Esophagogastric Varices Research Articles

Prealbumin is predictive for postoperative liver insufficiency in patients undergoing liver resection

To investigate the risk factors for postoperative liver insufficiency in patients with Child-Pugh class A liver function undergoing liver resection. A total of 427 consecutive patients undergoing partial hepatectomy from October 2007 to April 2011 at a single center (Department of Hepatic SurgeryI, Eastern Hepatobiliary Surgery Hospital, Shanghai, China) were included in the study. All the patients had preoperative liver function of Child-Pugh class A and were diagnosed as having primary liver cancer by postoperative histopathology. Surgery was performed by the same team and hepatic resection was carried out by a clamp crushing method. A clamp/unclamp time of 15 min/5 min was adopted for hepatic inflow occlusion. Patients' records of demographic variables, intraoperative parameters, pathological findings and laboratory test results were reviewed. Postoperative liver insufficiency and failure were defined as prolonged hyperbilirubinemia unrelated to biliary obstruction or leak, clinically apparent ascites, prolonged coagulopathy requiring frozen fresh plasma, and/or hepatic encephalopathy. The incidence of postoperative liver insufficiency or liver failure was observed and the attributing risk factors were analyzed. A multivariate analysis was conducted to determine the independent predictive factors. Among the 427 patients, there were 362 males and 65 females, with a mean age of 51.1 ± 10.4 years. Most patients (86.4%) had a background of viral hepatitis and 234 (54.8%) patients had liver cirrhosis. Indications for partial hepatectomy included hepatocellular carcinoma (391 patients), intrahepatic cholangiocarcinoma (31 patients) and a combination of both (5 patients). Hepatic resections of ≤ 3 and ≥ 4 liver segments were performed in 358 (83.8%) and 69 (16.2%) patients, respectively. Seventeen (4.0%) patients developed liver insufficiency after hepatectomy, of whom 10 patients manifested as prolonged hyperbilirubinemia unrelated to biliary obstruction or leak, 6 patients had clinically apparent ascites and prolonged coagulopathy, 1 patient had hepatic encephalopathy and died on day 21 after surgery. On univariate analysis, age ≥ 60 years and prealbumin < 170 mg/dL were found to be significantly correlated with postoperative liver insufficiency (P = 0.045 and P = 0.009, respectively). There was no statistical difference in postoperative liver insufficiency between patients with or without hepatitis, liver cirrhosis and esophagogastric varices. Intraoperative parameters (type of resection, inflow blood occlusion time, blood loss and blood transfusion) and laboratory test results were not associated with postoperative liver insufficiency either. Age ≥ 60 years and prealbumin < 170 mg/dL were selected on multivariate analysis, and only prealbumin < 170 mg/dL remained predictive (hazard ratio, 3.192; 95%CI: 1.185-8.601, P = 0.022). Prealbumin serum level is a predictive factor for postoperative liver insufficiency in patients with liver function of Child-Pugh class A undergoing hepatectomy. Since prealbumin is a good marker of nutritional status, the improved nutritional status may decrease the incidence of liver insufficiency.

Endoscopic ultrasonography at the choice of optimum medical tactics at esophagogastric varices

Endoscopic ultrasonography at the choice of optimum medical tactics at esophagogastric varices

Prevalence of Significant Gastrointestinal Pathology in Patients Presenting with Unexplained Anemia for Upper and Lower Endoscopy

