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Gil-Lopez F, Rios-Olais FA, Mercado LA, Harnois DM. Portal Vein Thrombosis in Patients Without Cirrhosis: Current Practical Approaches and Treatment Strategies. Diagnostics (Basel) 2025; 15:721. [PMID: 40150064 PMCID: PMC11941439 DOI: 10.3390/diagnostics15060721] [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: 01/21/2025] [Revised: 03/01/2025] [Accepted: 03/10/2025] [Indexed: 03/29/2025] Open
Abstract
Portal vein thrombosis in non-cirrhotic individuals, although uncommon, is an increasingly explored condition that affects mainly young people, consequently representing a significant disease burden. Reports primarily including western European populations have recently shed light regarding the pathophysiology, risk factors, natural history, treatment, and prognosis of this entity. Underlying predisposing conditions are documented in ~70% of cases, encompassing local risk factors, inherited and acquired thrombophilia, cancer, and systemic inflammatory conditions. Non-cirrhotic portal vein thrombosis can cause significant portal hypertension in the acute setting, but, more frequently, significant portal hypertension-related complications arise when the condition becomes chronic and portosystemic collaterals develop, increasing the risk for variceal bleeding and ascites. The diagnostic approach to screen for underlying thrombophilia remains a challenge, and recommendations in this regard, although scarce and backed by scarce evidence, have changed notably in the last years, leaning toward a universal screen in patients who develop this condition without a clear provoking factor. Recently, studies have shown that long-term anticoagulation may be appropriate even in the absence of clear provoking factors or underlying thrombophilia. Future studies should address which patients may benefit from this approach, which patients may not need it, and what the most appropriate strategies are to approach patients who do not recover portal vein patency with anticoagulation to further prevent portal hypertension-related complications.
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Affiliation(s)
- Fernando Gil-Lopez
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (F.G.-L.); (L.A.M.)
| | - Fausto Alfredo Rios-Olais
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City C.P. 14080, Mexico;
| | - Lydia A. Mercado
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (F.G.-L.); (L.A.M.)
| | - Denise M. Harnois
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (F.G.-L.); (L.A.M.)
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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2
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Mathew MA, Boucher KA. Extensive Portal Vein Thrombosis Following Laparoscopic Cholecystectomy: Interplay of Liver Cirrhosis, Psoriasis, and Anticoagulation Oversight. Cureus 2025; 17:e79958. [PMID: 40177431 PMCID: PMC11964119 DOI: 10.7759/cureus.79958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2025] [Indexed: 04/05/2025] Open
Abstract
Portal vein thrombosis (PVT) is a rare but serious condition often associated with liver cirrhosis, malignancy, and hypercoagulable states. While PVT following laparoscopic surgery is uncommon, certain risk factors can predispose patients to this complication. A 65-year-old male with a history of untreated plaque psoriasis and alcoholic liver cirrhosis with portal hypertension developed PVT after a robot-assisted laparoscopic cholecystectomy. The patient presented with abdominal swelling and mild epigastric pain two months postoperatively. Imaging revealed an occlusive thrombus in the portal vein extending into the splenic and superior mesenteric veins, accompanied by bowel congestion, edema, and early signs of ischemia. The patient had been on warfarin prior to surgery for an unclear reason but had failed to resume warfarin use postoperatively due to a lack of follow-up with his primary care physician. After managing the patient's PVT with a heparin drip followed by apixaban, his symptoms improved. A thrombophilia panel revealed decreased activity of antithrombin III, factor II, and protein C. Thorough preoperative history-taking and postoperative primary care follow-up are essential, particularly in patients with multiple thromboembolic risk factors. The unexpected role of untreated psoriasis as a potential contributor to PVT highlights the need for further research into the systemic effects of chronic inflammatory conditions.
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Affiliation(s)
- Merry A Mathew
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Kent-Andrew Boucher
- Department of Surgery, Texas Tech University Health Sciences Center, Odessa, USA
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3
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Willington AJ, Tripathi D. Current concepts in the management of non-cirrhotic non-malignant portal vein thrombosis. World J Hepatol 2024; 16:751-765. [PMID: 38818283 PMCID: PMC11135268 DOI: 10.4254/wjh.v16.i5.751] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/20/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024] Open
Abstract
Non-cirrhotic non-malignant portal vein thrombosis (NCPVT) is an uncommon condition characterised by thrombosis of the portal vein, with or without extension into other mesenteric veins, in the absence of cirrhosis or intra-abdominal malignancy. Complications can include intestinal infarction, variceal bleeding and portal biliopathy. In this article, we address current concepts in the management of NCPVT including identification of risk factors, classification and treatment, and review the latest evidence on medical and interventional management options.
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Affiliation(s)
- Adam J Willington
- Department of Hepatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Dhiraj Tripathi
- Department of Hepatology, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom
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4
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Walia D, Saraya A, Gunjan D. Vascular complications of chronic pancreatitis and its management. World J Gastrointest Surg 2023; 15:1574-1590. [PMID: 37701688 PMCID: PMC10494584 DOI: 10.4240/wjgs.v15.i8.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 08/25/2023] Open
Abstract
Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.
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Affiliation(s)
- Dinesh Walia
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anoop Saraya
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deepak Gunjan
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
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5
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Brenner DM, Brandt LJ, Fenster M, Hamilton MJ, Kamboj AK, Oxentenko AS, Wang B, Chey WD. Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists. Clin Gastroenterol Hepatol 2023; 21:264-279. [PMID: 36180010 DOI: 10.1016/j.cgh.2022.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 01/28/2023]
Abstract
Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.
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Affiliation(s)
- Darren M Brenner
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Lawrence J Brandt
- Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Marc Fenster
- Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Matthew J Hamilton
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amy S Oxentenko
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
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Salem R, Hameed W, Ravikumar R, Bharathkumar M, Devachandran J, Samraj K. Management of Mesenteric Venous Ischaemia: A Case Series With Newer Approaches. Cureus 2022; 14:e25704. [PMID: 35832762 PMCID: PMC9272985 DOI: 10.7759/cureus.25704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/05/2022] Open
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Khetarpal S. Superior Mesenteric Vein Thrombosis in a Pediatric Patient: Case Report and Review of the Literature. Pediatr Emerg Care 2021; 37:e769-e771. [PMID: 31977781 DOI: 10.1097/pec.0000000000001967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patients with inflammatory bowel disease are at increased risk of thromboembolism. There are various sites for thromboembolism including the cerebral, limbs, abdominal vessels, retina, and lungs. Here, we report a case of a 17-year-old patient with a history of Crohn disease presenting with abdominal pain. Upon further evaluation, the patient was found to have mesenteric vein thrombosis, which was discovered on computed tomographic scan. Potential causes, contributing factors, diagnosis, and treatment are discussed here.
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Acute Mesenteric Vein Thrombosis in a Pregnant Patient at 10 Weeks Gestation: A Case Report. Diagnostics (Basel) 2021; 11:diagnostics11081348. [PMID: 34441283 PMCID: PMC8391634 DOI: 10.3390/diagnostics11081348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 01/16/2023] Open
Abstract
Acute abdominal pain during pregnancy is challenging, both from a diagnostic and management perspective. A non-localized, persistent pain out of proportion to physical examination is a sign that advanced imaging may be necessary. Mesenteric venous thrombosis in a pregnant patient is extremely rare, but if diagnosis is delayed, can be potentially fatal to both the mother and the fetus. We present here a pregnant patient in the tenth week of gestation with classic clinical manifestations of mesenteric vein thrombosis and the corresponding findings on magnetic resonance imaging (MRI) and computed tomography (CT).
