367.
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Affiliation(s)
- Amr Shaaban Hanafy
- Internal Medicine Department, Hepatology Division, Zagazig University, Egypt.
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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Karuppasamy K. Utility of cone-beam computed tomography in the assessment of the porto-spleno-mesenteric venous system. Cardiovasc Diagn Ther 2017; 6:544-556. [PMID: 28123975 DOI: 10.21037/cdt.2016.11.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The common diagnostic tools available to evaluate the porto-spleno-mesenteric venous (PSMV) system provide either good hemodynamic information with limited morphological details [e.g., ultrasonography (US)] or excellent tomographic display of the anatomy with limited information about flow patterns [e.g., multidetector computed tomography (MDCT) and magnetic resonance imaging]. Although catheter-directed selective digital subtraction angiography (DSA) can provide excellent information about flow at a high temporal resolution and can generate images at a high spatial resolution, this technique is often limited by a lack of cross-sectional detail. In the assessment of the PSMV system, DSA is also limited by dilution of contrast and motion artefacts. Combining venous phase cone-beam computed tomography (CBCT) with DSA can generate high-quality tomographic data, which allows detailed evaluation of venous tributaries and flow patterns within the splenic, superior mesenteric, and inferior mesenteric venous systems individually. This enables clinicians to better understand the impact of nonobstructive resistance to flow (e.g., as in patients with cirrhosis) and obstructive resistance to flow (e.g., as in patients with thrombosis) within each system and plan treatment accordingly. In this review, we discuss the limitations of common diagnostic methods and the role venous CBCT in combination with DSA can play in assessing the PSMV system.
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Abstract
OBJECTIVES The aim of our study was to describe the changing prevalence, demographic features, etiologies, and treatment of ascites in children hospitalized during a 27-year period at the Johns Hopkins Hospital (Baltimore, MD). METHODS We retrospectively reviewed discharges from 1983 to 2010 to select patients whose records included a diagnosis of ascites. We assessed the etiologies and degrees of ascites (ascites grade 1 detectable only by radiologic tests; ascites grades 2 and 3 recognized by moderate and marked abdominal distension by physical examinations). RESULTS We classified 518 children into 9 etiology groups: intrahepatic disease (IH) (105), hepatic vein outflow obstruction (HVOO) (45), congestive heart disease (CH) (33), nephrotic syndrome (NS) (36), pancreatitis (26), inflammatory and infectious diseases (77), malignancy (49), idiopathic (71), and miscellaneous (76). IH and CH were predominant in the younger age group (0-5 years) versus HVOO, pancreatitis, and malignancy in the older age group (13-21 years) (P < 0.001). The prevalence of ascites increased over time from 1983 to 2006 and declined thereafter. Ascites grade 1 was more common than ascites grades 2 and 3 in all the groups (P = 0.048). IH and NS were more likely to have ascites grade 2 and 3 (P = 0.02). Although spironolactone was more frequently used in the IH group versus other etiologies, furosemide was used more frequently in NS and CH versus other etiologies (P < 0.001). CONCLUSIONS The increased prevalence of ascites during the initial study period could reflect improved detection radiologic detection. The proportion of severe ascites and the various medical treatments differed among the etiologic groups.
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Abstract
Portal vein thrombosis is a life-threatening vascular disorder of the liver. In this chapter, I will review the recent advance regarding the epidemiology, etiology, management, and prognosis of portal vein thrombosis.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China.