Purpose: We retrospectively analyzed patients to determine the presence of significant endoscopic pathology based on certain hematologic parameters (ferritin, MCV, MCH and hemoglobin). Methods: Endoscopy reports from 2009-2010 with the indication of unexplained anemia were reviewed. 257 patients met inclusion criteria. We excluded patients without both upper and lower endoscopy, without iron studies, with active bleeding, and without anemia based on hemoglobin (males hgb ≥14, females ≥12). Significant UGI pathology included Barrett's esophagus, esophagitis (LA class ≥ C), esophagogastric varices, peptic ulcer disease, duodenal ulcer, angioectasia, gastric antral vascular ectasia (GAVE), and cancer. Significant LGI pathology included adenomatous polyps >1cm, angioectasias, rectal ulcer, colitis, and cancer. Insignificant findings included hiatal hernia, gastritis, colon polyp <1cm, hemorrhoids, and diverticulosis. Results: 241 males and 16 females were included for this study. Of these 257 patients, significant GI pathology was found in 36%, UGI pathology in 28%, and LGI pathology in 12%. Simultaneous UGI and LGI pathology were present in 3.1% of subjects. Significant UGI pathology included Barrett's esophagus (7.4%), esophagitis (LA class ≥ C) (2.7%), esophagogastric varices (5.4%), peptic ulcer disease (5.4%), duodenal ulcer (1.2%), angioectasia (3.5%), GAVE (1.6%), and cancer (0.4%). Significant LGI pathology included adenomatous polyps >1cm (3.9%), angioectasias (2.7%), rectal ulcer (0.4%), colitis (0.8%), and cancer (4.3%). See table for differences in findings between those with lower or higher ferritin, MCV and MCH. Conclusion: The odds ratio (OR) of finding pathology was higher if any of these parameters was low with the exception of MCV for UGI and LGI pathology, and for MCH for UGI pathology. Ferritin <100, MCV <80 and MCH <26 had a higher OR for detecting cancer. None of the OR were statistically significant except ferritin <100 to detect any GI pathology. Although a ferritin level <100 was found to be predictive of significant GI pathology, 25% of patients with ferritin >100 were found to have significant pathology. We therefore feel that it is not justified to not perform endoscopy on the basis of normal hematological parameters, ferritin, MCV, and MCH.Table

Application of domestic staples in splenectomy and portoazygous devascularization

ObjectiveTo explore the application and efficacy of domestic staples in splenectomy and portoazygous devascularization. Methods From January 2002 to January 2008,102 protal hypertension patients were treated with portoazygos vein devascularization plus partial resection of the lower part of the esophagus with staple(study group)and the other 87 patients received portoazygos vein devascularization alone(control group). The duration of surgery, length of hospital stay, rate of perioperative compactions, outcomes of esophagogastric varices, rate of postoperative rebleeding, and survival rate were observed. Results The duration of surgery and length of hospital stay were shorter in the study group than in the control group(P＜0.05). The disappearance rate of esophagogastric varices was higher in the study group than in the control group 6 months after surgery(P＜ 0.05). All the patients were followed up for 3 years. The 1, 2, 3, 4, 5 year cumulative rebleeding rates in the observed group were higher than those in the control group(P＜ 0.05). 1, 2, 3year cumulative rebleeding rates were lower in the study group than in the control group while 1, 2, 3year cumulative survival rates were higher(P ＜ 0.05). Conclusions Domestic staples are simple, safe and effecive in splenectomy and portoazygos devascularization Key words: Staple; Portal Hypertension; Esophagogastric varice; Devascularization

Esophagogastric varices in patients with primary biliary cirrhosis

Esophagogastric varices in patients with primary biliary cirrhosis

Therapeutic and Diagnostic Tactics for Bleedings from Esophagogastric Varices

Objective: to elaborate therapeutic and diagnostic tactics for bleedings from esophagogastric varices (EGV) in an intensive care unit (ICU). Subjects and methods: The experience in treating 102 patients with profuse bleeding from EGV, admitted to the ICU, Acad. V. Vakhidov Republican Specialized Center of Surgery, in 2000—2008, was summarized. Results. The findings show that just less than 40% of the patients with hepatic cirrhosis are admitted for the clinical manifestations of active bleeding from EGV, the latter being profuse in 17.6%. These indicate that the noticeable admission preponderance of patients with first-degree blood loss and the low proportion of those with critical third-degree blood loss are noteworthy. Retrospective analysis demonstrated that hemostasis was achieved in 97 (95.1%) patients, by applying solely conservative measures using a Blakemore tube (in both variants of its use). After removal of the Blakemore tube, stable hemostasis retained in 88.9% of the patients with bleedings from the veins of the middle third of the esophagus, in 71.8% of cases of those from its lower third and only in 24.1% of the patients with those from the cardiac stomach. Conclusion. According to the results of the study, we propose the therapeutic and diagnostic tactics for patients with profuse bleedings from EGV, which involve the use of a Blakemore tube and a complex of conservative measures with traditional hemostatic therapy, the administration of portal pressure-reducing agents to prevent or treat hepatic failure. Key words: bleeding, esophagogastric varices, hepatic failure, intensive therapy.

