Etiology and Complications of Portal Vein Thrombosis

Clinical characteristics and predictors of benign portal vein thrombosis in patients with liver cirrhosis: A retrospective single-center study

Portal vein thrombosis (PVT) is a common thrombotic complication of cirrhosis. It can lead to variceal bleeding and bowel ischemia and also complicate liver transplantation. Identifying the possible risk factors associated with PVT can aid in identifying patients at high risk, enabling their screening and potentially preventing PVT through the rational use of anticoagulants. This study focuses on examining the clinical characteristics of PVT in cirrhotic patients and identifying the clinical and biochemical factors that are linked to the development of PVT. Consecutive hospitalized cirrhotic patients between 2015 and 2023 were identified through the hospital's computerized medical records based on the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding system and retrospectively analyzed. 928 individuals were included in this study; 783 (84.3%) without PVT and 145 (15.7%) with benign PVT. Hepatitis B virus (HBV) was significantly more common in the PVT group (P-value = .02), while alcohol and primary sclerosing cholangitis (PSC) were less common in this group (P-value = .01 and .02, respectively). Hepatocellular carcinoma (HCC) (P-value < .01), ascites (P-value = .01), and spontaneous bacterial peritonitis (SBP) (P-value = .02) were more common in the PVT group. Patients with PVT had a higher international normalized ratio (INR) level (P-value = .042) and lower plasma albumin (P-value = .01). No differences were identified in white blood cell, hemoglobin, platelet, and bilirubin levels. However, patients with PVT had higher model for end-stage liver disease (MELD) (P-value = .01) and Child-Pugh scores (P-value = .03). This study demonstrated a higher likelihood of PVT presence in cirrhotic patients with advanced age, HBV, and HCC, along with ascites, SBP, splenomegaly, hypoalbuminemia, elevated INR, and a higher MELD score. Nevertheless, additional research endeavors are necessary to accurately ascertain and validate supplementary risk factors within a broader demographic.

Prevalence and Risk Factors for Portal Cavernoma in Adult Patients with Portal Vein Thrombosis

Portal vein thrombosis (PVT) represents a restriction or occlusion of the portal vein by a blood clot, which can appear in liver cirrhosis, inherited or acquired thrombophilia, malignancies, abdominal infection, abdominal inflammation, and injury to the portal vein; it can evolve to local venous extension, recanalization, or portal cavernoma (PC). This research represents an observational study of patients admitted with a diagnosis of PVT between January 2018 and December 2022. We assessed the rate of and risk factors for PC. In total, 189 patients with PVT were included; the rate of PC was 14.8%. In univariate and multivariate analysis, the main risk factors for the presence of PC were etiology (thrombophilia, myeloproliferative disorders, local inflammatory diseases, and idiopathic causes), prior PVT, and complete versus incomplete or single-branch portal obstruction. In patients with superior mesenteric vein (SMV) thrombosis, distal obstruction was more prone to PC than proximal obstruction. The main predictive factors were etiology, prior PVT, complete PVT obstruction, and no prior non-selective beta-blocker (NSBB) use; in patients with SMV thrombosis, the distal extension was more significantly associated with the risk of PC. We propose a composite score for the prediction of PC which includes etiology, prior diagnosis of PVT, prior NSBB use, complete versus incomplete PVT, and distal versus proximal SMV thrombosis, with good accuracy (AUC 0.822) and an estimated sensitivity of 76.92% and specificity of 82.39% at a cut-off value of 4.

Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report

BACKGROUND

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT.

CASE PRESENTATION

A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure.

CONCLUSIONS

Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.

