Splenic Vein Research Articles

Associations and Hospital Outcomes of Splanchnic Vein Thrombosis in Patients with Polycythemia Vera

Background: Thrombosis means the presence of a blood clot in a blood vessel. While thrombosis is a relatively common condition in deep veins of the limbs and the lungs, its incidence in splanchnic veins is at least 25 times lower compared to the former. Splanchnic Vein Thrombosis (SVT) involves portal, hepatic, splenic or mesenteric veins. Polycythemia Vera (PV) is one of the significant myeloproliferative neoplasms (MPN) that cause SVT. Objectives: This study examines the relationship between PV and SVT and its impact on hospital outcomes, explicitly focusing on mortality rates in affected patients. Methods: This retrospective cohort study uses the 2018 to 2020 National Inpatient Sample (NIS) database. Our inclusion criteria were for patients 18 years or older with Splanchnic Vein thrombosis and Polycythemia Vera diagnosis during hospitalization. We defined splanchnic vein thrombosis as patients with portal and hepatic vein thrombosis. We examined these patients' demographics and their relationship with hospital outcomes, such as length of hospital stay, cost of hospitalization and mortality. Using univariate and multivariate logistics regression models, we measured mortality as the primary outcome. Result: We identified 160,570 patients with SVT, among whom 1,120 (0.69%) had PV. PV patients were primarily female and white, with a mean age of 58.9. The PV cohort exhibited a lower mortality rate of 4.5% compared to the SVT from other etiology. Being black, increasing age, and increasing comorbidity indices were associated with increasing mortality. Though not statistically significant, there was a trend of decreasing mortality in both unadjusted and adjusted models for PV [0.68, 95% CI (0.26-1.05)] and [0.55, 95% CI (0.26-1.16)], likely underpowered by the rarity of diagnosis. Conclusion: Our study shows that the mortality of SVT from PV was 45% lower compared to other causes of SVT. PV did not pose an increased mortality risk compared to other etiologies, and it was not statistically significant. There is a need for further studies to understand better and ultimately help in management guidelines for SVT in PV compared to SVT due to other causes.

Patient Outcomes after Initial High Dose Versus Low Dose Romiplostim for Inpatient Management of Immune Thrombocytopenia

Introduction: Romiplostim is a thrombopoietin receptor agonist approved by the US FDA for chronic immune thrombocytopenia (ITP) in patients who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. The recommended dose is 1 mcg/kg/week subcutaneously, escalated weekly by increments of 1 mcg/kg to achieve and maintain a platelet count of 50 x 10 9 /L g ( Kuter et al 2021). It has been postulated that starting at the maximum recommended dose of 10 mcg/kg/week in patients with severe bleeding may swiftly increase platelets and minimize bleeding ( Roumier et al 2021). However, this approach may also increase the risk of major thrombotic events (TE). It is unclear if the more aggressive dosing strategy results in more rapid, robust responses and a tolerable safety profile compared to the FDA approved approach. Methods: This retrospective chart review included adult patients who initiated romiplostim while admitted for ITP at a Mayo Clinic Enterprise site from May 2018 to May 2022. Outcomes included rate of TE at 30 days and 90 days and time to first TE in patients receiving initial romiplostim doses of < 5 mcg/kg (low dose, LD) and > 5 mcg/kg (high dose, HD), median time to platelet response (defined as platelets > 30 x10 9/L and > 50 x10 9/L on 2 separate checks) in LD vs HD, and cost to the institution comparing LD to HD. Outcomes were summarized using descriptive statistics. Statistical analysis was done using BlueSky. Fischer's exact test and chi-squared were performed for categorical data, and Wilcoxon rank sum test were done for continuous variables. Results: Forty-five patients met eligibility criteria: 33 (73%) received initial romiplostim doses < 5 mcg/kg and 12 (27%) received doses > 5 mcg/kg. The majority of patients (43/45 (96%)) presented with platelets < 50 x 10 9/L. The median age was 65 years (68 in LD vs 57 HD). There were 24 (73%) males in the LD group vs five (42%) in the HD group. At baseline, 64% (n = 21) of LD patients and 75% (n = 9) of HD patients presented with bleeding. Major bleeding (defined by 2019 ASH ITP guidelines) was present in 21% (n= 7) vs 17% (n = 2) of patients, LD versus HD, respectively ( Neunert et al 2019). The overall incidence of TE in this study was 24% (n = 11): LD 5 (15%) and HD 6 (50%) (p = 0.044) at 90 days. Median days to TE was 21 days, 12 days in LD group (range 5-21) vs 24.5 days (range 14-58) in HD group (p = 0.067). TE included deep vein thrombosis (DVT, n = 6), DVT with pulmonary embolism (n = 1), portal vein thrombus (n = 1), multiple brain infarcts (n = 1), splenic vein thrombus (n = 1), and left atrial appendage thrombus (n = 1). The median platelet count at the time of TE was 304 x 10 9/L, 415 x 10 9/L (range 58-900) in the LD group vs 323 x 10 8/L (range 33-1427) in the HD group (p = 0.79). Thirty-two (71%) out of 45 patients had a response to romiplostim: 22 in the LD group (71%) vs 10 (83.3%) in the HD group (p = 0.698). Of the patients that responded, the median time to response was 6 days in the LD group vs 11.5 days in the HD group (p = 0.09) The median dose at time of initial response was 2 mcg/kg in the LD group and 6 mcg/kg in the HD group. Wholesale Acquisition Cost (WAC) was used to determine the cost per dose, rounded to the nearest vial size. The average WAC for the initial dose in LD patients was $1806.80 compared to $6061.79 in HD patients. Conclusion:There was a significantly increased incidence of thrombosis in patients admitted with ITP that received initial romiplostim doses > 5 mcg/kg, with no differences in the time to platelet response. Careful consideration of risks versus benefits should be given prior to initiating romiplostim at doses higher than recommended doses.

