Introduction

Splanchnic vein thrombosis (SVT) is a local complication of acute pancreatitis (AP) that may lead to subsequent complications such as portal hypertension, gastrointestinal bleeding, and mesenteric ischemia.^1,2 Despite its clinical significance, there is limited data in the literature concerning the temporal development and associated risk factors of SVT.

Aims & Methods

Our aim was to understand the time course and risk factors of SVT in the early phase of AP. To identify relevant studies we conducted a systematic search across four major medical databases (Embase, MEDLINE via PubMed, Scopus, and Cochrane Central Register of Controlled Trials) on 27th of October 2022. We included studies that employed appropriate imaging techniques in adult patients with AP, reported SVT data from the early phase of AP, and provided reliable information about the timing of imaging relative to AP symptom onset or hospital admission. We excluded studies that reported data on patients with a recent history of malignant disease or recent surgical procedures. We calculated the proportion of patients affected by SVT with 95% confidence intervals (CI). We conducted subgroup analyses based on diagnostic timing and disease characteristics. To assess the risk of bias we used the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies and the GRADEpro tool to determine the level of evidence. The protocol for this method was registered prospectively in the PROSPERO database, with registration number CRD42022367578.

Results

Data from 14 eligible studies and 1,951 patients was pooled; the proportion of patients with SVT in the early phase of AP (within 11 days after symptom onset or 5 days after hospital admission) was 0.13 (CI 0.07-0.23). The occurrence was lowest 0-3 days after symptom onset at 0.06 (CI 0.03-0.1), it increased to 0.23 (CI 0.16-0.31) between 3-11 days. Disease factors influencing SVT occurrence were severity (mild: 0.14 (CI 0.04-0.39), moderate: 0.23 (CI 0.09-0.47), severe: 0.31 (CI 0.15-0.54), p=0.21), etiology (alcoholic 0.31 (CI 0.13-0.58), biliary 0.12 (CI 0.04-0.3), p=0.03), and pancreatic necrosis (absent 0.10 (CI 0.04-0.25), under 30% 0.25 (CI 0.1-0.5), over 30% 0.55 (CI 0.29-0.78), p= 0.01).

Conclusion

One in eight patients develops SVT in the early phase of AP. Alcoholic etiology and pancreatic necrosis increase the risk of SVT. In addition, this risk seems to increase with the duration of AP; therefore, looking for and diagnosing SVT with imaging is important in the management of AP.

References

1. Nawacki L, Matykiewicz J, Stochmal E, Gluszek S. Splanchnic Vein Thrombosis in Acute Pancreatitis and Its Consequences. Clin Appl Thromb Hemost. 2021;27.
2. Valeriani E, Riva N, Di Nisio M, Ageno W. Splanchnic Vein Thrombosis: Current Perspectives. Vascular Health and Risk Management. 2019;15.

Clinical Case Summary

For decompensated advanced chronic liver disease (dACLD) individuals, the onset of refractory ascites (RA) represents a dramatic event (6-month survival rate < 50%). In this setting, a relevant proportion of RA patients develop Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI) with limited therapeutic and survival chances.
An 81-year-old female dACLD RA patient was admitted to our department to receive large-volume paracentesis (LVP). Eradicated HCV infection, type II diabetes, and chronic obstructive pulmonary disease were her comorbidities.
The AKI onset imposed the intravenous (i.v.) human albumin (HA) (1 g/kg/die) administration, followed by the proper dosage of terlipressin (for HRS-AKI) within the first 72 hours (h), subsequently discontinued due to the persistence of anuria and the worsening of respiratory failure.
To simultaneously address uremic symptoms and facilitate ascites drainage, a Tenckhoff catheter was placed, and peritoneal dialysis (PD) started with a single icodextrin dwell, resulting in the removal of 14 L of ascites and an improvement in AKI within the subsequent 72h. After one week, she was discharged, receiving a specific PD schedule. After the readmission due to the difficulties in administering i.v. HA, we proposed administering HA via the intraperitoneal route, creating an HA-enriched PD (PD+HA) home-performable schedule by adding two vials of 100 ml of HA 20% to 800 ml of icodextrin solution (40 g in 1000 ml/die; lasting: 12 hours; frequency: every other day) (Figure 1).
The patient has been performing this PD schedule for 12 months (~0.5 L of ascites is discharged every other day before performing PD+HA dwell). During the follow-up, no PD-related complications (e.g., peritonitis) and liver-related events requiring hospitalization have been observed.
We report the first successful use of PD+HA, highlighting the cruciality of a multidisciplinary (hepatologists-nephrologists) approach in the management of dACLD-RA HRS-AKI patients.