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10
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Qi X, Guo X. An early decision of transjugular intrahepatic portosystemic shunt may be considered for non-malignant and non-cirrhotic portal vein thrombosis with ascites: a concise review of the theoretical possibility and practical difficulty. Arch Med Sci 2016; 12:1381-1383. [PMID: 27904533 PMCID: PMC5108399 DOI: 10.5114/aoms.2016.62921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/16/2015] [Indexed: 02/07/2023] Open
Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
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Zhou J, Ke L, Yang D, Chen Y, Li G, Tong Z, Li W, Li J. Predicting the clinical manifestations in necrotizing acute pancreatitis patients with splanchnic vein thrombosis. Pancreatology 2016; 16:973-978. [PMID: 27727096 DOI: 10.1016/j.pan.2016.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 08/08/2016] [Accepted: 10/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Splanchnic venous thrombosis (SVT) is a relatively rare but important complication of necrotizing acute pancreatitis (NAP). Clinical manifestations and severity of this complication in different patients vary greatly, ranging from mild abdominal discomfort even asymptomatic to lethal gastrorrhagia or hepatic failure. The aim of the present study was to develop a model to predict the clinical manifestations of SVT in NAP patients. METHODS This retrospective cohort study was conducted in the surgical intensive care unit (SICU) of Jinling Hospital. Patients with the presence of both pancreatic necrosis and SVT were selected for possible inclusion. Both univariate and multivariate logistic regression analyses were applied using 12 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP(C - reactive protein) levels, etc to assess potential predictors for symptomatic pancreatic splanchnic venous thrombosis (PSVT) in this cohort. A prognostic nomogram was also applied to develop an easy-to-use prediction model. RESULTS A total of 104 patients with necrotizing acute pancreatitis (NAP) and splanchnic vein thrombosis (SVT) from January 2012 to December 2013 were enrolled for analysis. A quarter of study subjects (26 of 104, 25%) developed variable symptomatic manifestations including variceal bleeding, persistent ascites and enteral nutrition (EN) intolerance during the disease course. In the multivariable regression model, the following factors were found to be associated with the occurrence of symptomatic SVT: Balthazar's computed tomography (CT) score (OR = 1.818; 95% CI: 1.251-2.641; P = 0.002), intra-abdominal pressure (IAP) (OR = 1.172; 95% CI: 1.001-1.251; P = 0.043 and presence of SMVT (OR = 6.946; 95% CI: 2.290-21.074; P = 0.001). A prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.842. CONCLUSIONS Balthazar's CT score, IAP and SMVT are predictors of symptomatic SVT in NAP patients. The nomogram we conducted can be used as an easy-to-use risk stratification tool in either clinical practice or future studies.
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Affiliation(s)
- Jing Zhou
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Lu Ke
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China.
| | - Dongliang Yang
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Yizhe Chen
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Gang Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Zhihui Tong
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
| | - Weiqin Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China.
| | - Jieshou Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, People's Republic of China
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Dell’Era A, Seijo S. Portal vein thrombosis in cirrhotic and non cirrhotic patients: from diagnosis to treatment. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1215907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Alessandra Dell’Era
- Dipartimento di Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli Studi di Milano, UOC Gastroenterologia - ASST Fatebenefratelli Sacco - Ospedale ‘Luigi Sacco’ Polo Universitario, Milan, Italy
| | - Susana Seijo
- CTO, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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De Stefano V, Qi X, Betti S, Rossi E. Splanchnic vein thrombosis and myeloproliferative neoplasms: molecular-driven diagnosis and long-term treatment. Thromb Haemost 2016; 115:240-9. [PMID: 26333846 DOI: 10.1160/th15-04-0326] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023]
Abstract
Splanchnic vein thrombosis (SVT) encompasses Budd-Chiari syndrome (BCS), extrahepatic portal vein obstruction (EHPVO), and mesenteric vein thrombosis. Philadelphia-negative myeloproliferative neoplasms (MPNS) are the leading systemic cause of non-cirrhotic and non-malignant SVT and are diagnosed in 40% of BCS patients and one-third of EHPVO patients. In SVT patients the molecular marker JAK2 V617F is detectable up to 87% of those with overt MPN and up to 26% of those without. In the latter, other MPN molecular markers, such as mutations in JAK2 exon 12, CALR and MPL genes, are extremely rare. Immediate anticoagulation with heparin is used to treat acute patients. Upon clinical deterioration, catheter-directed thrombolysis or a transjugular intrahepatic portosystemic shunt is used in conjunction with anticoagulation. Orthotopic liver transplantation is the only reliable option in BCS patients with a lack of a response to other treatments, without contraindication due to MPN. Long-term oral anticoagulation with vitamin K-antagonists (VKA) is recommended in all SVT patients with the MPN-related permanent prothrombotic state; the benefits of adding aspirin to VKA are uncertain. Cytoreduction is warranted in all SVT patients with an overt MPN, but its appropriateness is doubtful in those with molecular MPN without hypercythaemia.