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Caiano LM, Riva N, Carrier M, Gatt A, Ageno W. Treatment of portal vein thrombosis: an updated narrative review. Minerva Med 2021; 112:713-725. [PMID: 33832217 DOI: 10.23736/s0026-4806.21.07526-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Portal vein thrombosis (PVT) is the most frequent among the splanchnic vein thrombosis, accounting for 90% of cases. More than half of PVT are provoked by liver cirrhosis, solid cancer or myeloproliferative neoplasms. The remaining cases are non-malignant non-cirrhotic PVT and include either unprovoked events or thrombosis secondary to other less common risk factors (e.g. abdominal surgery, intrabdominal inflammations/infections, or hormonal stimuli). Anticoagulant therapy in patients with acute symptomatic PVT should be started early after diagnosis, if no active bleeding, to obtain greater vessel recanalization and reduce the occurrence of portal-hypertension related complications. Gastroesophageal varices do not represent a contraindication to anticoagulant treatment, as long as adequate measures have been undertaken for the prophylaxis of gastroesophageal bleeding. Different treatment options (unfractionated or low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants [DOACs]) can be considered. In this narrative review we will discuss the treatment of PVT in the three most common scenarios (cirrhosis-associated, cancer-associated and non-malignant non-cirrhotic PVT). We will also discuss the role of the DOACs and summarise recent guidelines on this topic.
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Affiliation(s)
- Lucia M Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.,Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta -
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Rugivarodom M, Charatcharoenwitthaya P. Nontumoral Portal Vein Thrombosis: A Challenging Consequence of Liver Cirrhosis. J Clin Transl Hepatol 2020; 8:432-444. [PMID: 33447527 PMCID: PMC7782107 DOI: 10.14218/jcth.2020.00067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/27/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dysfunction have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable; however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anticoagulation treatment with vitamin K antagonist or low molecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hypertension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anticoagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anticoagulation is bleeding, most studies indicate that anticoagulation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive therapy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evidence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.
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Affiliation(s)
- Manus Rugivarodom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence to: Phunchai Charatcharoenwitthaya, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Wang-Lang Road, Bangkoknoi, Bangkok 10700, Thailand. Tel: +662-419-7282, Fax: +662-411-5013, E-mail:
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11
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Mubarak AA, Awad GE, Eltomey MA, Dawoud MAE. Non-contrast MR portography using time-spatial labeling inversion pulse for diagnosis of portal vein pathology. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0036-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To study the ability of non-contrast MR portography using time-spatial labeling inversion pulse (T-SLIP) as a non-invasive contrast-free imaging modality to delineate different portal vein pathological conditions.
The study included 25 patients with known history of portal vein disease and another 25 age-matched patients with normal portal vein. Both groups were examined by respiratory-triggered non-contrast MR portography using time-spatial labeling inversion pulse technique. Image quality was assessed first, and findings of diagnostic scans were compared to color duplex ultrasonography and selectively in those with diseased portal vein to portal-phase images of dynamic contrast-enhanced MRI.
Results
Significant relation was found between breathing regularity and image quality in T-SLIP sequence, with diagnostic scans sensitivity and specificity of 89.29% and 86.21%, respectively, for diagnosis of different portal vein pathological conditions.
Conclusions
Non-contrast MR portography is a useful technique for diagnosis of portal vein pathology in carefully selected patients.
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12
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Alzubaidi S, Patel I, Saini A, Knuttinen G, Naidu S, Kriegshuaser S, Albadawi H, Oklu R. Current concepts in portal vein thrombosis: etiology, clinical presentation and management. Abdom Radiol (NY) 2019; 44:3453-3462. [PMID: 31407054 DOI: 10.1007/s00261-019-02174-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this article is to focus on etiology, risk factors, clinical presentation and classification systems of acute and chronic PVT as well as focusing on current diagnostic and therapeutic options for the management of acute and chronic PVT. RESULTS PVT represents a serious clinical concern in cirrhotic patients and in those with specific local or systemic risk factors. The rate and extent of thrombus formation can significantly impact patient presentation and the resulting clinical outcomes. The presentation of acute PVT can range from abdominal pain to intestinal ischemia/infarction and even death, while chronic PVT can remain clinically silent. A number of imaging modalities including US, CT and MRI can be used to confirm the diagnosis. In addition to addressing underlying risk factors, AC therapy forms a cornerstone of treatment and has demonstrated efficacy in both acute and chronic settings. Proper caution should be used when initiating AC therapy in cirrhotic patients given their underlying coagulopathic status with attention now being paid to NOACs and LMWH. For patients with bowel ischemia, extensive thrombosis, contraindications or poor response to AC, or for those with co-morbidities that preclude AC, minimally invasive endovascular techniques offer alternative treatment options. CONCLUSION Familiarity with the etiology, clinical presentation and classification of PVT optimize early detection and incorporate effective therapeutic options, the management of these complex patients should be undertaken by a multidisciplinary team. Minimally invasive catheter-based therapies and endovascular portosystemic shunt creation demonstrated efficacy in the treatment of AC-resistant patients and for patients with extensive or complicated disease.
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13
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Kojima S, Watanabe N, Koizumi J, Kokubu S, Murashima N, Matsutani S, Obara K. Current status of portal vein thrombosis in Japan: Results of a questionnaire survey by the Japan Society for Portal Hypertension. Hepatol Res 2018; 48:244-254. [PMID: 28902450 DOI: 10.1111/hepr.12983] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 02/08/2023]
Abstract
AIM To investigate the current status of portal vein thrombosis (PVT) in Japan, the Clinical Research Committee of the Japan Society of Portal Hypertension undertook a questionnaire survey. METHODS A questionnaire survey of 539 cases of PVT over the previous 10 years was carried out at institutions affiliated with the Board of Trustees of the Japan Society of Portal Hypertension. RESULTS The most frequent underlying etiology of PVT was liver cirrhosis in 75.3% of patients. Other causes included inflammatory diseases of the hepatobiliary system and the pancreas, malignant tumors, and hematologic diseases. The most frequent site was the main trunk of the portal vein (MPV) in 70.5%, and complete obstruction of the MPV was present in 11.5%. Among the medications for PVT, danaparoid was given to 45.8%, warfarin to 26.2%, heparin to 17.3%, and anti-thrombin III to 16.9%. Observation of the course was practiced in 22.4%. Factors contributing to therapeutic efficacy were implementation of various medications, thrombi localized to either the right or left portal vein only, non-complete obstruction of the MPV and Child-Pugh class A liver function. A survival analysis showed that the prognosis was favorable with PVT disappearance regardless of treatment. CONCLUSION The questionnaire survey showed the current status of PVT in Japan. Any appropriate medication should be given to a patient with PVT when PVT is recognized. It is necessary to compile a large amount of information and reach a consensus on safe and highly effective management of PVT.