An assessment of surgery for portal hypertensive patients performed at a single community hospital

The outcomes of surgery for portal hypertensive patients at a single community hospital in the last two decades were retrospectively examined. From June 1989 to March 2008, 13 of 848 (1.5%) portal hypertensive patients admitted and treated at the community hospital underwent surgery. The types of surgery performed were a distal splenorenal shunt for 2 patients, gastric devascularization and splenectomy for 8, laparoscopic gastric devascularization and splenectomy for 1, distal gastrectomy for 1, and splenectomy alone for 1. This study reviewed the postoperative records of the endoscopic findings and additional treatments, and the perioperative records. No patient had bleeding from esophagogastric varices during the 75-month mean follow-up period after surgery. Five patients had one or two series of endoscopic treatment for recurrent likely-to-bleed esophageal varices. One patient needed interventional radiology for recurrent gastric varices. No patients died due to upper gastrointestinal bleeding. The survival rates were 87.5% after 5 years and 46.9% after 10 years. Surgery for portal hypertensive patients performed at a single community hospital is still safe and effective, and has been adequately incorporated into the late treatment strategy for portal hypertensive patients.

Clinical analysis of portal vein thrombosis after splenocaval shunt plus devascularization in treatment of portal hypertension

Objective To explore the clinical characteristics of portal vein thrombosis(PVT) after splenocaval shunt plus devascularization in treatment of portal hypertension and find Out ways for its prevention.Methods The formation,diagnosis,treatment of PVT and variceal rehemorrhage in 110 patients with portal hypertension who received splenocaval shunt plus devascularization procedures (Combined Group)and 92 patients subjected to pericardial devascularization operation(PCDV Group) were retrospectively analyzed.Meanwhile,the effect of two procedures on PVT was compared.Results The incidence of PVT was 10.0%in combined group and 22.8%in PCDV group (P<0.05).The rebleeding rate from esophagogastric varices because of PVT in combined group was 3.6%,which was significantly lower than that of 10.8%in PCDV group(P<0.05).Conclusion Splenoeaval shunt plus devascularization is a better choice to decrease the incidence of PVT.The postoperative anti-coagulation therapy in the early stage is important for the prevention of PVT. Key words: Hypertension,portal; Shunt; Thrombosis; Devascularization

S1475: Endoscopic Variceal Ligation (EVL) Alone Versus Endoscopic Variceal Ligation Plus Propranolol in Variceal Bleeding Prophylaxis in Cirrhotic Patients

Bleeding from esophagogastric varices is a major complication of portal hypertension. Beta-blockers are a well-established cornerstone of portal hypertension treatment. Band ligation is the best endoscopic treatment to prevent esophageal variceal bleeding. The exact benefit of beta-blocker association to band ligation remains to be defined.

Hemorrhagic Duodenal Varices Treated Successfully With Endoscopic Injection Sclerotherapy Using Cyanoacrylate and Ethanolamine-oleate: A Case Report

We report a case of a 50-year-old man with a medical history of alcoholic cirrhosis, in addition to esophagogastric and duodenal varices (DV), who was transferred to our institution because of hemorrhagic DV. Emergent esophagogastroduodenoscopy showed hemorrhagic varices in the horizontal portion of the duodenum. Abdominal contrast-enhanced CT showed hemodynamics of DV derived from anastomosis between the superior mesenteric vein and right renal vein. Cyanoacrylate was injected into the DV. Subsequently, 5% ethanolamine-oleate was injected endoscopically as a sclerosant into the DV feeding vein. Radiographic fluoroscopic findings revealed that the injected cyanoacrylate and sclerosant remained, respectively, in the varices and its feeder. Five days later, CT showed that the injected cyanoacrylate occupied the DV, and thrombus formation of the afferent vein led to bifurcation of superior mesenteric vein. This case showed the usefulness of endoscopic injection sclerotherapy using cyanoacrylate and sclerosant for the management of DV.