Contrast-enhanced ultrasound of the liver: Vascular pathologies and interventions

Over the past two decades, contrast-enhanced ultrasound (CEUS) has been established as a method complementary to B-mode ultrasound and color Doppler sonography for diagnosing vascular liver pathologies and interventions.The objective of this review is to elucidate the application of CEUS in diagnosing vascular pathologies and interventional procedures.Considering the limitations of ultrasound, CEUS presents a similar alternative to other imaging modalities, such as computed tomography and magnetic resonance imaging, for evaluating vascular pathologies, guiding interventions, identifying complications, and assessing outcomes post intervention. Due to its widespread availability and the absence of radiation exposure, CEUS should be employed as a primary modality. · CEUS plays an important role in the detection of vascular liver pathologies.. · CEUS is helpful in characterizing vascular pathologies.. · CEUS is helpful in guiding interventions and identifying complications..

Metastatic papillary renal cell carcinoma with portal vein tumor thrombosis confirmed on blind liver biopsy

Portal vein tumor thrombosis (PVTT) is an uncommon condition in which tumor cells expand into the vessels, causing blood clot formation in the portal vein. PVTT is mainly associated with hepatocellular carcinoma, leading to an unfavorable prognosis; however, it can also develop in patients with other cancer types. Herein, we report a case of metastatic renal cell carcinoma diagnosed by a blind liver biopsy in a patient with dynamic computed tomography-confirmed portal vein thrombosis and cholangiopathy. This case illustrates the importance of systematic surveillance with routine laboratory tests and contrast-enhanced imaging studies on patients with cancer to detect potential liver infiltration of metastatic cancer.

A special case of acute portal vein thrombosis

Among the risk factors and underlying etiology of acute portal vein thrombosis, viral hepatitis is an extremely rare cause. We report a case of a young healthy 40-year-old male who was diagnosed with acute hepatitis A virus infection and presented with acute portal vein thrombosis. This article describes the possible pathophysiological mechanisms, clinical symptoms, and treatment of acute portal vein thrombosis in this patient. Based on this patient's history and treatment, we encourage testing for hepatitis A serological markers in the emergency department in a population with recent hepatitis A exposure risk factors and concurrent unexplained acute portal thrombosis.

An Unusual Instigator of Spontaneous Bacterial Peritonitis: Salmonella typhimurium

Salmonella is an unusual cause of spontaneous bacterial peritonitis (SBP). It is commonly seen in asymptomatic patients with normal or high ascitic fluid protein levels and an immunocompromised state such as AIDS and hematological and solid organ malignancies other than liver. SBP from non-typhoidal Salmonella species should be considered, even in the absence of underlying immunosuppression. Our patient presented with a history of high-grade fever and frequent loose stools with decompensated alcoholic liver cirrhosis. While evaluating the SBP etiology, ascitic fluid turned out positive for the non-typhoidal Salmonella species, which was red, turbid, and hemorrhagic due to portal vein and superior mesenteric vein thrombosis. We thus report an extremely rare case of SBP caused by Salmonella typhimurium in our patient.

A Young Male With Non-cirrhotic Cryptogenic Portal Cavernoma: An Authoritative Case Study

The growth of several porto-portal collateral veins encircling an existing stenosed or obstructed entry vein is an uncommon condition known as portal cavernoma. It is traditionally shown as the entry vein thrombosis (portal vein thrombosis - PVT) outcome. A male of 25 years with stomach discomfort for three days that was acute, nonprogressive, and was not accompanied by fever, loose stools, or vomiting. After he had undergone abdominal ultrasonography, portal vein thrombosis was discovered, and based on no involvement of suprahepatic veins according to ultrasonography, Budd-Chiari syndrome was ruled out. It was accompanied by dilated periportal tortuous veins and visible mesenteric and peri-splenic collaterals. Moderate splenomegaly was also present. All these features on ultrasound were suggestive of the "portal cavernoma" formation. The patient is not an alcoholic and does not have any chronic, hereditary, or metabolic liver disease. Thrombophilia and cancer screening through tumor markers were also negative. We, with this, present a rare case of non-cirrhotic idiopathic portal cavernoma. This rare case contributes to advancing medical and scientific knowledge that will encourage further dialogue on the topic.

Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong?

Purpose

This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC).

Materials and Methods

An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out.

Results

The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D.

Conclusion

Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.

Acute portal venous thrombosis as an extrahepatic manifestation of acute hepatitis A infection

Among the many potential causes and risk factors for acute portal venous thrombosis, viral hepatitis has been regarded as a rare associated condition. We present the first case in the literature of a 30-year-old previously healthy male who presented with acute portal venous thrombosis associated with acute hepatitis A virus (HAV) infection, describing the probable pathophysiology mechanism, work-up and treatment pursued. We encourage that hepatitis A serological markers should be routinely included in the investigation for acute portal venous thrombosis of unknown aetiology, in unvaccinated patients with risk factors of a recent HAV exposure.

Usefulness of Imaging and Biological Tools for the Characterization of Portal Vein Thrombosis in Hepatocellular Carcinoma

This study aims to evaluate the performance of contrast-enhanced ultrasound (CEUS) and biological tests to characterize portal vein thrombosis (PVT). We retrospectively analyzed 101 patients with PVT, liver cirrhosis, and hepatocellular carcinoma (HCC). In all patients, demographic, biologic, imaging, and endoscopic data were collected. All patients underwent CEUS and a second line imaging technique (CE-CT/MRI) to characterize PVT. Of the 101 cirrhotic subjects, 77 (76.2%) had HCC. CEUS had 98.6% sensitivity (Se) and 89.3% specificity (Sp) for the characterization of PVT type. A significant correlation was found between alpha-fetoprotein (AFP) levels and the PVT characterization at CEUS (r = 0.28, p = 0.0098) and CT/MRI (r = 0.3, p = 0.0057). Using the AFP rule-out cutoff values for HCC (AFP < 20 ng/dL), 78% of the subjects were correctly classified as having benign PVT, while 100% of the subjects were correctly classified as tumor-in-vein (TIV) when the rule-in cutoff value was used (AFP ≥ 200 ng/dL). Using multiple regression analysis, we obtained a score for classifying PVT. The PVT score performed better than CEUS (AUC—0.99 vs. AUC—0.93, p = 0.025) or AFP serum levels (AUC—0.99 vs. AUC—0.96, p = 0.047) for characterizing PVT. In conclusion, CEUS is a sensitive method for the characterization of PVT. The PVT score had the highest performance for PVT characterization.

Portal Vein Thrombosis and Pyogenic Liver Abscess With Concomitant Bacteroides Bacteremia in a Patient With COVID-19 Infection: A Case Report and Brief Review

The 2019 coronavirus disease (COVID-19) can present with a wide variety of clinical manifestations, including a hypercoagulable state leading to both arterial and venous thrombosis. Portal vein thrombosis (PVT) in the setting of COVID-19 has rarely been reported in the medical literature. Pylephlebitis with concomitant liver abscess is a rare complication of intra-abdominal infection. Here, we present the case of a 49-year-old man who initially presented with intermittent fevers and generalized weakness of 1-month duration and was subsequently found to have COVID-19 infection, PVT, and Bacteroides fragilis bacteremia with associated pyogenic liver abscess. The patient was treated with intravenous antibiotics and oral anticoagulation with plan to follow up outpatient with gastroenterology in 3 months to ensure resolution of PVT and liver abscess.

Extrahepatic Portal Vein Thrombosis in Childhood: Risk Factors, Clinical Manifestations, and Management

OBJECTIVE

Extrahepatic portal vein thrombosis (EHPVT) is a common cause of portal hypertension in children. The aim of the present study was to identify the clinical manifestations and the risk factors for development of EHPVT in pediatric patients.

SUBJECTS AND METHODS

This was a single-center retrospective cohort study. A total of 12 children (6 boys and 6 girls) took part in the study. We noted the clinical presentations and the predisposing risk factors for development of EHPVT in all patients. In addition, as all of them had undergone an esophagogastroduodenoscopy for detection and grading of esophageal varices as part of the treatment algorithm, we analyzed the endoscopic findings and the therapeutic approach.