Diagnosis and Therapy of Visceral Vein Thrombosis: An Update Based on the Revised AWMF S2k Guideline.

Splanchnic or visceral vein thromboses (VVTs) are atypical thrombotic entities and include thrombosis of the portal vein, hepatic veins (Budd-Chiari syndrome), mesenteric veins, and splenic vein. All VVTs have in common high 30-day mortality up to 20% and it seems to be difficult to diagnose VVT early because of their rarity and their wide spectrum of unspecific symptoms. VVTs are often associated with myeloproliferative neoplasia, thrombophilia, and liver cirrhosis. VVT is primarily diagnosed by sonography and/or computed tomography. In contrast to venous thromboembolism, D-dimer testing is neither established nor helpful. Anticoagulation is the first-line therapy in patients with stable circulation and no evidence of organ complications. Anticoagulation improves significantly recanalization rates and stops the progress of thrombosis. Low-molecular-weight heparin, vitamin K antagonists, as well as direct-acting oral anticoagulants are possible anticoagulants, but it is noteworthy to be aware that all recommendations supporting the off-label use of anticoagulants are based on poor evidence and consist predominantly of case series, observational studies, or studies with small case numbers. When choosing a suitable anticoagulation, the individual risk of bleeding and thrombosis must be weighted very carefully. In cases of bleeding, bowel infarction, or other complications, the optimal therapy should be determined on a case-by-case basis by an experienced multidisciplinary team involving a surgeon. Besides anticoagulation, there are therapeutic options including thrombectomy, balloon angioplasty, stenting, transjugular placement of an intrahepatic portosystemic shunt, liver transplantation, and ischemic bowel resection. This article gives an overview of current diagnostic and therapeutic strategies.

Residual Aligner-based Network (RAN): Motion-separable structure for coarse-to-fine discontinuous deformable registration