References

1. Moreau, R.; Delègue, P.; Pessione, F.; Hillaire, S.; Durand, F.; Lebrec, D.; Valla, D.-C. Clinical Characteristics and Outcome of Patients with Cirrhosis and Refractory Ascites. Liver Int 2004, 24, 457–464, doi:10.1111/j.1478-3231.2004.0991.x.
2. Moore, K.P.; Wong, F.; Gines, P.; Bernardi, M.; Ochs, A.; Salerno, F.; Angeli, P.; Porayko, M.; Moreau, R.; Garcia-Tsao, G.; et al. The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club. Hepatology 2003, 38, 258–266, doi:10.1053/jhep.2003.50315.
3. Nadim, M.K.; Kellum, J.A.; Forni, L.; Francoz, C.; Asrani, S.K.; Ostermann, M.; Allegretti, A.S.; Neyra, J.A.; Olson, J.C.; Piano, S.; et al. Acute Kidney Injury in Patients with Cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) Joint Multidisciplinary Consensus Meeting. J Hepatol 2024, 81, 163–183, doi:10.1016/j.jhep.2024.03.031
4. Brown, E.A.; Blake, P.G.; Boudville, N.; Davies, S.; de Arteaga, J.; Dong, J.; Finkelstein, F.; Foo, M.; Hurst, H.; Johnson, D.W.; et al. International Society for Peritoneal Dialysis Practice Recommendations: Prescribing High-Quality Goal-Directed Peritoneal Dialysis. Perit Dial Int 2020, 40, 244–253, doi:10.1177/0896860819895364.

Clinical Case Summary

Sarcoidosis is a multisystem disease characterized by the presence of non-caseating granulomas in affected organs. Hepatic involvement is often silent and underdiagnosed. Otherwise, it can result in cholestasis and, more rarely, portal hypertension (PH) in long-standing hepatic disease. Here, we report the case of portal vein thrombosis (PVT) in a non-cirrhotic patient, revealing systemic sarcoidosis. A 58-year-old male presenting with dull abdominal pain and erythematous skin nodes on the lower limbs. The initial lab analysis revealed an elevation in GGT to 2.5 ULN and an elevated CRP level at 30 mg/L. Abdominal ultrasound showed dysmorphic liver and portal cavernoma. Thoraco-abdominopelvic CT revealed hilar and mediastinal enlarged lymph nodes, dysmorphic liver, thrombotic material within portal vein and the consequent development of a portal cavernoma and perisplenic collaterals. Ultrasound elastography showed a result of 4,4 KPa. Esophagogastroduodenoscopy was negative for varices. Thorough immunological workup, homocysteine, protein C and anti-thrombin III S assays were normal. The search for JAK2V617F and factor II mutations were negative as well as the flow cytometric measurement of PNH clone. Tuberculosis screening, including a tuberculin test, a chest x-ray and interferon gamma release assay (IGRA) was negative. Calcium and phosphorus levels were normals. Angiotensin converting enzyme (ACE) level was high at 101 UI/L. Spirometry, bronchial fibroscopy and bronchoalveolar lavage were normals. Skin biopsy showed granulomatous dermatitis without caseous necrosis. Liver biopsy revealed the presence of non-caseating granulomas in the lobules. Based on these results, the diagnosis of multisystemic sarcoidosis has been retained. The patient was put on direct oral anticoagulants, corticosteroids and hydroxychloroquine. His symptoms improved and a follow-up CT scan done four months later showed a repermeabilisation of the portal vein.