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Affiliation(s)
- Seiichiro Kojima
- Clinical Research Committee Member, Japan Society of Portal Hypertension
| | - Norihito Watanabe
- Clinical Research Committee Member, Japan Society of Portal Hypertension
| | - Jun Koizumi
- Clinical Research Committee Member, Japan Society of Portal Hypertension
| | - Shigehiro Kokubu
- Clinical Research Committee Member, Japan Society of Portal Hypertension
| | - Naoya Murashima
- Clinical Research Committee Member, Japan Society of Portal Hypertension
| | - Shoichi Matsutani
- Chairperson of Clinical Research Committee Member, Japan Society of Portal Hypertension
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Riva N, Ageno W. Approach to thrombosis at unusual sites: Splanchnic and cerebral vein thrombosis. Vasc Med 2017; 22:529-540. [PMID: 29202678 DOI: 10.1177/1358863x17734057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Splanchnic vein thrombosis (SVT) and cerebral vein thrombosis (CVT) are two manifestations of unusual site venous thromboembolism (VTE). SVT includes thrombosis in the portal, mesenteric or splenic veins, and the Budd-Chiari syndrome. CVT encompasses thrombosis of the dural venous sinuses and thrombosis of the cerebral veins. Unusual site VTE often represents a diagnostic and therapeutic challenge because of the heterogeneity in clinical presentation, the limited evidence available in the literature on the acute and long-term prognosis of these diseases, and the lack of large randomized controlled trials evaluating different treatment options. This narrative review describes the approach to patients with SVT or CVT by examining the diagnostic process, the assessment of potential risk factors and the appropriate anticoagulant treatment.
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Affiliation(s)
- Nicoletta Riva
- 1 Department of Pathology, University of Malta, Msida, Malta
| | - Walter Ageno
- 2 Department of Medicine and Surgery, University of Insubria, Varese, Italy
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15
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Abstract
Portal vein thrombosis (PVT) in the cirrhotic population is a challenging clinical phenomenon requiring a nuanced management approach. Uncertainty exists regarding the clinical significance of PVT in the cirrhotic population because the data for PVT are based mainly on retrospective, small cohort studies. Therefore, strong recommendations regarding the optimal timing, modality, and duration of therapy for PVT in the cirrhotic population cannot be made. However, this review aims to summarize the current literature and provide stepwise guidance in diagnosing and managing PVT in patients with cirrhosis.
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Riva N, Ageno W. Clinical manifestations and imaging tools in the diagnosis of splanchnic and cerebral vein thromboses. Thromb Res 2017; 163:252-259. [PMID: 28673473 DOI: 10.1016/j.thromres.2017.06.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 12/19/2022]
Abstract
Splanchnic vein thrombosis (SVT) and cerebral vein thrombosis (CVT) are uncommon manifestation of venous thromboembolism (VTE), occurring less frequently than deep vein thrombosis of the lower extremities and pulmonary embolism. SVT encompasses portal vein thrombosis, mesenteric vein thrombosis, splenic vein thrombosis and the Budd-Chiari syndrome. It is therefore a heterogeneous disease, with differences in clinical manifestations according to the site of thrombosis. CVT includes thrombosis of the cortical or deep cerebral veins and thrombosis of the major dural venous sinuses. Clinical presentation is variable, with a wide spectrum of signs and symptoms that can mimic other cerebral diseases. There are no clinical algorithms or specific laboratory tests that can guide in the identification of SVT and CVT; therefore, the diagnosis relies exclusively on imaging tests. Conventional angiography once was the gold standard for the diagnosis of SVT and CVT, but it is rarely used nowadays. Abdominal ultrasound (US), computed tomography (CT) and magnetic resonance (MR) with angiography are currently used for the diagnosis of SVT; while cerebral CT and MR with angiography are currently used for the diagnosis of CVT. These imaging tests have different sensitivities/specificities and different advantages/disadvantages that should be kept into consideration when choosing the appropriate imaging test based on the suspected site of thrombosis. This narrative review summarizes the clinical and diagnostic approach to SVT and CVT.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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Leonardi F, Maria ND, Villa E. Anticoagulation in cirrhosis: a new paradigm? Clin Mol Hepatol 2017; 23:13-21. [PMID: 28288507 PMCID: PMC5381832 DOI: 10.3350/cmh.2016.0110] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/09/2017] [Indexed: 02/06/2023] Open
Abstract
The liver plays a crucial role in coagulation cascade. Global hemostatic process is profoundly influenced by the presence of liver disease and its complications. Patients with cirrhosis have impaired synthesis of most of the factors involved in coagulation and fibrinolysis process due to a reduced liver function and altered platelet count secondary to portal hypertension. Altered routine tests and thrombocytopenia were considered in the past as associated with increased risk of bleeding. These concepts explain both the routine use of plasma and/or platelets transfusion in patients with liver cirrhosis, especially before invasive procedures, and why these patients were considered "auto-anticoagulated". New recent evidences show that patients with liver cirrhosis have a more complex hemostatic alteration. Despite the presence of altered levels of factors involved in primary hemostasis, coagulation and fibrinolysis, patients with stable cirrhosis have a rebalanced hemostatic, which however can easily be altered by decompensation or infection, both in hemorrhagic or thrombotic direction. Patients with cirrhosis have an increased risk of venous thrombotic events (namely portal vein thrombosis) while bleeding seems to be related to the grade of portal hypertension rather than to a hemostatic imbalance. The use of anticoagulants both as treatment or prophylaxis is safe, reduces the rate of portal vein thrombosis and decompensation, and improves survival. Standard laboratory coagulation tests are unable to predict bleeding and are inadequate for the assessment of hemostatic status in these patients, hence more comprehensive tests are required to guide the management of thrombotic and bleeding complications.
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Affiliation(s)
- Filippo Leonardi
- Department of Internal Medicine, Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena,Italy
| | - Nicola De Maria
- Department of Internal Medicine, Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena,Italy
| | - Erica Villa
- Department of Internal Medicine, Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena,Italy
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Vascular imaging of the mesenteric vasculature. Best Pract Res Clin Gastroenterol 2017; 31:3-14. [PMID: 28395786 DOI: 10.1016/j.bpg.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 10/31/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Imaging of the mesenteric vasculature is crucial in diagnosing vascular disease of the gastro-intestinal tract such as acute or chronic mesenteric ischemia caused by arterial stenosis, embolism or thrombosis, mesenteric vein thrombosis and mesenteric aneurysm or dissection. The reference standard for imaging of the mesenteric vasculature is digital subtraction angiography. However, modalities as duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are developing rapidly and may provide accurate imaging non-invasively. This review provides an up-to-date overview of the anatomic resolution, clinical application, emerging techniques and future perspectives of these four radiological modalities for imaging of the mesenteric vasculature.
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Achar S, Dutta HK, Gogoi RK. Extrahepatic Portal Vein Obstruction in Children: Role of Preoperative Imaging. J Indian Assoc Pediatr Surg 2017; 22:144-149. [PMID: 28694570 PMCID: PMC5473299 DOI: 10.4103/0971-9261.207634] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Aim: Extrahepatic portal vein obstruction (EHPVO) is characterized by features of recent thrombosis or portal hypertension with portal cavernoma as a sequel of portal vein obstruction. Imaging of spleno-portal axis is the mainstay for the diagnosis of EHPVO. The aim of this study is to analyze the role of imaging in the preoperative assessment of the portal venous system in children with EHPVO. Materials and Methods: A hospital-based cross-sectional study was conducted on twenty children with EHPVO aged between 1 and 18 years over a period of 1 year. The children were evaluated clinically, followed by upper gastrointestinal endoscopy. Radiological assessment included imaging of the main portal vein, its right and left branches, splenic vein, and superior mesenteric vein using color Doppler ultrasonography (CDUSG) and magnetic resonance portovenogram (MRP). Evidence of portal biliopathy, status of collaterals, and possible sites for portosystemic shunt surgery were also examined. Results: All the patients presented in chronic stage with portal cavernoma and only one patient (5%) had bland thrombus associated with cavernoma. The CDUSG and MRPs had a sensitivity of 66.6-90% and 96.7% and specificity of 91.5% and 98.3% respectively with regard to the assessment of the extent of thrombus formation and flow in the portal venous system. Both the modalities were found to be complementary to each other in preoperative assessment of EHPVO. However, the sensitivity of MRP was slightly superior to CDUSG in detecting occlusion and identifying portosystemic collaterals and dilated intrahepatic biliary radicals. Conclusion: Results of the present study indicate that MRP is well suited and superior to CDUSG in the preoperative imaging of patients with EHPVO.