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Affiliation(s)
- Valerio De Stefano
- Valerio De Stefano, MD, Institute of Hematology, Catholic University, Largo Gemelli 8, 00168 Rome, Italy, Tel.: +39 06 30154968, Fax: +39 06 30155209, E-mail:
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Llop E, Seijo S. [Treatment of non-cirrhotic, non-tumoural portal vein thrombosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 39:403-10. [PMID: 26547613 DOI: 10.1016/j.gastrohep.2015.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/25/2015] [Accepted: 09/04/2015] [Indexed: 12/20/2022]
Abstract
Thrombosis of the splenoportal axis not associated with liver cirrhosis or neoplasms is a rare disease whose prevalence ranges from 0.7 to 3.7 per 100,000 inhabitants. However, this entity is the second most common cause of portal hypertension. Prothrombotic factors are present as an underlying cause in up to 70% of patients and local factors in 10-50%. The coexistence of several etiological factors is frequent. Clinical presentation may be acute or chronic (portal cavernomatosis). The acute phase can present as abdominal pain, nausea, vomiting, fever, rectorrhagia, intestinal congestion, and ischemia. In this phase, early initiation of anticoagulation is essential to achieve portal vein recanalization and thus improve patient prognosis. In the chronic phase, symptoms are due to portal hypertension syndrome. In this phase, the aim of treatment is to treat or prevent the complications of portal hypertension. Anticoagulation is reserved to patients with a proven underlying thrombophilic factor.
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Affiliation(s)
- Elba Llop
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Susana Seijo
- CTO, Department of Medicine, Icahn School of Medicine at Mount Sinai, Nueva York, Estados Unidos.
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15
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Qi X, Wu F, He C, Fan D, Han G. Thrombotic risk factors in Chinese nonmalignant and noncirrhotic patients with portal vein thrombosis: an observational study with a systematic review of the literature. Eur J Gastroenterol Hepatol 2015; 27:77-83. [PMID: 25426980 DOI: 10.1097/meg.0000000000000221] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Until now, no data on the routine screening for thrombotic risk factors in Chinese nonmalignant and noncirrhotic patients with portal vein thrombosis (PVT) have been reported. METHODS A total of 141 nonmalignant and noncirrhotic patients with PVT who underwent screening tests for thrombotic risk factors between September 2009 and August 2012 were included in this study. RESULTS The JAK2 V617F mutation was found in 35 of the 141 patients tested. Neither the JAK2 exon 12 mutation nor the MPL W515 L/K mutation was found in any of the 50 patients tested. Overt myeloproliferative neoplasms (MPNs) were diagnosed in 13 patients (polycythemia vera, n=1; essential thrombocythemia, n=9; idiopathic myelofibrosis, n=3). Latent MPNs were considered in 23 patients with the JAK2 V617F mutation but without any significant abnormalities, as determined through regular blood tests. Anticardiolipin IgG antibodies were positive in none of the 136 patients tested. Paroxysmal nocturnal hemoglobinuria was not found in any of the 141 patients tested. Neither the factor V G1691A mutation nor the factor II G20210A mutation was found in any of the 72 patients tested. The C677T mutation in 5,10-methylenetetrahydrofolate reductase (MTHFR) was found in 29 of the 38 patients tested. Hyperhomocysteinemia was detected in eight of the 39 patients tested. CONCLUSION MPNs are an important thrombotic risk factor in Chinese patients with PVT. However, the extreme rarity of paroxysmal nocturnal hemoglobinuria, anticardiolipin IgG antibodies, and factor V G1691A and factor II G20210A mutations has precluded any support for the implementation of routine screening for these thrombotic factors in such patients. Additional case-control studies should confirm the role of the MTHFR C677T mutation and hyperhomocysteinemia in the pathogenesis of PVT.