Value of multi-slice spiral CT portal venography in prediction of esophagogastric variceal bleeding

To assess the clinical value of multi-slice spiral CT portal venography in prediction of esophagogastric variceal bleeding. The relation was detected between esophagogastric variceal bleeding and the location of left gastric vein orifice on portal system. Also the correlation was studied between the severity of esophageal varices endoscopically and the diameter of portal vein with multi-slice spiral CT portal venography. Sixty-nine patients with esophagogastric varices confirmed by both endoscopy and 16-detector row CT portal venography due to cirrhosis were enrolled. Excellent image quality of portal collateral vessels with CTPV was obtained in all patients. The portal and left gastric veins were visualized both with CTPV 69/69 (100%). Esophageal and gastric varices were visualized with CTPV 62/69 (89.9%) and 50/69 (72.5%) respectively. The left gastric vein orifice was located on the portal vein in 42 cases. There was correlation between esophagogastric variceal hemorrhage and the location of left gastric vein orifice (Chi(2) = 4.406, P < 0.05). But no relation was found between the severity of esophageal varices and the diameter of portal vein (P > 0.05). CTPV can not only provide important and accurate information of collateral circulation in patients with portal hypertension, but also measure the diameter of collateral blood vessel. There is a higher probability of esophagogastric variceal bleeding for the patients with left gastric vein orifice on portal vein. The combined approaches of CTPV and endoscopy can not only diagnose the severity of esophagogastric varices, but also predict the risk of esophagogastric variceal bleeding.

Laparoscopic Splenectomy and Periesophagogastric Devascularization with Endoligature for Portal Hypertension in Children

Bleeding from esophagogastric varices is an importment complication of portal hypertension. Recently, significant progress in laparoscopic technology has enabled the devascularization of the lower esophagus and upper stomach in a less invasive way. In this article, we report our preliminary experience with laparoscopic splenectomy and periesophagogastric devascularization by endoligature and its effectiveness for bleeding varices with hypersplenism in children. Six children with bleeding portal hypertension and developed severe thrombocytopenia and/or leukopenia underwent laparoscopic splenectomy and selective pericardial devascularization by using silk endoligature combined with a Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH). The patients included 5 males and 1 female, who ranged in age from 8 to 17 years. After a massive splenectomy was performed, we devascularized the periesophagogastric collateral vessels and perforating veins of the upper stomach to the level of the incisura angularis and the lower esophagus 5 or 6 cm away from the esophagocardia junction. The stem of the gastric coronary vein and paraesophageal collateral veins were not dissected in order to reserve portal blood flow toward the azygous shunt. All the procedures were completed successfully under a whole laparoscope. The operative time ranged from 180 to 270 minutes. Intraoperative blood loss was estimated to be from 80 to 200 mL. None of the patients required a blood transfusion. There were no significant complications either intra- operatively or postoperatively, and all patients had returned to usual activity by 5 days. Postoperative platelet count and white blood cell count increased in individual patients. The data were statistically significant (p = 0.006 and 0.002, respectively). During a postoperative follow-up period of 8-40 months, all children were asymptomatic, with improved growth and hematology and no rebleeding, sepsis, or encephalopathy. Laparoscopic massive splenectomy with selective periesophagogastric devascularization is a feasible, effective, and safe surgical procedure and has all the benefits of minimally invasive surgery. It offers a new alternative modality for children with bleeding portal hypertension and hypersplenism.

Idiopathic intrahepatic arterioportal fistula treated by hepatectomy assisted by balloon‐occluded retrograde transvenous obliteration: Report of an elderly case

An 80-year-old woman with hepatic encephalopathy and esophagogastric varices was admitted. Doppler sonography and arteriography demonstrated an arterioportal fistula in the right anterior superior segment of the liver. Two attempts at transcatheter arterial embolization failed to manage the fistula and portacaval collaterals. We carried out hepatectomy and balloon-occluded retrograde transvenous obliteration, by which the portal flow changed from hepatofugal to hepatopetal. The resected specimen demonstrated multiple small holes in the right portal vein, which are arterioportal fistula. The underlying liver was normal. After treatment, esophagogastric varices and hepatic encephalopathy were markedly improved. Hepatectomy is useful as a reliable therapy for arterioportal fistula in case of failure of transarterial embolization.