RESULTS

The median age of subjects at diagnosis was 3.5 years (range: 1-17 years). The most frequent initial clinical manifestation was upper gastrointestinal bleeding (6 cases, 50.0%) followed by splenomegaly (3 cases, 25.0%). The most frequent systemic risk factor for EHPVT was presence of inherited prothrombotic disorder (10 cases, 83.3%), and the most common local risk factor for EHPVT was umbilical vein catheterization (5 cases, 41.7%). Esophageal varices were revealed in all the study participants, and in the most cases, they were grade ≥2. Propranolol was used as primary or secondary prophylaxis in 7 children (58.3%), and in 5 children (41.7%), a shunt was performed (Meso-Rex bypass in 3 children and splenorenal shunt in 2 children).

CONCLUSION

Patients with known systemic or local risk factors for EHPVT are indicated for proactive ultrasound screening for early diagnosis and timely management.

Idiopathic Portal Vein Thrombosis in a Non-cirrhotic Patient: A Discussion of Management and a Review of Literature

Portal vein thrombosis (PVT) is most commonly seen in people with predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal disease, or haematologic disorders. However, the incidence of idiopathic portal vein thrombosis in non-cirrhotic people is low and approximately 25% of existing cases have no identifiable cause. If untreated, complications can include portal hypertension, a cavernous transformation of the portal vein, varices, septic thrombosis, or intestinal ischemia. We report the case of a 27-year-old female who presented to her general practitioner with two weeks of epigastric pain. She was referred for an upper abdominal USG and CT imaging, which identified portal vein thrombosis with a normal appearance of the gallbladder, liver, and spleen. Thrombophilia screen was negative for Factor V Leiden and prothrombin mutations and lupus anticoagulant. The tumour markers alpha-fetoprotein and carcinoembryonic antigen were also within normal limits. The patient was started on rivaroxaban indefinitely following advice from a vascular surgeon and haematologist. Subsequent follow-up imaging also revealed cavernous transformation of the portal vein. We present this case to discuss the diagnosis, management and treatment of this patient and to review the current evidence available in managing idiopathic portal vein thrombosis in non-cirrhotic patients, especially the role of anticoagulation in chronic cases.

Portal Vein Thrombosis after the Consumption of Date Seed Powder: A Case Study

Date seeds can be used as ingredients to enhance the nutritional value of some functional foods for human consumption as well as additives in pharmaceutical and cosmetic industries. However, there are no reports on the complications of date seeds after oral consumption. We currently report a patient with no history of gastrointestinal disease, who has been admitted to the hospital with portal vein thrombosis (PVT) and suffered from complications.

Portal vein thrombosis: an overview of current treatment options

Portal vein thrombosis (PVT) is a splanchnic vascular disorder characterised by a recent or chronic thrombotic occlusion of the portal venous system. Its aetiology is miscellaneous, and its management is demanding since PVT can play a critical role as far as morbidity and mortality are concerned. Indeed, PVT can develop as a complication of portal hypertension (PH), in association or not with advanced chronic liver disease, and aggravate its clinical consequences such as variceal bleeding and ascites. Furthermore, a diagnosis of PVT in a non-cirrhotic context can potentially reveal a previously unknown hypercoagulable condition, requiring further diagnostic steps and specific treatment in addition to anticoagulation. In addition to established therapeutic approaches, new strategies, including newer pharmacological treatments and interdisciplinary invasive procedures, gain more attention and have been increasingly introduced into clinical practice. This review aims at discussing the current knowledge in terms of treatment options for PVT.