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Affiliation(s)
- Shashidhar Achar
- Department of Radiodiagnosis, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Hemonta Kumar Dutta
- Department of Pediatric Surgery, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Rudra Kanta Gogoi
- Department of Radiodiagnosis, Assam Medical College and Hospital, Dibrugarh, Assam, India
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Dronkers CEA, Klok FA, Huisman MV. Current and future perspectives in imaging of venous thromboembolism. J Thromb Haemost 2016; 14:1696-710. [PMID: 27397899 DOI: 10.1111/jth.13403] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Indexed: 01/16/2023]
Abstract
Several thrombus imaging techniques for the diagnosis of venous thromboembolism (VTE) are available. The most prevalent forms of VTE are deep vein thrombosis of the lower extremities and pulmonary embolism. However, VTE may also occur at unusual sites such as deep veins of the upper extremity and the splanchnic and cerebral veins. Currently, the imaging techniques most widely used in clinical practice are compression ultrasonography and computed tomography (CT) pulmonary angiography. Moreover, single-photon emission CT, CT venography, positron emission tomography, and different magnetic resonance imaging (MRI) techniques, including magnetic resonance direct thrombus imaging, have been evaluated in clinical studies. This review provides an overview of the technique, diagnostic accuracy and potential pitfalls of these established and emerging imaging modalities for the different sites of venous thromboembolism.
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Affiliation(s)
- C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Praktiknjo M, Meyer C, Strassburg CP, Trebicka J. [Recent thrombosis of splanchnic veins : Two case reports of catheter-assisted local thrombolysis and thrombus aspiration]. Internist (Berl) 2016; 58:82-89. [PMID: 27573529 DOI: 10.1007/s00108-016-0120-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- M Praktiknjo
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland
| | - C Meyer
- Radiologische Klinik, Universitätsklinikum Bonn, Bonn, Deutschland
| | - C P Strassburg
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland
| | - J Trebicka
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland.
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22
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Kim JH, Lee JM, Yoon JH, Lee DH, Lee KB, Han JK, Choi BI. Portal Vein Thrombosis in Patients with Hepatocellular Carcinoma: Diagnostic Accuracy of Gadoxetic Acid-enhanced MR Imaging. Radiology 2016; 279:773-83. [PMID: 26780538 DOI: 10.1148/radiol.2015150124] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose To assess the diagnostic performance of gadoxetic acid-enhanced magnetic resonance (MR) imaging in the evaluation of portal vein thrombosis (PVT) in patients with hepatocellular carcinoma (HCC). Materials and Methods This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. A total of 366 patients with HCC who underwent gadoxetic acid-enhanced MR imaging between January 2007 and May 2013, including 134 with malignant PVT, 49 with benign PVT, and 183 without PVT matched for age and sex, comprised our study population. PVTs were complete in 125 patients and partial in 58 and were located in a major portal vein (n = 159) or segmental portal vein (n = 24). Two radiologists independently reviewed the MR images and assessed the sensitivity, specificity, and accuracy in the detection and characterization of PVT according to location (major vs segmental) and type (complete vs partial). The Fisher exact or χ(2) test was used to evaluate sensitivity difference between the subsets. Results Gadoxetic acid-enhanced MR imaging showed good sensitivity (reviewer 1, 84% [154 of 183 patients]; reviewer 2, 70% [129 of 183 patients]) and high specificity (reviewer 1, 89% [163 of 183 patients]; reviewer 2, 96% [176 of 183 patients]) in the detection of PVT. Diagnostic accuracy for differentiating malignant PVT from benign PVT was high (reviewer 1, 92% [141 of 154 patients]; reviewer 2, 95% [122 of 129 patients]). However, there was slightly lower sensitivity for detecting segmental PVT compared with that of major PVT in the malignant PVT group (reviewer 1, 95% [104 of 110 patients] vs 88% [21 of 24 patients]; reviewer 2, 82% [90 of 110 patients] vs 79% [19 of 24 patients]; P = .203 and .775 for reviewers 1 and 2, respectively). Conclusion Gadoxetic acid-enhanced MR imaging provided good diagnostic performance in the detection of PVT and the differentiation of malignant from benign PVT in patients with HCC. However, caution is needed when evaluating potential candidates for curative treatment because of the low sensitivity for segmental PVT in the malignant PVT group. (©) RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Jae Hyun Kim
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | - Jeong Min Lee
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | - Jeong Hee Yoon
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | - Dong Ho Lee
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | - Kyung Bun Lee
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | - Joon Koo Han
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | - Byung Ihn Choi
- From the Departments of Radiology (J.H.K., J.M.L., J.H.Y., D.H.L., J.K.H., B.I.C.) and Pathology (K.B.L.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
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Imaging Diagnosis of Splanchnic Venous Thrombosis. Gastroenterol Res Pract 2015; 2015:101029. [PMID: 26600801 PMCID: PMC4620257 DOI: 10.1155/2015/101029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/22/2015] [Indexed: 12/15/2022] Open
Abstract
Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.
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Abstract
Background In contrast to an acute occlusion of the visceral arteries, which is the most important differential diagnosis for an occlusion of the portal venous system and which poses a highly dangerous situation ending in gangrene of the bowel wall, the symptoms of an acute occlusion of the portal venous system are quite unspecific. To rule out an acute arterial occlusion, diagnostic evaluation has to be carried out quickly in order to decide on the necessity of therapeutic steps concerning a recanalization of the occluded vessels. Only few therapeutic options are available to recanalize and remodel the portal venous system, depending on the underlying disease, the age of the occlusion, its extension, and the effect on the bowel wall, stomach, spleen, and abdominal wall. Moreover, the efficacy of recanalization procedures mainly depends on the formation and number of collateral venous blood supply, its degree, and the anatomic structure. Possible complications of portal hypertension like varices, gastrointestinal vasculopathy, ascites, and splenomegaly also influence the success of recanalization procedures. Only in cases of acute thrombotic occlusion systemic lytic therapy promises to be successful. Therefore, other options such as transjugular intrahepatic recanalization, e.g. by means of the TIPS (transjugular intrahepatic portosystemic shunt) procedure, have to be evaluated. Methods Review of the literature. Results Noninvasive methods such as ultrasound (US), computed tomography, and especially magnetic resonance imaging (MRI) allow the evaluation of therapeutic options as well as their success, the feasibility of technical procedures, the detection of possible risks, and a calculation of risks and benefits. Conclusion In order to arrive at the correct therapeutic decision, a combination of MRI and US methods combined with color Doppler guarantee the most efficient diagnostic results in cases with acute or chronic occlusions of the portal venous system.
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Affiliation(s)
- Karlheinz Hauenstein
- Institute of Diagnostic and Interventional Radiology, University Medicine Rostock, Rostock, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology, University Medicine Rostock, Rostock, Germany
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25
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Abstract
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.