Deformable image registration, the estimation of the spatial transformation between different images, is an important task in medical imaging. Deep learning techniques have been shown to perform 3D image registration efficiently. However, current registration strategies often only focus on the deformation smoothness, which leads to the ignorance of complicated motion patterns (e.g., separate or sliding motions), especially for the intersection of organs. Thus, the performance when dealing with the discontinuous motions of multiple nearby objects is limited, causing undesired predictive outcomes in clinical usage, such as misidentification and mislocalization of lesions or other abnormalities. Consequently, we proposed a novel registration method to address this issue: a new Motion Separable backbone is exploited to capture the separate motion, with a theoretical analysis of the upper bound of the motions’ discontinuity provided. In addition, a novel Residual Aligner module was used to disentangle and refine the predicted motions across the multiple neighboring objects/organs. We evaluate our method, Residual Aligner-based Network (RAN), on abdominal Computed Tomography (CT) scans and it has shown to achieve one of the most accurate unsupervised inter-subject registration for the 9 organs, with the highest-ranked registration of the veins (Dice Similarity Coefficient (%)/Average surface distance (mm): 62%/4.9mm for the vena cava and 34%/7.9mm for the portal and splenic vein), with a smaller model structure and less computation compared to state-of-the-art methods. Furthermore, when applied to lung CT, the RAN achieves comparable results to the best-ranked networks (94%/3.0mm), also with fewer parameters and less computation.

Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension: a report of two cases

BackgroundLeft-sided portal hypertension including gastric venous congestion may be caused by ligating the splenic vein during pancreaticoduodenectomy with portal vein resection or total pancreatectomy. The usefulness of reconstruction with the splenic vein has been reported in such cases. However, depending on the site of the tumor and other factors, it may be impossible to leave sufficient length of the splenic vein, making anastomosis difficult. We report two patterns of reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension.Case presentationThe first patient was a 79-year-old man who underwent pancreaticoduodenectomy for pancreatic cancer. The root of the splenic vein was infiltrated by the tumor, and we resected this vein at the confluence of the portal vein. Closure of the portal vein was performed without reconstruction of the splenic vein. To prevent left-sided portal hypertension, we anastomosed the right gastroepiploic vein to the middle colic vein. Postoperatively, there was no suggestion of left-sided portal hypertension, such as splenomegaly, varices, and thrombocytosis. The second case was a 63-year-old woman who underwent total pancreatectomy for pancreatic cancer. The splenic vein–superior mesenteric vein confluence was infiltrated by the tumor, and we resected the portal vein, including the confluence. End-to-end anastomosis was performed without reconstruction of the splenic vein. We also divided the left gastric vein, left gastroepiploic vein, right gastroepiploic vein, and right gastric vein, which resulted in a lack of drainage veins from the stomach and severe gastric vein congestion. We anastomosed the right gastroepiploic vein to the left renal vein, which improved the gastric vein congestion. Postoperatively, imaging confirmed short-term patency of the anastomosis site. Although the patient died because of tumor progression 8 months after the surgery, no findings suggested left-sided portal hypertension, such as varices. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy is useful to prevent left-sided portal hypertension.

Laparoscopic spleen-preserving distal pancreatectomy: A novel technique with splenic artery resection and splenic vein preservation.

Laparoscopic spleen-preserving distal pancreatectomy (LSDP) is widely performed to treat benign and low-grade malignant diseases. Although preservation of splenic vessels may be desirable considering the risk of postoperative complications, it is sometimes difficult due to tumor size, inflammation, and proximity of the tumor and splenic vessels. Herein, we present the first case of LSDP with splenic artery resection and splenic vein preservation. A 40-year-old woman with a pancreatic tumor was referred to our hospital. Contrast-enhanced computed tomography (CT) revealed a tumor in the pancreatic tail that was in contact with the splenic artery and distant from the splenic vein. The splenic artery and vein were separated from the pancreas near the dissection line. The splenic artery was resected after pancreatic dissection using a linear stapler. After the pancreatic tail was separated from the splenic hilum while preserving the splenic vein, the distal side of the splenic artery was resected, and the specimen was removed. The postoperative course was uneventful and the patient was discharged on postoperative Day 9. Four months after surgery, postoperative follow-up CT findings showed neither splenic infarction nor gastric varices. This technique is an alternative method of splenic preservation when there is no attachment of the tumor to the splenic vein or uncontrolled expected bleeding of the splenic artery using the Kimura technique.

