Anticoagulant therapy in patients with non-cirrhotic portal vein thrombosis: effect on new thrombotic events and gastrointestinal bleeding

Spaander, Manon; Hoekstra, Jildou; Hansen, Bettina E.; Buuren, Henk R. van; Leebeek, F. W. G.; Janssen, Harry L.A.

doi:10.1111/jth.12121

Cited by 105 publications

(99 citation statements)

References 25 publications

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“…Although transfusion of blood products was required in 75% patients and rescue shunt surgery due to failure to control bleeding in 6/57 (11%) patients, there were no deaths related to the first bleeding episode, which is in accordance with previous data (3,11,24,25) on the extremely low mortality of variceal bleeding in patients with PVT. This low mortality occurred despite 26% of patients bleeding while under anticoagulation treatment, confirming previous observations in an independent population (25,26) that anticoagulation did not have a major impact on the outcome of variceal bleeding in patients with PVT. A similar observation has been reported in patients with cirrhosis.…”

Section: Discussionsupporting

confidence: 90%

“…Although gastrointestinal bleed at diagnosis of PVT, (13) anticoagulant therapy, (25) extension of thrombosis to the splenic vein, presence of gastric fundal varices, (32) and thrombosis of the superior mesenteric vein (34) have all been described as predictive factors associated with rebleeding episodes during follow-up, we could not confirm these findings in our study. Finally, in our cohort of patients with PVT the mortality was very low, only occurring in nine patients (5%) with an actuarial probability of survival of 99% and 96% at 1 and 5 years, respectively, confirming the good prognosis of these patients.…”

Section: Discussioncontrasting

confidence: 73%

“…Finally, in our cohort of patients with PVT the mortality was very low, only occurring in nine patients (5%) with an actuarial probability of survival of 99% and 96% at 1 and 5 years, respectively, confirming the good prognosis of these patients. (13,25,33,35) In our study, by univariate Cox regression analysis, age, altered liver enzymes, and ascites were significantly associated with mortality, as observed by Janssen et al (25,34) and Orr et al (33) In this study, selection bias was minimized by including all patients with noncirrhotic, nontumoral PVT registered and followed at the two centers. The long study period of over 20 years could be associated with a change in the management of patients seen early in the study compared to those diagnosed more recently, with the latter patients being more likely to receive anticoagulation and consequently a greater possibility of portal vein recanalization.…”

Section: Discussionsupporting

confidence: 63%

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Natural history and management of esophagogastric varices in chronic noncirrhotic, nontumoral portal vein thrombosis

et al. 2016

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In patients with chronic noncirrhotic, nontumoral portal vein thrombosis (PVT), the usually recommended strategy for endoscopic screening and management of varices is the same as in cirrhosis. However, the efficacy of this policy in patients with PVT is unknown. We assessed the course of gastroesophageal varices in a large cohort of patients with chronic PVT. Patients prospectively registered in two referral centers for vascular liver disorders were eligible for the study. Endpoints were development and growth of varices and the incidence and outcome of portal hypertensionrelated bleeding. Included were 178 patients with chronic PVT. Median follow-up was 49 (1-598) months. Variceal bleeding was the initial manifestation in 27 (15%) patients. Initial endoscopy in the remaining 151 patients showed no varices in 52 (34%), small esophageal varices in 28 (19%), large esophageal varices (LEVs) in 60 (40%), and gastric varices without LEVs in 11 (7%). Ascites and splenomegaly were independent predictors for the presence of varices. In patients without varices, the probability of developing them was 2%, 22%, and 22% at 1, 3, and 5 years, respectively. In those with small esophageal varices, growth to LEVs was observed in 13%, 40%, and 54% at 1, 3, and 5 years, respectively. In patients with LEVs on primary prophylaxis, probability of bleeding was 9%, 20%, and 32% at 1, 3, and 5 years, respectively. Nine (5%) patients died after a median 51 (8-280) months, only one due to variceal bleeding. Conclusions: The course of varices in chronic noncirrhotic, nontumoral PVT appears to be similar to that in cirrhosis; using the same therapeutic approach as for cirrhosis is associated with a low risk of bleeding and death. (HEPATOLOGY 2016;63:1640-1650 C hronic noncirrhotic, nontumoral portal vein thrombosis (PVT) is a rare vascular disorder of the liver, with variceal bleeding being its main manifestation. (1,2) Indeed, several retrospective cohort studies have shown a high prevalence of esophageal varices (EVs) at the time of chronic PVT diagnosis. (3,4) Due to the low incidence and prevalence of PVT, specific studies aimed at determining adequate strategies for endoscopic screening and management of varices are scarce and small-sized. Consequently, the 2015 Baveno VI Consensus suggested applying to patients with PVT the same recommendations validated for patients with cirrhosis and portal hypertension, i.e., to perform a baseline endoscopy at diagnosis of PVT and subsequent endoscopies at 2-year or 3-year intervals in patients with no EVs or small EVs (SEVs) at baseline, to use beta-blockers or endoscopic band ligation (EBL) as a primary prophylaxis, and to Abbreviations: EBL, endoscopic band ligation; EV, esophageal varix; GOV, gastroesophageal varix; GV, gastric varix; IGV, isolated gastric varix; LEV, large esophageal varix; NSBB, nonselective beta-blocker; PVT, portal vein thrombosis; SEV, small esophageal varix.