Association of portal venous system thrombosis with endoscopic variceal treatment: a systematic review and meta-analysis

The association of endoscopic variceal treatment (EVT) with the development of portal venous system thrombosis (PVST) in liver cirrhosis remains uncertain. A systematic review and meta-analysis aimed to investigate the incidence of PVST after EVT and to explore the association of EVT with the development of PVST in liver cirrhosis. All relevant studies were searched via the PubMed, EMBASE, and Cochrane Library databases. The incidence of PVST in patients treated with and without EVT was pooled. Risk ratios with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was calculated. Meta-regression, sensitivity, and subgroup analyses were used to analyze the source of heterogeneity. Thirteen studies involving a total of 833 patients were included. The pooled incidence of PVST after EVT was 10.4% (95% CI, 4.9-17.7%). There was a statistically significant heterogeneity (I2 = 83.3%, P < 0.0001). Meta-regression, sensitivity, and subgroup analyses did not find the source of heterogeneity. Four studies compared the incidence of PVST between patients treated with and without EVT. The incidence of PVST was significantly higher in the EVT group than that in the no-EVT group (risk ratio: 2.23; 95% CI, 1.11-4.49; P = 0.02). The heterogeneity was not statistically significant (I2 = 0%, P = 0.43). In conclusion, PVST after EVT may not be scare, and EVT may increase the risk of PVST in liver cirrhosis.

Portal Vein Thrombosis Secondary to Occult Polycythemia Vera

Portal vein thrombosis (PVT) is an uncommon finding in patients without cirrhosis. The underlying x\aetiology is challenging and the condition has a wide differential diagnosis. We present a case of PVT in an anaemic patient with chronic iron and folic acid deficiency masking underlying polycythemia vera (PV). Only a careful review of the patient's clinical history allowed the identification of a short period of laboratory erythrocytosis, 6 months before the clinical onset of PVT, while the patient was on iron and folic acid supplementation. The finding raised clinical suspicion of PV previously masked by iron deficiency anaemia. Subsequent investigation confirmed the presence of the JAK2 V617F mutation and, ultimately, showed that the patient met all diagnostic criteria for PV. Myeloproliferative disorders (MPD) are associated with systemic prothrombotic states. PV is distinguished clinically from other MPD by the presence of increased red blood cell mass. Moreover, patients with abnormal haematocrit values in the pre-JAK2 V617F era may have had occult or latent PV. Diagnosis confirmation requires a combination of major and minor criteria to capture occasional cases of occult PV. This case emphasizes the importance of always considering MPD in the aetiological investigation of PVT, even in patients who apparently do not fulfil the diagnostic criteria.

LEARNING POINTS

We describe a rare gastroenterological presentation of a haematological condition, which provided an unexpected diagnosis.Myeloproliferative disorders should always be considered in the investigation of portal vein thrombosis.

Update on Shunt Surgery

Background

Bleeding from esophagogastric varices is a life-threatening complication from portal hypertension. It occurs in 15% of patients and has a mortality rate of 20-35%.

Summary

The primary therapy for variceal bleeding is medical. In cases of recurrent bleeding, a definitive therapy is required. In cases of parenchymal decompensation, liver transplantation is the causal therapy, but if liver function is preserved, portal decompression is the therapy of choice. The use of the transjugular intrahepatic portosystemic shunt (TIPS) has achieved widespread acceptance, although evidence for surgical shunts is comparable or better in patients with good hepatic reserve. The type of surgical shunt depends on the patent veins of the portomesenteric system. If total occlusion is present, a devascularization procedure might be indicated.

Key Messages

Therapy, taking into account liver function, morphology of the portovenous system, and imminent liver transplantation, should be performed by an interdisciplinary team of gastroenterologists, interventional radiologists, and gastrointestinal surgeons.

Liver Disease and Hemostasis (Review) Part 2. Cholestatic Liver Disease and Hemostasis

The presence or development of liver disorders can significantly complicate the course of critical illness and terminal conditions. Systemic hemostatic disorders are common in Intensive Care Units patients with cholestatic liver diseases, so the study of the mechanisms of their development can contribute to the understanding of the development of multiorgan failure in critical illness.

