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      Portal vein thrombosis in patients with cirrhosis

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          Abstract

          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.

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          Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis.

          Erica Villa, Calogero Cammà, Marco Marietta … (2012)
          We performed a randomized controlled trial to evaluate the safety and efficacy of enoxaparin, a low-molecular-weight heparin, in preventing portal vein thrombosis (PVT) in patients with advanced cirrhosis. In a nonblinded, single-center study, 70 outpatients with cirrhosis (Child-Pugh classes B7-C10) with demonstrated patent portal veins and without hepatocellular carcinoma were assigned randomly to groups that were given enoxaparin (4000 IU/day, subcutaneously for 48 weeks; n = 34) or no treatment (controls, n = 36). Ultrasonography (every 3 months) and computed tomography (every 6 months) were performed to check the portal vein axis. The primary outcome was prevention of PVT. Radiologists and hepatologists that assessed outcomes were blinded to group assignments. Analysis was by intention to treat. At 48 weeks, none of the patients in the enoxaparin group had developed PVT, compared with 6 of 36 (16.6%) controls (P = .025). At 96 weeks, no patient developed PVT in the enoxaparin group, compared with 10 of 36 (27.7%) controls (P = .001). At the end of the follow-up period, 8.8% of patients in the enoxaparin group and 27.7% of controls developed PVT (P = .048). The actuarial probability of PVT was lower in the enoxaparin group (P = .006). Liver decompensation was less frequent among patients given enoxaparin (11.7%) than controls (59.4%) (P < .0001); overall values were 38.2% vs 83.0%, respectively (P < .0001). The actuarial probability of liver decompensation was lower in the enoxaparin group (P < .0001). Eight patients in the enoxaparin group and 13 controls died. The actuarial probability of survival was higher in the enoxaparin group (P = .020). No relevant side effects or hemorrhagic events were reported. In a small randomized controlled trial, a 12-month course of enoxaparin was safe and effective in preventing PVT in patients with cirrhosis and a Child-Pugh score of 7-10. Enoxaparin appeared to delay the occurrence of hepatic decompensation and to improve survival. Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.
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            Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators.

            Gennaro D'Amico, Roberto de Franchis (2003)
            Several treatments have been proven to be effective for variceal bleeding in patients with cirrhosis. The aim of this multicenter, prospective, cohort study was to assess how these treatments are used in clinical practice and what are the posttherapeutic prognosis and prognostic indicators of upper digestive bleeding in patients with cirrhosis. A training set of 291 and a test set of 174 bleeding cirrhotic patients were included. Treatment was according to the preferences of each center and the follow-up period was 6 weeks. Predictive rules for 5-day failure (uncontrolled bleeding, rebleeding, or death) and 6-week mortality were developed by the logistic model in the training set and validated in the test set. Initial treatment controlled bleeding in 90% of patients, including vasoactive drugs in 27%, endoscopic therapy in 10%, combined (endoscopic and vasoactive) in 45%, balloon tamponade alone in 1%, and none in 17%. The 5-day failure rate was 13%, 6-week rebleeding was 17%, and mortality was 20%. Corresponding findings for variceal versus nonvariceal bleeding were 15% versus 7% (P =.034), 19% versus 10% (P =.019), and 20% versus 15% (P =.22). Active bleeding on endoscopy, hematocrit levels, aminotransferase levels, Child-Pugh class, and portal vein thrombosis were significant predictors of 5-day failure; alcohol-induced etiology, bilirubin, albumin, encephalopathy, and hepatocarcinoma were predictors of 6-week mortality. Prognostic reassessment including blood transfusions improved the predictive accuracy. All the developed prognostic models were superior to the Child-Pugh score. In conclusion, prognosis of digestive bleeding in cirrhosis has much improved over the past 2 decades. Initial treatment stops bleeding in 90% of patients. Accurate predictive rules are provided for early recognition of high-risk patients.
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              Vascular disorders of the liver.

              Laurie DeLeve, Dominique-Charles Valla, Guadalupe Garcia-Tsao (2009)
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                Author and article information

                Journal
                Journal ID (nlm-ta): Gastroenterol Rep (Oxf)
                Journal ID (iso-abbrev): Gastroenterol Rep (Oxf)
                Journal ID (publisher-id): gastro
                Title: Gastroenterology Report
                Publisher: Oxford University Press
                ISSN (Electronic): 2052-0034
                Publication date (Print): May 2017
                Publication date (Electronic): 24 April 2017
                Publication date PMC-release: 24 April 2017
                Volume: 5
                Issue: 2
                Pages: 148-156
                Affiliations
                [1 ]Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
                [2 ]Department of Clinical Research, University of Bern, Bern, Switzerland
                [3 ]Department of Internal Medicine I, University of Bonn, Bonn, Germany
                [4 ]Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
                [5 ]European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain
                Author notes
                [* ] Corresponding author. Laboratory for Liver Fibrosis and Portal Hypertension, Department of Internal Medicine I, University Clinic Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany. Email: jonel.trebicka@ 123456ukbonn.de
                [† ]All authors contributed equally to this review.
                Article
                Publisher ID: gox014
                DOI: 10.1093/gastro/gox014
                PMC ID: 5421355
                PubMed ID: 28533912
                SO-VID: eb417e7a-8562-4e8b-8f79-ff1769ff6915
                Copyright © © The Author(s) 2017. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-Sen University.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com.

                History
                Date received : 17 March 2017
                Date accepted : 17 March 2017
                Page count
                Pages: 9
                Funding
                Funded by: Swiss National Science Foundation
                Award ID: 31003A_163143
                Funded by: DFG
                Award ID: SFB TRR 57, P18
                Categories
                Subject: Review Articles

                Keywords: portal vein thrombosis,liver cirrhosis,thrombophilia tests,low-molecular-weight heparin,transjugular intrahepatic portosystemic shunt,liver transplantation
                Data availability:
                Keywords: portal vein thrombosis, liver cirrhosis, thrombophilia tests, low-molecular-weight heparin, transjugular intrahepatic portosystemic shunt, liver transplantation

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