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Key Words
- ACLA, anti-cardiolipin antibody
- AFP, alpha feto protein
- BCS, Budd-Chiari syndrome
- CDUS, color doppler ultrasonography
- CT, computed tomography
- CTP, Child Turcotte Pugh
- EHPVO, extra hepatic portal venous obstruction
- EST, endoscopic sclerotherapy
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- IGF-1, insulin like growth factor-1
- IGFBP-3, insulin like growth factor binding protein-3
- INR, international normalized ratio
- JAK-2, Janus kinase 2
- LA, lupus anticoagulant
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MPD, myeloproliferative disorder
- MRI, magnetic resonance imaging
- MTHFR, methylenetetrahydrofolate reductase
- MVT, mesenteric vein thrombosis
- OCPs, oral contraceptive pills
- PAI-1 4G-4G, plasminogen activator inhibitor type 1- 4G/4G genotype
- PNH, paroxysmal nocturnal hemoglobinuria
- PV, portal vein
- PVT
- PVT, portal vein thrombosis
- PWUS, Pulsed Wave ultrasonography
- RFA, radio frequency ablation
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- TAFI, thrombin activatable fibrinolysis inhibitor
- TARE, Trans arterial radioembolization
- TB, tuberculosis
- TIPS, transjugular intrahepatic portosystemic shunt
- UFH, unfractionated heparin
- acute and chronic
- anticoagulation
- imaging
- prothrombotic
- rtPA, recombinant tissue plasminogen activator
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Affiliation(s)
- Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Kwa CXW, Tan VKM, Ong HS. Anticoagulation in the treatment of portovenous emboli after cyanoacrylate injection for a bleeding gastric varix. Singapore Med J 2015; 56:e14-6. [PMID: 25640106 DOI: 10.11622/smedj.2015016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
We herein report the use of endoscopic n-butyl-2-cyanoacrylate injections to obliterate a gastric varix, which led to cyanoacrylate embolisation in the splenic and portal veins in a single patient. Cyanoacrylate embolisation is a known but uncommonly reported complication of endoscopic sclerotherapy. This case report illustrates the successful management of this complication (i.e. cyanoacrylate embolisation in the splenic and portal veins) with anticoagulation and analyses the presentation and management of other cases of cyanoacrylate embolisation reported in the literature.
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Affiliation(s)
- Charlene Xian Wen Kwa
- Department of Anaesthesiology, Academia Level 5, Singapore General Hospital, Outram Road, Singapore 169608.
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Waiswa M, Seremba E, Ocama P, Ddungu H, Opio K, Okello C, O'shea T, Verhovsek M, Mutyabule R. Splanchnic venous thrombosis driven by a constitutively activated JAK2 V617F philadelphia-negative myeloproliferative neoplasm: a case report. Afr Health Sci 2014; 14:1069-73. [PMID: 25834519 DOI: 10.4314/ahs.v14i4.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Splanchnic venous thrombosis (SVT) has varied etiology with Philadelphia-negative myeloproliferative neoplasms (MPNs) being the most frequent underlying prothrombotic factor. Hematological indices often remain within normal range because of portal hypertension and its sequelae, causing diagnostic challenges. The high frequency of JAK2 mutation among patients with SVT reinforces the diagnostic utility of JAK2V617F testing. CASE REPORT We report a case of a 62-year-old black man with progressive abdominal swelling and features of decompensated chronic liver disease found to have SVT-portal vein thrombosis and how JAK2 V617F was useful in unmasking an underlying myeloproliferative neoplasm. CONCLUSION A high index of suspicion for an underlying prothrombotic factor is critical for patients presenting with thrombosis in unusual sites. This is useful in prognostic stratification and patient outcomes. JAK2 mutation screening is now part of the standard diagnostic workup in SVT.
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Affiliation(s)
- Musa Waiswa
- Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Emmanuel Seremba
- Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Ponsiana Ocama
- Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Henry Ddungu
- Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Keneth Opio
- Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Clement Okello
- Department of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
| | - Timothy O'shea
- Department of Medicine, McMaster University, Hamilton Ontario, Canada
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Hwang J, Kim YK, Lee WJ, Choi D, Park MJ, Park HJ, Hong SS, Lee MH. Unenhanced magnetic resonance portography using repetitive arterial or vein labeling method at 3.0-T. J Comput Assist Tomogr 2013; 37:856-861. [PMID: 24270106 DOI: 10.1097/rct.0b013e31829002ca] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to determine whether unenhanced magnetic resonance (MR) angiography using repetitive arterial or vein labeling (RAVEL) is feasible to visualize effectively the intrahepatic portal vein (PV) at 3.0 T. METHODS Forty patients underwent liver MR imaging (MRI) with unenhanced MR portography using RAVEL. Two radiologists performed a consensus review of unenhanced MR portography and portal-phase MRI with regard to anatomic type of PV, vessel conspicuity, and image quality. RESULTS For determination of the anatomic type of PV, the 2 techniques were equivalent. There were tendencies toward increased conspicuity for right segmental PV and its branches with unenhanced MR portography and for left PV with conventional MRI, although significant differences were not found between MRIs (P > 0.05). Image quality for unenhanced MR portography was poor in 1, moderate in 8, and good in 31 patients. CONCLUSIONS Unenhanced MR portography using RAVEL at 3.0 T is feasible and provides effective visualization of intrahepatic PV.
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Affiliation(s)
- Jiyoung Hwang
- From the *Department of Radiology, Soonchunhyang University Seoul Hospital; †Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine; and ‡Department of Radiology, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
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Abstract
Pancreatitis is an inflammatory process with local and systemic manifestations. One such local manifestation is thrombosis in splanchnic venous circulation, predominantly of the splenic vein. The literature on this important complication is very sparse. This review offers an overview of mechanism of thrombosis, its pathophysiology, diagnosis, and management in the setting of acute as well as chronic pancreatitis.
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Seijo S, García-Criado Á, Darnell A, García-Pagán JC. Diagnóstico y tratamiento de la trombosis portal en la cirrosis hepática. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:660-6. [DOI: 10.1016/j.gastrohep.2012.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/09/2012] [Indexed: 12/15/2022]
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Qian LJ, Zhu J, Zhuang ZG, Xia Q, Cheng YF, Li JY, Xu JR. Differentiation of neoplastic from bland macroscopic portal vein thrombi using dual-energy spectral CT imaging: a pilot study. Eur Radiol 2012; 22:2178-85. [PMID: 22622347 DOI: 10.1007/s00330-012-2477-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 03/14/2012] [Accepted: 03/22/2012] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To assess the feasibility and value of dual-energy spectral computed tomography (DESCT) imaging for differentiating neoplastic from bland macroscopic portal vein (PV) thrombi. METHODS Computed tomography (CT) images of 44 patients with macroscopic PV thrombus (bland group, n = 16; neoplastic group, n = 28) were reviewed. Iodine-based material decomposition images in the portal venous phase were reconstructed to compare the iodine indices between groups, including thrombus iodine density (I (T)), thrombus-aorta iodine density ratio (I (T)/I (A)), and thrombus-PV iodine density ratio (I (T)/I (P)). Differential diagnostic performances of DESCT were calculated in the subgroup of 21 patients with histopathological evidence (bland group, n = 12; neoplastic group, n = 9). RESULTS The iodine indices of the neoplastic group were significantly higher than those in the bland group (P < 0.001). A threshold I (T) of 1.14 mg/mL, I (T)/I (A) of 0.17, and I (T)/I (P) of 0.17 in the portal venous phase yielded 100 %, 88.9 %, and 100 % sensitivity, and 91.7 %, 91.7 %, and 83.3 % specificity, respectively, in differentiating neoplastic from bland PV thrombi. CONCLUSIONS DESCT imaging with quantification of thrombus iodine density in the portal venous phase appears to be a promising new method for distinguishing neoplastic from bland macroscopic PV thrombi. KEY POINTS • Differentiating the nature of portal vein thrombus is of great clinical significance. • Iodine-based material decomposition imaging reflects iodine distribution after contrast media administration. • Dual-energy CT with iodine quantification can distinguish bland from neoplastic PV thrombi.