The review discusses current data on changes in hemostatic parameters in patients with cholestatic liver diseases, proposes a mechanism for the development of such disorders, which involve interactions of phospholipids with platelet and endotheliocyte membranes. It is suggested that a trend for thrombosis in patients with cholestatic liver disease is due to increased accumulation of bile acids in the systemic circulation. Available data demonstrate that the antiphospholipid syndrome may predispose to the formation of blood clots due to alterations of phospholipid composition of membranes of platelets and vascular endothelial cells by circulating antiphospholipid antibodies. Clarifying the mechanisms contributing to changes of the blood coagulation system parameters in liver disorders will aid to development of optimal correction of hemostatic disorders in patients with chronic liver diseases.

Escalating interventional recanalization therapy in non-cirrhotic, non-malignant acute portal vein thrombosis

OBJECTIVE

To evaluate the effectiveness of interventional therapy in acute, non-malignant, non-cirrhotic portal vein thrombosis.

METHODS

We present a retrospective study of eight consecutive patients who presented with an acute non-malignant, non-cirrhotic portal vein thrombosis and were treated by mechanical recanalization using an escalating scheme including local aspiration, thrombolysis, rheolysis and the implantation of transjugular intrahepatic portosystemic shunt or other visceral stents.

RESULTS

Recanalization rates applying the escalating scheme were good, with a success rate of 75%. However, major complications occurred in 50% of patients, mostly due to bleeding at the percutaneous access site, and minor complications in 12.5% of patients.

CONCLUSION

Interventional therapy is effective in acute portal vein thrombosis, but should only be performed at specialized centers and based on an individual treatment decision.

Update on Management of Portal Vein Thrombosis and the Role of Novel Anticoagulants

The clinical management of portal vein thrombosis (PVT) remains ambiguous due to its heterogeneous presentations and its associations with liver disease, malignancy, and hypercoagulable states. The natural history and clinical outcome of PVT are highly variable, dependent upon size, extent and degree of the thrombotic occlusion, as well as the physiological impact of patient comorbidities. While existing clinical guidelines consistently recommend low molecular weight heparin or vitamin K antagonist anticoagulation in cirrhotic patients with symptomatic acute PVT, management of asymptomatic and chronic PVT may need to be determined on a case-by-case basis, factoring in the state of underlying liver disease. In general, patients with PVT and underlying malignancy should be anticoagulated to alleviate symptoms and prevent recurrences that could disrupt the cancer management. However, existing clinical data does not support routine anticoagulation of cirrhotic patients with asymptomatic PVT in the absence of underlying cancer. While low molecular weight heparin and vitamin K antagonist remain the most commonly used agents in PVT, an emerging body of clinical evidence now suggests that direct-acting oral anticoagulants may be used safely and effectively in PVT. As such, direct-acting oral anticoagulants may offer a more convenient anticoagulation alternative for PVT management in future practice.

Elevated International Normalized Ratio: A Risk Factor for Portal Vein Thrombosis in Cirrhotic Patients

Background

Portal vein thrombosis (PVT) is a complication that is commonly seen in patients with cirrhosis and an entity that leads to increased mortality in patients who undergo liver transplantation. This study aims to establish a link between an elevated international normalized ratio (INR) and the presence of PVT in a cohort of cirrhotic patients.

Methods

We retrospectively reviewed the electronic medical records of all patients diagnosed with cirrhosis in SBH Health System from 2013 to 2018. Among these patients we extracted baseline demographic data, laboratory results, co-morbidities and the presence of PVT.

Results

In total there were 268 patients who met our inclusion criteria. Twenty-two patients had PVT, while 246 patients did not. Of the 22 patients with PVT there was a statistically significant increase in INR when compared to patients without PVT. There was also a statistically significant increase in total bilirubin, alkaline phosphatase and platelet count.

