Introduction

Portal vein thrombosis is a common complication of cirrhosis regardless of etiology. Medical management with anticoagulant treatment was a subject of debate with many questions about the balance between bleeding risk and therapeutic benefit. Recently, it has been proven that anticoagulant treatment improves the prognosis of liver disease and portal hypertension, without any additional bleeding risk.

Aims & Methods

The aim of our study is to identify the prognostic impact of anticoagulant treatment for portal vein thrombosis in cirrhotic patients.
It is a retrospective study including all patients followed for cirrhosis at our institution between January 2017 and August 2022. The diagnosis and monitoring of portal vein trunk recanalization were performed by Doppler ultrasound and computed tomography scan
Treatment was decided on a case-by-case basis and was dependent on the stage of liver disease, patient age, and extension of thrombus
Patients excluded: patients with portal cavernoma. upper endoscopy was systematically performed before treatment.
The prognosis improvement rate was determined by the Child-Pugh score at baseline and at completion of the study.

Results

A total of 53 patients with portal vein thrombosis were included among 285 cirrhotic patients followed during this period.
Portal vein thrombosis was diagnosed in 11.3% (n = 6).
The mean age was 54 years, with a male-to-female ratio of 0.7 (22 males/31 females).
The etiology of cirrhosis included chronic hepatitis B in 11.3% (n = 6), chronic hepatitis C in 5.6% (n = 3), primary biliary cholangitis in 3.7% (n = 2), autoimmune hepatitis in 1.8% (n = 1), Budd-Chiari syndrome in 1.8% (n = 1), Wilson's disease in 1.8% (n = 1), and idiopathic causes in 73.5% (n = 39). Before PVT diagnosis, the Child-Pugh score was classified as follows: A in 71.6% (n = 38), B in 24.5% (n = 13), and C in 3.7% (n = 2).
The main cirrhosis decompensations were bleeding related to portal hypertension in 67.9% (n = 36), ascites in 54.7% (n = 29), and hepatocellular carcinoma (HCC) in 3.7% (n = 2).
Anticoagulant treatment was indicated in 47.1% (n = 25) of cases, 48% of patients (n = 12) were treated with low molecular weight heparin (LMWH), 44% (n = 11) with direct oral anticoagulants (DOACs), and 8% (n = 2) with acenocoumarol. Among patients treated with anticoagulants, 68% (n = 17) had hemorrhagic decompensation, 56% (n = 14) had ascitic decompensation, 8% (n = 2) had hepatic encephalopathy, and 4% (n = 1) had hepatocellular carcinoma.

Conclusion

In our study, 71% of patients had a Child Pugh A score at the time of PVT diagnosis. 40% of patients maintained a stable Child score during follow-up and 28% even improved their prognostic stage.

References

https://doi.org/10.1016/j.jhep.2023.02.023
https://doi.org/10.1016/j.jhep.2023.10.002
https://doi.org/10.1016/j.jhep.2023.03.022
https://doi.org/10.1016/j.jhep.2023.05.040

Clinical Case Summary

Introduction: Adult intussusception, the telescoping of one segment of the small intestine into another, is an uncommon cause of intestinal obstruction. Unlike the more frequent ileocolic intussusception, jejuno-jejunal intussusception is even rarer. In adults, intussusception often has a lead point, such as a polyp.[1][2][3]
Case presentation: A 48-year-old male presented with a three-day history of progressively worsening crampy abdominal pain, nausea, and vomiting. He denied fever, bloody stools, or recent changes in bowel habits. Past medical history was unremarkable. Physical examination revealed moderate abdominal distention and tenderness in the upper abdomen.
Laboratory tests showed mild leukocytosis, but other findings were within normal limits. An abdominal X-ray demonstrated nonspecific bowel gas pattern. Due to ongoing concerns and suspected bowel obstruction, an abdominal ultrasound was performed.
The ultrasound revealed a characteristic finding known as the "target sign" within the epigastric area. This sign appears as a concentric ring pattern with a central echogenic core, suggestive of intussusception.
Given the high risk of bowel ischemia , the patient underwent an emergency laparoscopic exploration. Laparoscopy revealed an jejunal intussusception caused by a pedunculated polyp. The involved bowel segment and the polyp were successfully resected laparoscopically.
Histopathological examination of the resected polyp revealed a benign hyperplastic polyp. The patient recovered well post-operatively and was discharged home on postoperative day three.
Conclusion: Intussusception in adults should be considered in the differential diagnosis of patients with acute abdominal pain and suspected bowel obstruction. Ultrasound can be a valuable tool in identifying the characteristic signs of intussusception and may even suggest the presence of a lead point, such as a polyp.

References

1. Panzera F, Di Venere B, Rizzi M, Biscagia A, Pratico CA, Nasti G, Mardighani A, Nunes TF, Inchingolo R. Bowel intussusception in adult: Prevalence, diagnostic tools and therapy. World J Methodol. 2021 May 20;11(3):81-87. doi: 10.5662/wjm.v11.i3.81. eCollection 2021 May 20. PMID:34026581
2. Lin NH, Liao WH. Echography of intussusception in an adult. Quant Imaging Med Surg. 2023 Jan 1;13(1):536-537. doi: 10.21037/qims-22-266. Epub 2022 Nov 9. PMID: 36620131
3. Sun M, Li Z, Shu Z, Wu Q, Liu X. Adult intussusception: a challenge to laparoscopic surgery? PeerJ. 2022 Nov 30; 10:e14495. doi: 10.7717/peerj.14495. eCollection 2022. PMID: 36518277