Thrombogenesis-related characteristics of platelets and platelet indices in pregnant COVID-19 women

Introduction. Thrombosis emerging in COVID-19 represents one of its most common complications. The period of pregnancy is accompanied by elevated susceptibility to infectious diseases and increased risk of thrombosis.Aim: to assess time-dependent change in platelet count and platelet indices in general clinical blood test in pregnant COVID-19 women related to illness onset and developed thrombosis.Materials and Methods. A retrospective analysis of 230 case histories from pregnant COVID-19 women at the third trimester was carried out. Of these, 99 women were selected who met the inclusion criteria: COVID-19 infection laboratory-verified by polymerase chain reaction (PCR); third trimester of pregnancy; presence/absence of thrombotic complications. All patients were divided into 2 groups: the control group consisted of 94 pregnant women aged 31.5 [28.0; 35.0] years without thrombotic complications and the average gestational age at illness onset was 34.1 [30.2; 37.6] weeks; the main group included 5 patients aged 33.0 [28.5; 37.5] years and the average gestational age at illness onset was 33.2 [30.2; 37.8] weeks, with thrombotic complications emerged during the disease course: thrombosis of upper and lower extremity veins; massive pulmonary embolism; thrombosis of the splenic vein at the spleen hilum; left atrial thrombus. The following parameters were evaluated dynamically (on day 6–8, 9–11, 12–15, 16–23 and 24–72 of the disease): total platelet count, thrombocrit, mean platelet volume, platelet distribution width (PDW), large platelet count. A comparative analysis of the study data and a correlation analysis with the time from disease onset and detected thrombosis were carried out.Results. Over the entire observation period, there were noted increased RDW (16.30 [15.80; 16.50]%), average platelet volume (10.70 [9.70; 11.80] fl), and large platelet count (73.00 [59.00; 96.00]×109/L) along with platelet count (182.50 [155.00; 184.50]×109/L) tended to elevate in main vs. control group. A correlation was established between the above parameters and illness onset as well as thrombogenesis time point (p < 0.05). The beginning of developing thrombosis in main group was mainly recorded on day 12–15 after the onset. РDW increased in both groups by day 16–23 of illness, but more pronounced changes were found in main group reaching 16.50 [16.40; 16.60]% compared to control group (16.10 [15.80; 16.40]%). By day 16–23, thrombocrit in both groups positively correlated with illness onset. In addition, large platelet count tended to rise in main group remaining, however, below the normal limit: 0.13 [0.11; 0.20]% compared to control group (0.26 [0.21; 0.31]%). Large platelet count was quite high and increased daily in both groups; the average large platelet count throughout entire observation period was lower in the main (73.00 [59.00; 96.00]×109/L) vs. control group (81.00 [66.00; 102.00]×109/L), so that in the former it sharply decreased down to 55.00 [42.00; 78.00]×109/L on day 16–23.Conclusion. These data mirror the course of thrombotic process and may serve as the basis for assessing the prognosis of thrombotic complications and identification of high-risk groups among pregnant COVID-19 women.