Conclusions

Elevated INR levels are associated with the presence of PVT in patients with cirrhosis. These findings suggest a hypercoagulable state and could assist clinicians in risk-stratifying patients when making the decision to initiate anti-coagulation therapy.

AngioJet-assisted transvenous-transhepatic mechanical thrombectomy in the portal vein

Purpose

To evaluate AngioJet-assisted transvenous portal vein (PV) thrombectomy for non-cirrhotic patients with total portal vein and mesenteric vein thrombosis (PVMVT).

Material and methods

From 2015 to 2016 four patients (3 male, mean 43.9 years, range 33-52 years) with acute (3 cases) and acute-on-chronic (1 case) PVMVT underwent transvenous thrombolysis. All patients received initial AngioJet (Boston Scientific, Natick, MA, USA) thrombectomy followed by continuous catheter directed thrombolysis with Urokinase (Medac, Wedel, Germany) for 22-52 hours. Transjugular intrahepatic portosystemic shunts (TIPS), using Viatorr stent grafts (W.L. Gore and Associates, AZ, USA; mean diameter: 10 mm, length: 60-80 mm), were implanted in all patients. Patients were followed clinically and with imaging (mean 646 days, range 392 to 936 days).

Results

Technical success was 100%. Therapeutic success was achieved in 75% of cases. AngioJet-assisted thrombectomy substantially reduced thrombus load in the acute cases, while only slight improvement was achieved in the acute-on-chronic case. Continuous thrombolysis subtotally re-established PV flow in the acute cases, while only minimal improvement was seen in the acute-on-chronic case. Following TIPS implantation complete PV recanalisation could be achieved in all acute cases. In the acute-on-chronic case initial stagnant PV flow was seen; however, PV and TIPS re-occluded 10 days after implantation. During follow-up PV remained patent in acute cases.

Conclusions

AngioJet-assisted thrombectomy was technically feasible and uncomplicated in all of our patients. The initial results suggest that AngioJet-assisted thrombectomy facilitates recanalisation in acute and severe cases of PVMVT.

Portomesenteric Thrombosis Secondary to Acute Cholecystitis: A Case Report

Portomesenteric venous thrombosis (PMVT) is an uncommon clinical problem. Common risk factors include intra-abdominal infections, abdominal surgeries, malignancy, cirrhosis, and inherited thrombophilia. Early recognition and treatment of PMVT are important to avoid serious complications like mesenteric ischemia and infarction. Acute cholecystitis is a clinical condition encountered daily but rarely may be complicated by development of portomesenteric venous thrombosis. Only few cases have been reported of superior mesenteric vein thrombosis secondary to cholecystitis. We report a case of a forty-one-year-old male patient who developed partial portal and superior mesenteric vein thrombosis after mild acute cholecystitis for which surgery had been deferred. Patient had no other identifiable risk factors for thrombosis. Patient was successfully treated with 6 months of anticoagulation with warfarin and complete recanalization of portomesenteric veins was achieved at the end of treatment.

Rationale for the use of statins in liver disease

The evolution of chronic liver injuries from benign and manageable dysfunction to life threatening end-stage liver disease with severe complications renders chronic liver disease a global health burden. Because of the lack of effective medication, transplantation remains the only and final curative option for end-stage liver disease. Since the demand for organ transplants by far exceeds the supply, other treatment options are urgently required to prevent progression and improve end-stage liver disease. Statins are primarily cholesterol-lowering drugs used for primary or secondary prevention of cardiovascular diseases. In addition to the primary effect, statins act beneficially through different pleiotropic mechanisms on inflammation, fibrosis, endothelial function, thrombosis, and coagulation to improve chronic liver diseases. However, concerns remain about the efficacy and safety of statin treatment because of their potential hepatotoxic risks, and as of now, these risks impede broader use of statins in the treatment of chronic liver diseases. The aim of this review is to comprehensively describe the mechanisms by which statins improve prospects for different chronic liver diseases with special focus on the pathophysiological rationale and the clinical experience of statin use in the treatment of liver diseases.