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Affiliation(s)
- Li Jun Qian
- Department of Radiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, No. 1630 Dongfang Rd. Pudong, Shanghai, 200127, People's Republic of China
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Aslam R, Yeh BM, Yee J. MR imaging evaluation of the hepatic vasculature. Magn Reson Imaging Clin N Am 2011; 18:515-23, xi. [PMID: 21094453 DOI: 10.1016/j.mric.2010.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Assessment of the hepatic vasculature is essential for tumor staging, surgical planning, and understanding of liver disease. Technological advances have made contrast-enhanced magnetic resonance (MR) imaging comparable to multidetector-row computed tomography for diagnostic vascular imaging with respect to spatial resolution. Unenhanced MR angiographic sequences enable reasonable clinical assessment of vessels without contrast agents in patients with contraindications or renal insufficiency. Furthermore, MR angiography may be used to provide directional information through manipulation of the signal intensity of flowing blood. A major limitation to consistent contrast-enhanced MR angiography is the timing of MR image acquisition with arrival of the contrast bolus in the structures of interest. In this article, the authors discuss currently available techniques for imaging of the hepatic vasculature.
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Affiliation(s)
- Rizwan Aslam
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, School of Medicine, 505 Parnassus Avenue, M372, Box 0628, San Francisco, CA 94143-0628, USA
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33
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Abstract
First differentiated from arterial causes of acute mesenteric ischemia 75 years ago, acute mesenteric venous thrombosis (MVT) is an uncommon disorder with non-specific signs and symptoms, the diagnosis of which requires a high index of suspicion. The location, extent, and rapidity of thrombus formation determine whether intestinal infarction ensues. Etiologies, when identified, usually can be separated into local intra-abdominal factors and inherited or acquired hypercoagulable states. The diagnosis is most often made by contrast-enhanced computed tomography, though angiography and exploratory surgery still have important diagnostic as well as therapeutic roles. Anticoagulation prevents clot propagation and is associated with decreased recurrence and mortality. Thrombectomy and thrombolysis may preserve questionably viable bowel and should be considered under certain circumstances. Evidence of infarction mandates surgery and resection whenever feasible. Although its mortality rate has fallen over time, acute MVT remains a life-threatening condition requiring rapid diagnosis and aggressive management. Chronic MVT may manifest with complications of portal hypertension or may be diagnosed incidentally by noninvasive imaging. Management of chronic MVT is directed against variceal hemorrhage and includes anticoagulation when appropriate; mortality is largely dependent on the underlying risk factor.
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Affiliation(s)
- Ian G Harnik
- Montefiore Medical Center, Bronx, NY 10467, USA.
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Shimada K, Isoda H, Okada T, Kamae T, Arizono S, Hirokawa Y, Shibata T, Togashi K. Non-contrast-enhanced hepatic MR angiography: Do two-dimensional parallel imaging and short tau inversion recovery methods shorten acquisition time without image quality deterioration? Eur J Radiol 2011; 77:137-42. [DOI: 10.1016/j.ejrad.2009.05.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 05/28/2009] [Indexed: 10/20/2022]
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Kokabi N, Lee E, Echevarria C, Loh C, Kee S. Sinistral portal hypertension: presentation, radiological findings, and treatment options - a case report. J Radiol Case Rep 2010; 4:14-20. [PMID: 22470692 DOI: 10.3941/jrcr.v4i10.512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Sinistral portal hypertension occurs when a pathological process causes occlusion of the splenic vein. The resultant elevated splenic bed venous pressure causes formation of gastric varices which can lead to hematemesis as a common presentation for this disease process. We present a case of sinistral portal hypertension in a patient with acute hematemesis as the primary presentation. Despite the challenging diagnosis process, the patient underwent splenectomy and was managed appropriately according to previously published literature.
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Affiliation(s)
- Nima Kokabi
- University of Sydney, Faculty of Medicine, Northern Clinical School, Sydney, Australia
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Tang ZH, Qiang JW, Feng XY, Li RK, Sun RX, Ye XG. Acute mesenteric ischemia induced by ligation of porcine superior mesenteric vein: multidetector CT evaluations. Acad Radiol 2010; 17:1146-52. [PMID: 20646939 DOI: 10.1016/j.acra.2010.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 04/21/2010] [Accepted: 04/21/2010] [Indexed: 01/16/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate multidetector computed tomography (MDCT) for detecting the early changes and dynamic evolution of acute mesenteric ischemia (AMI) induced by the ligation of superior mesenteric vein (SMV) in an experimental porcine model. MATERIALS AND METHODS Twelve pigs were randomly assigned to three experimental groups, and one control group with three pigs in each group. After laparotomy, the SMV was separated and ligated in nine pigs and separated without ligation in three controls. MDCT pre- and postcontrast with arterial, venous, and delayed phase scans, and CT angiography reconstructions of mesenteric vessels were carried out at preoperation, 6 hours, 12 hours, and 18 hours after ligation. The findings of mesenteric vessels, bowel, abdominal cavity at pre- and postoperation, and dynamic evolution were correlated with pathology. RESULTS AMI-induced pathological changes were identified in all nine experimental pigs. MDCT angiography clearly delineated main trunk of the SMV, peripheral major and minor tributaries up to brushy vasa recta, and the location and shape of ligations. The early ischemic findings were bowel wall thickening, mesenteric edema, ascites, and pronounced bowel enhancement. Superior mesenteric artery and its major branches appeared spasm with poor filling and delayed and prolonged visualization. SMV and its tributaries were poorly delineated with delayed opacification. We also saw thinning of bowel wall, dilatating bowel with fluid, aggravating mesenteric edema and ascites, and poor enhanced bowel over time. CONCLUSION MDCT detects early changes of mesenteric ischemia and its evolution after ligation of porcine SMV, and may find application in early diagnosis of human venous occlusive AMI.
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Tsochatzis EA, Senzolo M, Germani G, Gatt A, Burroughs AK. Systematic review: portal vein thrombosis in cirrhosis. Aliment Pharmacol Ther 2010; 31:366-74. [PMID: 19863496 DOI: 10.1111/j.1365-2036.2009.04182.x] [Citation(s) in RCA: 222] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND As current imaging techniques in cirrhosis allow detection of asymptomatic portal vein thrombosis during routine ultrasonography, more patients with cirrhosis are diagnosed with portal vein thrombosis. Although a consensus on noncirrhotic extra-hepatic portal vein thrombosis has been published, no such consensus exists for portal vein thrombosis with cirrhosis. AIM To perform a systematic review of nonmalignant portal vein thrombosis in cirrhosis in terms of prevalence, pathogenesis, diagnosis, clinical course and management. METHODS Studies were identified by a search strategy using MEDLINE and EMBASE. RESULTS Portal vein thrombosis is encountered in 10-25% of cirrhotics. In terms of pathophysiology, cirrhosis is no longer considered a hypocoagulable state; rather than a bleeding risk in cirrhosis, various clinical studies support a thrombotic potential. Clinical findings of portal vein thrombosis in cirrhosis vary from asymptomatic disease to a life-threatening condition at first presentation. Optimal management of portal vein thrombosis in cirrhosis is currently not addressed in any consensus publication. Treatment strategies most often include the use of anticoagulation, while thrombectomy and transjugular intrahepatic portosystemic shunts are considered second-line options. CONCLUSIONS Portal vein thrombosis in cirrhosis has many unresolved issues, which are often the critical problems clinicians encounter in their everyday practice. We propose a possible research agenda to address these unresolved issues.