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Affiliation(s)
- Xingshun Qi
- aXijing Hospital of Digestive Diseases bState Key Laboratory of Cancer Biology, Fourth Military Medical University, Xi'an, China
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Spaander MCW, Hoekstra J, Hansen BE, Van Buuren HR, Leebeek FWG, Janssen HLA. Anticoagulant therapy in patients with non-cirrhotic portal vein thrombosis: effect on new thrombotic events and gastrointestinal bleeding. J Thromb Haemost 2013; 11:452-9. [PMID: 23289370 DOI: 10.1111/jth.12121] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 12/10/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS It remains unclear when anticoagulant therapy should be given in patients with non-cirrhotic portal vein thrombosis (PVT). The aim of this study was to assess the effect of anticoagulation on recurrent thrombotic events and gastrointestinal bleeding in non-cirrhotic PVT patients. METHODS Retrospective study of all patients with non-cirrhotic PVT (n = 120), seen at our hospital from 1985 to 2009. Data were collected by systematic chart review. RESULTS Sixty-six of the 120 patients were treated with anticoagulants. Twenty-two recurrent thrombotic events occurred in 19 patients. The overall thrombotic risk at 1, 5 and 10 years was 4%, 8% and 27%, respectively. Seventy-four percent of all recurrent thrombotic events occurred in patients with a prothrombotic disorder. Anticoagulant therapy tended to lower the risk of recurrent thrombosis (hazard ratio [HR] 0.2, P = 0.1), yet the only significant predictor of recurrent thrombotic events was the presence of a prothrombotic disorder (HR 3.1, P = 0.03). In 37 patients, 83 gastrointestinal bleeding events occurred. The re-bleeding risk at 1, 5 and 10 years was 19%, 46% and 49%, respectively. Anticoagulation therapy (HR 2.0, P ≤ 0.01) was a significant predictor of (re)bleeding. Anticoagulation therapy had no effect on the severity of gastrointestinal bleeding. Poor survival was associated with recurrent thrombotic events (HR 3.1 P = 0.02), whereas bleeding (HR 1.6 P = 0.2) and anticoagulant treatment (HR 0.5 P = 0.2) had no significant effect on survival. CONCLUSIONS In non-cirrhotic PVT patients recurrent thrombotic events are mainly observed in patients with underlying prothrombotic disorders. Anticoagulation therapy tends to prevent recurrent thrombosis but also significantly increases the risk of gastrointestinal bleeding.
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Affiliation(s)
- M C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Abstract
Hepatic vascular disorders are a set of conditions that may be acute, or may be insidious and subclinical for many years. They can be organized into 3 categories: obstruction to hepatic vascular inflow, obstruction to blood flow through the liver, and obstruction to hepatic vascular outflow. In the first category are portal vein thrombosis, hepatic artery thrombosis, and presinusoidal causes of vascular obstruction. In the second category are sickle cell disease, disseminated intravascular coagulation, intrasinusoidal malignancy, and infection. In the third category are macroscopic hepatic venous thrombosis, thrombosis of the retrohepatic inferior vena cava, and venoocclusive disease. There are 2 nodular conditions of the liver that are not neoplastic but the result of occlusion of hepatic vasculature with compensatory hyperplasia of well-vascularized parenchyma. Hepatic vascular disorders constitute a heterogeneous group of conditions that must be considered in the differential diagnosis of any patient with hepatic compromise.
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