Natural History of Isolated Splanchnic Vein Thrombosis in Cancer Patients

Introduction : Venous thromboembolism (VTE), especially pulmonary embolism (PE) and deep vein thrombosis (DVT), is associated with increased morbidity in cancer patients. However, the clinical course and optimal management of unusual and isolated splanchnic vein thrombosis (iSpVT) remain unclear. Past studies often excluded cancer patients or combined them in heterogeneous cohorts. We aimed to describe the natural history of cancer associated iSpVT. Methods : We queried a cancer registry linked database from a large safety-net hospital system from 2011-2020. Patients with incident cancer diagnosis and intra-abdominal venous thrombosis were identified by a combination of International Classification of Diseases (ICD) code and natural language processing (NLP) algorithm (Figure 1). iSpVT was defined as symptomatic or incidental portal, hepatic, splenic, mesenteric vein thrombosis without concurrent PE/DVT. Patients were excluded for remote SpVT >6 months (mo) before or >36 mo after cancer diagnosis, concurrent PE/DVT, existing anticoagulation (AC), or inadequate follow-up <3 mo (unless death). Thrombus type was classified as bland vs. tumor/mixed based on radiology impression. AC was defined by intention for extended therapeutic AC. Venous recanalization was defined as resolution or reduction in thrombus size in a subset of patients with repeat contrast radiology scans in 3-12 mo. VTE was defined as PE or DVT. Bleeding was defined as ISTH major (MB) or clinically relevant non-major (CRNMB). Cumulative incidence of VTE at 180 days (d) was estimated using competing risk method and overall mortality was assessed by Kaplan Meier estimator. Results : Figure 1 highlights the cohort selection where 298 of 15,342 patients (1.9%) met inclusion criteria for iSpVT. Median time from cancer diagnosis to iSpVT was 19d (IQR 0-138). Most occurred in upper gastrointestinal cancers; 54% were bland and 46% were tumor/mixed. Tumor (n=99) and bland (n-44) thrombi in hepatocellular carcinoma (HCC), along with bland thrombi in pancreatic ductal adenocarcinoma (PDCA) (n=24) comprised over half of iSpVT. AC rate differed by cancer and thrombus type. Most tumor thrombi regardless of cancer type did not receive AC (97%). Most HCC and PDCA regardless of thrombus type did not receive AC (96%). Among those with bland thrombi in other cancers, 39% received AC. Due to strong selection bias for AC, we analyzed future VTE, bleeding, recanalization, and mortality in different subgroups: 1) untreated iSpVT in HCC/PDCA (compare to similar patients without SpVT); 2) all other cancers with bland iSpVT (compare AC vs. no AC) (Table 2). Among 143 HCC patients with untreated iSpVT, 44 had bland thrombi. The 180d VTE incidence was 2.4% (95% CI 0.2-10.7), which was non-significantly lower than HCC patients without iSpVT at 4.7% (95% CI 3.2-6.7). In contrast, 99 HCC patients with tumor thrombi had twice the risk of VTE and mortality compared to bland thrombi. Among 32 PDCA patients with untreated iSpVT, 24 had bland splenic vein thrombi due to tumor encasement. The 180d VTE incidence was 13.5% (3.3-30.7), similar to PDCA patients without SpVT at 17.2% (13.2-21.7). Among 87 mixed cancer type patients with bland iSpVT, the overall 180d VTE incidence was 4.6% (1.5-10.6). Thirty-four received AC with a median duration of 81d (IQR 31-181). AC was associated with increased recanalization rate (46.7% vs. 21.7%); however, it was not associated with decreased VTE (12.1% vs. 0%) or mortality (42% vs. 42%) due to confounding by treatment indication. Notably, 3 of 4 VTE occurred < 2 weeks after stopping AC. Bleeding occurred in 26% (n=9) of patients on AC with 15% MB (n=5) and 12% CRNMB (n=4), at a median of 28d (IQR 7.5-115) after starting AC. Conclusion: iSpVT in cancer patients is not a singular entity but rather a heterogeneous disease based on cancer and thrombus type. Tumor thrombi are associated with higher risk of future VTE and mortality. Untreated iSpVT in HCC and PDCA appear to have similar risk of VTE as those without SpVT, which supports current practice of not anticoagulating these patients. Beyond these cancers, AC varies by perceived risk of thrombosis vs bleeding. Despite strong selection bias, AC is associated with higher recanalization rate but at a cost of high bleeding risk. Prospective studies in a cancer-specific context are needed to determine if iSpVT should be treated similarly as PE/DVT among cancer patients.

Multiple Splanchnic Venous Thromboses: A Fatal Complication of Recurrent Pancreatitis

Splanchnic Venous Thrombosis (SVT) is a condition associated with high morbidity. The etiologies of SVT include intra-abdominal inflammation or infection, surgical intervention, abdominal malignancies such as hepatocellular carcinoma (HCC) and pancreatic carcinoma, or abnormality in coagulation caused by various reasons such as liver cirrhosis. Most cases of pancreatitis are mild and self-limited. On the other hand, approximately one-quarter of patients with pancreatitis may develop vascular complications such as venous thrombosis. Pancreatitis associated with vascular complications is dangerous and potentially fatal. The survival of patients with pancreatitis and vascular complications depends on the early detection of these complications. We report a case of a middle-aged male who had recurrent pancreatitis. On radiological imaging, the patient was found to have a portal vein, splenic vein, and superior mesenteric vein thrombosis. The etiology of thrombosis was considered to be inflammation around the main portal trunk caused by pancreatitis Patient recovered after emergent and timely management with initially low molecular weight heparin and bridged by oral apixaban therapy. The article focuses on the aspects of etiology, pathogenesis, diagnosis, and management of acute pancreatitis with venous thrombosis. J Rang Med Col. September 2023; Vol. 8, No. 2: 60-63

Septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum: A case report of an abdominal variant of lemierre syndrome.