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Affiliation(s)
- E A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre and Division of Surgery, Royal Free Hospital, Hampstead, London NW3 2QG, UK
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Abstract
BACKGROUND Portal vein thrombosis (PVT) is an important cause of portal hypertension. It may occur as such with or without associated cirrhosis and hepatocellular carcinoma. Information on its management is scanty. AIM To provide an update on the modern management of portal vein thrombosis. Information on portal vein thrombosis in patients with and without cirrhosis and hepatocellular carcinoma is also updated. METHODS A pubmed search was performed to identify the literature using search items portal vein thrombosis-aetiology and treatment and portal vein thrombosis in cirrhosis and hepatocellular carcinoma. RESULTS Portal vein thrombosis occurs because of local inflammatory conditions in the abdomen and prothrombotic factors. Acute portal vein thrombosis is usually symptomatic when associated with cirrhosis and/or superior mesenteric vein thrombosis. Anticoagulation should be given for 3-6 months if detected early. If prothrombotic factors are identified, anticoagulation should be given lifelong. Chronic portal vein thrombosis usually presents with well tolerated upper gastrointestinal bleed. It is diagnosed by imaging, which demonstrates a portal cavernoma in place of a portal vein. Anticoagulation does not have a definite role, but bleeds can be treated with endotherapy or shunt surgery. Rarely liver transplantation may be considered. CONCLUSION Role of anticoagulation in chronic portal vein thrombosis needs to be further studied.
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Affiliation(s)
- Y Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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Unenhanced MR Portography With a Half-Fourier Fast Spin-Echo Sequence and Time-Space Labeling Inversion Pulses: Preliminary Results. AJR Am J Roentgenol 2009; 193:106-12. [DOI: 10.2214/ajr.08.1626] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Sorrentino P, D’Angelo S, Tarantino L, Ferbo U, Bracigliano A, Vecchione R. Contrast-enhanced sonography versus biopsy for the differential diagnosis of thrombosis in hepatocellular carcinoma patients. World J Gastroenterol 2009; 15:2245-51. [PMID: 19437565 PMCID: PMC2682240 DOI: 10.3748/wjg.15.2245] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To clarify which method has accuracy: 2nd generation contrast-enhanced ultrasound or biopsy of portal vein thrombus in the differential diagnosis of portal vein thrombosis.
METHODS: One hundred and eighty-six patients with hepatocellular carcinoma and portal vein thrombosis underwent in blinded fashion a 2nd generation contrast-enhanced ultrasound and biopsy of portal vein thrombus; both results were examined on the basis of the follow-up of patients compared to reference-standard.
RESULTS: One hundred and eight patients completed the study. Benign thrombosis on 2nd generation contrast-enhanced ultrasound was characterised by progressive hypoenhancing of the thrombus; in malignant portal vein thrombosis there was a precocious homogeneous enhancement of the thrombus. On follow-up there were 50 of 108 patients with benign thrombosis: all were correctly diagnosed by both methods. There were 58 of 108 patients with malignant thrombosis: amongst these, 52 were correctly diagnosed by both methods, the remainder did not present malignant cells on portal vein thrombus biopsy and showed on 2nd generation contrast-enhanced ultrasound an inhomogeneous enhancement pattern. A new biopsy during the follow-up, guided to the area of thrombus that showed up on 2nd generation contrast-enhanced ultrasound, demonstrated an enhancing pattern indicating malignant cells.
CONCLUSION: In patients with hepatocellular carcinoma complicated by portal vein thrombosis, 2nd generation contrast-enhanced ultrasound of portal vein thrombus is very useful in assessing the benign or malignant nature of the thrombus. Puncture biopsy of thrombus is usually accurate but presents some sampling errors, so, when pathological results are required, 2nd generation contrast-enhanced ultrasound could guide the sampling needle to the correct area of the thrombus.
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41
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Abstract
This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.
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Affiliation(s)
- Laurie D DeLeve
- Division of Gastrointestinal and Liver Diseases and the Research Center for Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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42
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Shimada K, Isoda H, Okada T, Kamae T, Arizono S, Hirokawa Y, Shibata T, Togashi K. Non-contrast-enhanced MR portography with time-spatial labeling inversion pulses: Comparison of imaging with three-dimensional half-fourier fast spin-echo and true steady-state free-precession sequences. J Magn Reson Imaging 2009; 29:1140-6. [DOI: 10.1002/jmri.21753] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Paraumbilical collateral veins on MRI as possible protection against portal venous thrombosis in candidates for liver transplantation. ACTA ACUST UNITED AC 2008; 33:536-41. [PMID: 17924159 DOI: 10.1007/s00261-007-9333-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We retrospectively evaluate the potential protective influence of patent paraumblical vein (PUV) collaterals against portal vein (PV) thrombosis and reduced PV diameter in candidates for orthotopic liver transplant (OLT) METHODS: Dynamic 3D contrast-enhanced MRI at 1.5T was obtained in 309 patients with cirrhosis without evidence of malignancy. All MR studies were reviewed by one reader for PUV collaterals, PV thrombosis and PV diameter. Statistical analysis was performed by Fisher exact tests; 50 selected studies were reviewed independently by two additional readers to determine interobserver agreement via intraclass correlation coefficient (ICC). RESULTS Patent PUV was noted in 119 of 309 patients (38.5%). Mean PV diameter was 13.4 +/- 3.0 mm in patients with PUV compared with 11.3 +/- 3.6 mm without PUV (P < 0.01). Main PV thrombosis was present in 13 of 309 patients (4.2%) and significantly more frequent in those without PUV than with PUV (6.3% vs. 0.8%, P < 0.05). ICC indicated almost perfect agreement among three readers for presence of PUV collaterals (ICC = 0.91) and PV thrombosis (ICC = 0.96). CONCLUSION Our results suggest that patients with patent PUV appear less likely to develop main PV thrombosis or small PV diameter, suggesting a protective effect of PUV on PV patency.
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Deng MH, Liu B, Fang HP, Pan WD, Tang ZF, Deng P, Zhong YS, Xu RY. Predictive value of D-dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus-related cirrhosis. World J Gastroenterol 2008. [PMID: 18161932 DOI: 10.3748/wjg.13.6588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specificity, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed. RESULTS The D-dimer levels in the group developing postoperative PVT was significantly higher than those in the group not developing PVT (P = 0.001), and the ROC semiquantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi-quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001). CONCLUSION Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 microg/mL, the possibility of PVT is very high.
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Affiliation(s)
- Mei-Hai Deng
- Department of Hepato-biliary Surgery, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China.
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Wang L, Li ZS, Lu JP, Wang F, Liu Q, Tian JM. Cavernous transformation of the portal vein: three-dimensional dynamic contrast-enhanced MR angiography. ACTA ACUST UNITED AC 2008; 33:463-8. [PMID: 17703273 DOI: 10.1007/s00261-007-9292-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND To investigate characteristic features of three-dimensional dynamic contrast-enhanced MR angiography (3D DCE-MRA) and validate its clinical significance for the diagnosis of cavernous transformation of the portal vein (CTPV). METHODS 3D DCE-MRA, along with subsequent data processing using three-dimensional reconstruction, was performed in 33 CTPV patients. We observed 33 emboli in the portal vein, 29 in the left and/or right portal branches, 18 in the superior mesenteric vein, and nine emboli in the splenic vein. RESULTS The main presentation of CTPV on 3D DCE-MRA was the replacement of the normal configuration of the portal vein by numerous distorted hepatopetal collateral vessels, the presence of arterio-portal venous shunts, and the appearance of hepatofugal collateral vessels in the abdominal cavity and wall. CONCLUSION 3D DCE-MRA can be used to simultaneously characterize the portal system and collateral vessels, and can improve the diagnosis and clinical treatment of CTPV.