Portal vein thrombosis in patients with cirrhosis

Portal vein thrombosis (PVT) is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare, but can be life-threatening. However, different aspects of clinical relevance, diagnosis and management of PVT are still areas of uncertainty and investigation in international guidelines. In this article, we elaborate on PVT classification, geographical differences in clinical presentation and standards of diagnosis, and briefly on the current pathophysiological understanding and risk factors. This review considers and highlights the pitfalls of the various treatment approaches and prophylactic treatments. Finally, we review the controversial issue of clinical impact of PVT on prognosis, especially considering liver transplantation and future perspectives.

Cateterismo de artéria mesentérica para tratamento de trombose de veia porta

A trombose de veia porta é uma causa rara de abdome agudo vascular e está diretamente relacionada a trombofilias hereditárias ou adquiridas. O caso de um paciente de 60 anos, sexo masculino, com quadro clínico de isquemia mesentérica confirmada por exame de imagem é apresentado. Foi submetido a enterectomia e enteroanastomose e, após esplenoportografia que detectou trombose de veia porta, indicou-se tratamento medicamentoso com infusão contínua de ativador tecidual do plasminogênio recombinante (Alteplase) através de cateterismo seletivo da artéria mesentérica superior. Trata-se de um tratamento inovador. Obteve-se sucesso na recanalização do sistema porta. O paciente evoluiu com quadro de sepse abdominal, necessitando de assistência em terapia intensiva por 25 dias. Evoluiu bem e recebeu alta hospitalar com o uso de anticoagulante. O artigo apresenta uma breve revisão de literatura e discussão do caso clínico.

Diagnosis and treatment of portal vein thrombosis after splenectomy and gastroesophageal devascularization

Splenectomy and gastroesophageal devascularization is the most common clinical treatment for upper gastrointestinal bleeding in patients with portal hypertension. Its advantages include exact treatment and little impact on liver function. However, due to the postoperative high blood coagulation state and hemodynamic changes, it greatly increases the incidence of portal vein thrombosis (PVT), which causes serious complications. Ultrasound, CT and MRI are main methods for the diagnosis of PVT. After diagnosis, using anticoagulation, intervention and surgery can achieve effective control and treatment. PVT mostly occurs perioperatively and therapeutic effects are therefore limited, so perioperative PVT prevention is particularly important. It is recommended that anticoagulation drugs be given preoperatively to prevent PVT formation, injury to the vascular endothelium of the portal vein system be avoided intraoperatively to reduce the formation of spleen vein stump and stabilize postoperative portal vein blood flow dynamics, and ultrasound be performed postoperatively to achieve early diagnosis and treatment.

[Recent thrombosis of splanchnic veins : Two case reports of catheter-assisted local thrombolysis and thrombus aspiration]

Recent non-cirrhotic and non-malignant splanchnic vein thrombosis is now defined as extrahepatic portal vein thrombosis with or without involvement of the mesenteric vein according to the Baveno VI consensus from 2015. An early diagnosis is often challenging due to unspecific symptoms with abdominal pain or diarrhea but extremely important because of the potential acute and chronic complications, such as mesenteric ischemia and portal hypertension; therefore, rapid treatment is crucial. We present two cases of severe splanchnic vein thrombosis, which were treated with catheter-directed local thrombolysis and thrombus aspiration. These minimally invasive catheter-directed techniques have recently been successfully used in selected patients. A review of the literature is provided in this article. In summary, the management of splanchnic vein thrombosis must be individually planned for each patient and should be performed at experienced centers, which can provide all therapeutic options. In selected cases with the correct indications transjugular transhepatic catheter-directed local thrombolysis is a safe option with a good outcome.

Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View

BACKGROUND

Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%.

METHODS

Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH.

RESULTS

The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise.

CONCLUSION

The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.