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Section: Discussionsupporting

confidence: 90%

Section: Discussioncontrasting

confidence: 73%

Section: Discussionsupporting

confidence: 63%

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Natural history and management of esophagogastric varices in chronic noncirrhotic, nontumoral portal vein thrombosis

et al. 2016

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“…Anticoagulation therapy was a predictor of bleed but not associated with severity of the bleeding. 123 …”

Section: Anticoagulationmentioning

confidence: 99%

Portal Vein Thrombosis

Chawla

Bodh

2015

Journal of Clinical and Experimental Hepatology

151

147

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Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion. ( J CLIN EXP HEPATOL 2015;5:22-40)

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“…1,12 In one study, around 20% of prothrombotic patients had a recurrence of thrombosis. 21 When anticoagulation fails or the superior mesenteric vein is involved, systemic treatment with a thrombolytic combined with low molecular weight heparin should be considered. In cases in which systemic anticoagulation is contraindicated, guided thrombolysis by catheter is indicated, 12,22 either via direct access (transjugular, trans-hepatic, or trans-splenic) or indirectly, injecting a thrombolytic agent into the superior mesenteric artery.…”

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confidence: 99%

Cateterismo de artéria mesentérica para tratamento de trombose de veia porta

et al. 2017

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Portal vein thrombosis is a rare vascular cause of acute abdomen and it is directly related to hereditary or acquired thrombophilias. This article presents the case of a 60-year-old male patient, with clinical signs of mesenteric ischemia that was confirmed by imaging examination. He underwent enterectomy and enteroanastomosis and, after detection of portal vein thrombosis by splenoportography, he was prescribed drug-based treatment with continuous infusion of recombinant tissue plasminogen activator (Alteplase) via selective catheterization of the superior mesenteric artery. This is a treatment innovation. The portal system was successfully recanalized. However, the patient developed abdominal sepsis and required intensive care for 25 days. His clinical status improved and he was discharged with a prescription for oral anticoagulant. This article presents a brief review of the literature and a discussion of portal vein thrombosis.Keywords: portal vein; thrombosis; thrombophilia; mesenteric ischemia; acute abdomen. ResumoA 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

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Anticoagulant therapy in patients with non-cirrhotic portal vein thrombosis: effect on new thrombotic events and gastrointestinal bleeding

Abstract: 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.

Cited by 105 publications

References 25 publications

Natural history and management of esophagogastric varices in chronic noncirrhotic, nontumoral portal vein thrombosis

Natural history and management of esophagogastric varices in chronic noncirrhotic, nontumoral portal vein thrombosis

Portal Vein Thrombosis

Cateterismo de artéria mesentérica para tratamento de trombose de veia porta

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