Prevalence of esophagogastric varices in patients with non‐alcoholic steatohepatitis

In non-alcoholic steatohepatitis (NASH), fibrosis begins around the central veins, as also happens with alcoholic liver disease, so the symptoms of portal hypertension may be due to central vein occlusion. The aim of this study was to define the prevalence of esophagogastric varices and the clinical outcome after endoscopic treatment in NASH patients with severe fibrosis. The subjects were 72 patients with clinicopathologically confirmed NASH who had bridging fibrosis (F3) or cirrhosis (F4) determined by the examination of liver biopsy specimens, and who underwent upper gastrointestinal endoscopy. The prevalence and pattern of endoscopically detected varices at the time of liver biopsy were evaluated. The results of NASH patients (n = 11) with endoscopically treated esophageal varices were compared to those with alcoholic (n = 67) and hepatitis C virus-associated cirrhosis (n = 152). Esophagogastric varices were detected in 34 out of the 72 (47.2%) patients; esophageal varices in 25 (34.7%) and gastric varices in nine (12.5%), while six of these patients had variceal bleeding. In NASH patients, the cumulative recurrence-free probability at 24 months after endoscopic treatment was 63.6%, the bleeding-free probability was 90.9%, and the 5-year survival was 100%. Only one out 11 patients died of liver failure at 70 months after treatment. About half of NASH patients with severe fibrosis had esophagogastric varices. The clinical status and course of the varices do not necessarily improve after endoscopic treatment. NASH patients with esophagogastric varices need to be followed up carefully, like patients with other chronic liver diseases.

Interventional Therapy of Portal Vein Occlusion after Liver Transplantation

Objective To evaluate the safety and efficacy of the interventional radiological techniques for management of portal vein occlusion after orthotopic liver transplantation.Methods 13 patients with PV occlusion(stenosis and/or thrombosis)after orthotopic liver transplantation were treated by interventional procedures.The patients were nine males and four females.They ranged from 28 to 60 years old(average age was 43).Three patients presented with PV thrombosis,nine presented PV anastomotic stoma stenosis,one presented PV thrombosis and PV anastomotic stoma stenosis,nine associated with esophagogastric varices(eight of them have experiences of hematemesis).The portal access was established via a percutaneous transhepatic route in seven patients,and via a transjugular intrahepatic portosystemic shunt(TIPS)approach in six.The interventional procedures included balloon angioplasty and stent placement in eight patients,catheter directed pharmacologic and mechanical thrombolysis for four times,balloon angioplasty in two patients,and associated with embolism of esophagogastric varices for nine times.Results The technical Success was achieved in all cases.No complications relating to the procedure occurred.Angiography re-examination indicated that portal blood flow was reestablished in all patients after the procedures.PV trunk's diameter was almost normal in 10 patients,and remaining stenosis was less than 30 percent of normal diameter in three patients.Follow-up time ranged from 6 to 48 months(average 28 months).Five patients'liver function improved apparently two weeks after the interventional therapy.Gastroscopy showed esophagogastric varices improved apparently in nine patients with portal hypertension and esophagogastric varices,and bleeding from esophagogastric varices did not occur after the interventional therapy.Clinical improvement was seen in four patients with symptomatic abdomen,characterized by progressive reduction of abdominal pain.distention,and diarrhea.Doppler US re-examination showed that PV's blood flow was normal.Conclusions Interventional radiological techniques are safe and effective in the treatment of portal vein occlusion after orthotopic liver transplantation. Key words: Liver transplantation; Portal vein occlusion; Portal vein thrombosis; Portal vein stenosis; Interventional therapy

Clinical Features and Treatment Outcomes of Upper Gastrointestinal Bleeding in Patients with Cirrhosis