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Affiliation(s)
- Li Wang
- Department of Radiology, Changhai Hospital, Shanghai, 200433, China
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Rossi S, Ghittoni G, Ravetta V, Torello Viera F, Rosa L, Serassi M, Scabini M, Vercelli A, Tinelli C, Dal Bello B, Burns PN, Calliada F. Contrast-enhanced ultrasonography and spiral computed tomography in the detection and characterization of portal vein thrombosis complicating hepatocellular carcinoma. Eur Radiol 2008; 18:1749-56. [PMID: 18369630 DOI: 10.1007/s00330-008-0931-z] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 01/09/2008] [Accepted: 02/07/2008] [Indexed: 12/20/2022]
Abstract
The aim was to compare the performances of contrast-enhanced (CE) ultrasonography (US) and spiral computed tomography (CT) in the detection and characterization of portal vein thrombosis complicating hepatocellular carcinoma (HCC). We studied 50 patients with HCC who had biopsy-proven portal vein thrombi that had been detected with US and color Doppler US. Thirteen of the thrombi involved the main portal trunk and 37 the segmental branches. CEUS and CT were performed within a week of thrombus biopsies. For each imaging technique, diagnoses of thrombosis (present/absent) and thrombus nature (malignancy/benignancy) were made by experienced readers under blinded conditions and compared with pathological findings to determine accuracy rates for thrombus detection and characterization. Forty-four of the 50 thrombi were pathologically diagnosed as malignant and the remaining six were benign. CEUS detected 50/50 (100%) thrombi and correctly characterized 49/50 (98%). CT detected 34/50 (68%) thrombi and correctly characterized 23 of these 34 (68%). CEUS outperformed CT in terms of both thrombus detection (P < 0.0001) and characterization (P = 0.0001). CEUS appears to be significantly superior to CT for detection and characterization of portal vein thrombosis complicating HCC, and it should be considered in the staging of these tumors.
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Affiliation(s)
- Sandro Rossi
- VI Department of Internal Medicine and Interventional Ultrasonography, Policlinico S. Matteo Foundation, IRCCS, P.le Golgi n. 19, 27100, Pavia, Italy.
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Cakmak O, Elmas N, Tamsel S, Demirpolat G, Sever A, Altunel E, Killi R. Role of contrast-enhanced 3D magnetic resonance portography in evaluating portal venous system compared with color Doppler ultrasonography. ACTA ACUST UNITED AC 2008; 33:65-71. [PMID: 17440768 DOI: 10.1007/s00261-007-9229-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM The purpose of this study was to evaluate the capability of contrast-enhanced three-dimensional (3D) MR portography in detecting abnormal findings associated with the portal venous system compared with the results of color Doppler ultrasonography (CDUS). MATERIALS AND METHODS MR portography findings were retrospectively compared with the results of CDUS examinations in 161 patients, who were suspected of having portal venous system abnormalities. Portal venous vessels were divided into main 5 groups including the main portal vein, its left and right intrahepatic branches, splenic vein and superior mesenteric vein. Imaging findings were classified as normal, occluded, or partially thrombosed. Results of clinical and imaging follow-up examinations including CDUS, MR portography or angiography, if available, were used as a proof of final diagnosis. The potential sites of varicose veins and collateral vessels were also examined by both imaging methods. RESULTS Vascular abnormalities were identified in 79 of 161 patients. There was a statistically significant agreement between the results of MR portography and CDUS in evaluating portal venous system (kappa = 0.871, P < 0.05). The sensitivity of MR portography was slightly superior to CDUS in detecting partially thrombosis and occlusion in the main portal venous vessels. In addition, MR portograms were superior to CDUS in the management of patients with portal hypertension by identifying portosystemic collaterals more adequately, and clearly demonstrated portal venous vessels that cannot be visualized at CDUS. CONCLUSION Results of present study indicates that contrast-enhanced 3D MR portography is well suited and superior to CDUS in the management of patients with portal hypertension.
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Affiliation(s)
- Ozgur Cakmak
- Department of Radiology, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
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Deng MH, Liu B, Fang HP, Pan WD, Tang ZF, Deng P, Zhong YS, Xu RY. Predictive value of D-dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus-related cirrhosis. World J Gastroenterol 2007; 13:6588-92. [PMID: 18161932 PMCID: PMC4611301 DOI: 10.3748/wjg.v13.i48.6588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis.
METHODS: A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specificity, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed.
RESULTS: The D-dimer levels in the group developing postoperative PVT was significantly higher than those in the group not developing PVT (P = 0.001), and the ROC semi-quantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi-quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001).
CONCLUSION: Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 μg/mL, the possibility of PVT is very high.
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Salanitri J. Portal vein thrombosis with unusual hepatic enhancement pattern: diagnosis using 64-slice multidetector computed tomography and 3 Tesla magnetic resonance imaging. ACTA ACUST UNITED AC 2007; 51 Suppl:B292-5. [PMID: 17991088 DOI: 10.1111/j.1440-1673.2007.01833.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Portal vein thrombosis is a potentially life-threatening condition with occasionally uncertain clinical symptoms and signs. Consequently, the diagnosis may be first made by the radiologist using cross-sectional imaging modalities. A case of extensive portal venous system thrombosis extending into the superior mesenteric vein associated with an unusual pattern of central hepatic enhancement imaged by both 64-slice multidetector CT and 3 Tesla MRI is presented with a discussion of the imaging features of both modalities.
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Affiliation(s)
- J Salanitri
- Queensland Diagnostic Imaging, St Andrews Hospital, 457 Wickham Terrace, Brisbane, Queensland, Australia.
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Magnetic resonance portal venography: use of fast-acquisition true FISP imaging in the detection of portal vein thrombosis. Clin Radiol 2007; 62:1180-8. [PMID: 17981166 DOI: 10.1016/j.crad.2007.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Revised: 06/18/2007] [Accepted: 06/27/2007] [Indexed: 12/26/2022]
Abstract
AIM To determine the accuracy of true fast imaging with steady-state precession (true FISP) in the diagnosis of portal vein thrombosis in patients with cirrhosis and compare it to contrast-enhanced three-dimensional (3D) magnetic resonance (MR) angiography, the reference standard. MATERIALS AND METHODS Twenty-four consecutive patients with suspected portal venous thrombosis underwent contrast-enhanced 3D MR angiography and true FISP imaging of the portal vein. All patients had undergone at least one other imaging study, either computed tomography, (CT) or ultrasound. Both sets of MR images were evaluated for patency of the portal venous system and for image quality. RESULTS Portal vein thrombosis was diagnosed in six of the 24 patients. Four patients with portal vein thrombosis were accurately diagnosed on the true FISP sequence. This sequence also accurately diagnosed the patency of the portal vein in 17 patients. However, the results were inconclusive in three patients. The image quality of the true FISP sequence of the three inconclusive patients was graded as either poor or fair. Of these three patients, contrast-enhanced 3D MR angiography confirmed portal vein thrombosis in two patients and portal vein stenosis in one patient. True FISP imaging had a sensitivity of 67% and a specificity of 100% for the diagnosis of portal vein thrombosis. CONCLUSION The results of the present study show that the true FISP sequence is useful in diagnosing portal vein thrombosis. It could be employed as an adjunct to contrast-enhanced MR angiography in the severely debilitated patient where respiratory motion may degrade the images or in patients where the use of intravenous contrast medium is not possible due to poor venous access.
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