Disclosure

There is not any actual or potential conflict of interest

Introduction

Many studies have indicated a high effectiveness of fecal microbiota transplantation (FMT) in treatment of recurrent or refractory Clostridioides difficile infection (rCDI). Nevertheless, there is still lack of data from subpopulations regarding application of FMT and factors related to its response.

Aims & Methods

The aim of the study was to analyse the data and evaluate retrospectively the efficacy and safety of FMT for recurrent CDI. While working on the task we analysed retrospectively data of characteristics and outcomes of hospitalised patients from tertiary center who received FMT from 2015 to 2022. In all cases FMT was performed through the nasoenteric tube placed during gastroscopy. Frozen donor faces were used for FMT from unrelated healthy donors. To avoid effect of the single donor, FMT from 2-3 unrelated donors was used. Three days prior FMT vancomycin was applied and preparation with macrogol was administered according to European guidelines. Good response to 1 FMT was considered as improvement, more than 1 FMT as suboptimal response.

Results

FMT was performed for total of 98 patients, out of which 75 patients with recurrent CDI (23 patients needed 2 FMT, 6 - 3FMT and 2 -5FMT). The average age of patients was 68 years. 56 % (42) were women. 41 (54.7%) of patients previously used antibiotics, 2 (2.6%) steroids and 4 (5.3%) proton pump inhibitors (PPI). None of them was under immunosuppressive therapy. After the first FMT procedure clinical improvement was observed in 52 patients (69.3%). What is more 23 out of 30 patients initially non-responding patients had a clinical resolution after a second FMT. Whereas, the remaining 6 patients needed 3 FMT and 1 needed 5 FMT. Though, patients who required more than 1 FMT comorbidity had any cardiovascular disease (CV) such as cardiac insufficiency, diabetes mellitus (DM) or inflammatory bowel disease (IBD). Odds of suboptimal effect of therapy (need of more than 1 FMT) was associated with prior use of metronidazole then vancomycin or fidaxomicin surprisingly. According to our data there was only one irrelevant adverse event documented (abdominal pain). There was no death attributed to CDI in the studied population.

Conclusion

In our study, FMT was effective and safe treatment of recurrent CDI in our population. Nevertheless, at the same time we have identified risk factors of suboptimal response to FMT in our cohort such as CV disease, DM and IBD, as well as use of metronidazole.

References

1. Cammarota G, Ianiro G, Tilg H, et al. European consensus conference on faecal microbiota transplantation in clinical practice. Gut. 2017;66(4):569-580
2. Rao K, Safdar N. Fecal microbiota transplantation for the treatment of Clostridium difficile infection. J Hosp Med. 2016 Jan;11(1):56-61
3. Ziakas PD, Zacharioudakis IM, Zervou FN, et al. Asymptomatic carriers of toxigenic C. difficile in long-term care facilities: A meta-analysis of prevalence and risk factors. PLoS One 2015;10:e0117195
4. Hvas CL, Dahl Jørgensen SM, Jørgensen SP, Storgaard M, Lemming L, Hansen MM, Erikstrup C, Dahlerup JF. Fecal Microbiota Transplantation Is Superior to Fidaxomicin for Treatment of Recurrent Clostridium difficile Infection. Gastroenterology. 2019 Apr;156(5):1324-1332.e3
5. Lee CH, Steiner T, Petrof EO, Smieja M, Roscoe D, Nematallah A, Weese JS, Collins S, Moayyedi P, Crowther M, Ropeleski MJ, Jayaratne P, Higgins D, Li Y, Rau NV, Kim PT. Frozen vs Fresh Fecal Microbiota Transplantation and Clinical Resolution of Diarrhea in Patients With Recurrent Clostridium difficile Infection: A Randomized Clinical Trial. JAMA. 2016 Jan 12;315(2):142-9
6. Crobach MJT, Vernon JJ, Loo VG, et al. Understanding Clostridium difficile colonization. Clin Microbiol Rev 2018;31:e00021-17