With recent progress in treatment modalities, mortality from upper gastrointestinal (UGI) bleeding has decreased appreciably. The aim of this study was to establish how UGI bleeds are managed in Korean patients with cirrhosis and to evaluate treatment outcomes. A total of 479 episodes of acute UGI bleeding in 464 patients with cirrhosis were included during a six-month period at nine tertiary medical centers. Treatment outcomes were assessed by failure to control bleeding, rebleeding and mortality. The source of bleeding was esophagogastric varices in 77.7% of patients, nonvariceal lesions in 15.9%, and undefined in 6.5%. For control of bleeding, endoscopic and pharmacologic treatments were used in 74.7% and 81.9% of patients, respectively. Variceal ligation was a major technique for endoscopic treatment (90%), and terlipressin and somatostatin were the main pharmacologic agents used (96.4%). Initial hemostasis was achieved in 86.8% of cases, but rebleeding occurred in 3.8% and 16.8% of cases within five days and six weeks of hemorrhage, respectively. Five-day and six-week mortality were 11.3% and 25.9%, respectively. Survival of patients with variceal bleeding seems to be remarkably improved than previous reports, which may suggest the advances in hemostatic methods for control of variceal hemorrhage.

Partial splenic embolization

Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.

Endoscopic hemostasis for bleeding gastric varices treated by combination of variceal ligation and sclerotherapy with N-butyl-2-cyanoacrylate

Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices. Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary. Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27). This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.

Influência do grau de insuficiência hepática e do índice de congestão portal na recidiva hemorrágica de cirróticos submetidos a cirurgia de Teixeira-Warren

Bleeding from esophagogastric varices is the worst and most lethal complication of cirrhotic portal hypertension. Distal splenorenal shunt (Warrens surgery) is used in the therapeutic of this patients, Child A and B, with rebleeding after clinical endoscopic therapy. The portal vein congestion index is elevated in cirrhotic portal hypertension and could predict rebleeding after Warrens surgery in these patients. To verify if the portal vein congestion index or liver function (Child-Pugh) at preoperative are predictive factors of rebleeding after Warrens surgery. Sixty-two cirrhotic patients were submitted to Warrens surgery at "Santa Casa" Medical School and Hospital - Liver and Portal Hypertension Unit, São Paulo, SP, Brazil. Fifty-eight were analyzed for Child-Pugh class and 36 for portal vein congestion index, divided in two groups: with or without rebleeding and statistical analysis was performed. In the rebleeding group, 69% were Child B, with portal vein congestion index = 0.09. The group without rebleeding show us 62% patients Child A with portal vein congestion index = 0.076. The difference was significant for Child-Pugh class but not to portal vein congestion index. Portal vein congestion index was not predictive of rebleeding after Warrens surgery, but cirrhotics Child B have more chance to rebleed after this surgery than Child A.

Chronic oral anticoagulant therapy for extrahepatic visceral thrombosis is safe

Patients with hypercoagulability may thrombose visceral veins with resultant portal hypertension, esophagogastric varices, and hemorrhage. The role of chronic oral anticoagulant therapy in such patients is unclear. On the one hand, such patients are prone to significant hemorrhage and thus anticoagulant therapy may seem contraindicated. On the other hand, because the causal pathophysiology is typically hypercoagulability, it would seem rational to treat these patients with chronic anticoagulant therapy in order to both prevent other visceral and systemic thromboses and perhaps, over time, reduce the degree of portal hypertension. Experience and poor prognosis associated with the more common portal hypertension due to hepatic cirrhosis may bias judgment. We retrospectively reviewed the course of chronic oral anticoagulant therapy regarding both the safety and effectiveness using our long-term follow-up of a cohort of seven patients with visceral thrombosis resulting in extrahepatic non-cirrhotic portal hypertension. Seven consecutive patients encountered over the past 19 years were observed for 78 patient-years, the first 14 patient-years prior to anticoagulant therapy and the latter 64 patient-years on oral anticoagulant therapy. No patients rethrombosed either visceral or systemic vessels while on oral anticoagulant therapy. There were no fatal or serious hemorrhagic events on oral anticoagulant therapy; in fact, upper gastrointestinal bleeding decreased from 1.2 to 0.2 bleeds/year. The endoscopic grade of esophageal varices decreased in four of five patients who underwent serial endoscopy, and platelet counts increased in all seven patients. Chronic oral anticoagulant therapy is safe and not associated with an increase in upper gastrointestinal bleeding in such patients. Additionally, and by inference, perhaps in conjunction with the natural history of portal hypertension, such therapy is possibly effective in reducing portal hypertension in patients with hypercoagulability-induced extrahepatic portal hypertension.