Septic thrombophlebitis of the internal jugular vein also known as Lemierre syndrome occurs secondary to an oropharyngeal infection often leading to septic embolisms to distant sites. Anaerobic gram-negative bacillus, Fusobacterium nucleatum and Fusobacterium necrophorum are commonly isolated organisms. Fusobacterium species has also been reported to complicate an intra-abdominal infection leading to septic thrombophlebitis of portal vein also known as pylephlebitis or abdominal variant of lemierre syndrome. The patient was a middle-aged female patient with chief complaints of abdominal discomfort, intermittent fever and vomiting for one month. The final diagnosis was septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum. Patient was managed with broad spectrum intravenous antibiotics with coverage against gram-negative bacilli, anaerobes, and aerobic streptococcus species with therapeutic anticoagulation. Patient gradually improved and was discharged on oral apixaban. She was instructed to follow up with gastrointestinal specialist upon discharge in anticipation of the need for liver transplant in future. Due to its high mortality and associated long term disease morbidity, clinicians should always strive towards early diagnosis and treatment of the condition with involvement of multidisciplinary teams.

Evaluation of inferior mesenteric vein drainage patterns in the Turkish population: A multidetector computed tomography study

Background/Aim: The inferior mesenteric vein (IMV) plays a crucial role in the venous system as it joins the superior mesenteric vein (SMV) and splenic vein to form the portal vein. The widespread adoption of multidetector computed tomography (MDCT) has greatly enhanced our ability to assess abdominal vascular structures. This study aimed to investigate the IMV drainage patterns in a Turkish population using MDCT. Methods: This descriptive, single-center, retrospective study included patients who had undergone abdominal computed tomography (CT) in the portal phase at our hospital for various clinical indications. Excluded from the study were patients who did not undergo imaging in the portal venous phase, those with incomplete evaluation of all IMV segments, and individuals who had undergone pancreaticoduodenal or intestinal surgery for any reason. We retrospectively analyzed a total of 877 contrast-enhanced MDCT examinations performed at our hospital between March 2022 and March 2023. Patients were classified based on their IMV drainage patterns into the following categories: type 1 (drainage into the splenic vein), type 2 (drainage into the SMV), type 3 (drainage at the junction level), type 4 (drainage into the branches of the SMV), and type 5 (patients in whom IMV assessment was not possible). Results: The mean age of the patients was 48.7 years (range: 24–92 years), with 449 (51.2%) being male and 428 (48.8%) female. The distribution of patients according to IMV drainage patterns was as follows: type 1, n=379 (43.2%); type 2, n=398 (45.4%); type 3, n=71 (8.1%); type 4, n=15 (1.7%); and type 5, n=14 (1.6%). Conclusion: Our study findings indicate that in the Turkish population, the IMV predominantly drains into the SMV before joining the splenic vein. This disparity from certain studies in the literature underscores the variability in IMV drainage patterns, emphasizing the importance of individualized patient evaluation in this regard.

THU365 Diabetic Ketoacidosis Unmasking Acute Pancreatitis With A Hidden Surprise

Abstract Disclosure: Y. Arya: None. A. Syal: None. S. Teja Sathi: None. J.V. Mayrin: None. Background: Development of diabetic ketoacidosis (DKA) in acute pancreatitis is rare and requires high clinical suspicion, particularly in cases such as ours where it might lead to presentation and hence, unmasking of pancreatitis. Our case was also complicated by splenic vein thrombosis, making it a therapeutic dilemma. Case Presentation: We describe the case of a female in her mid-40s who presented to the emergency department with complaints of severe epigastric abdominal pain, associated with vomiting, for the past one day. She was hemodynamically stable, and her laboratory analysis revealed a lipase greater than twenty times the upper limits of normal. Patient was also noted to have a random capillary blood glucose of 500 mg/dL with positive urine beta hydroxybutyrate and an anion gap of thirty-five. She was diagnosed with DKA and managed with intravenous (IV) insulin along with IV fluids. Her abdominal pain failed to respond which triggered us to obtain imaging. She underwent a computed tomography (CT) scan of her abdomen and pelvis which showed extensive pancreatic inflammation and necrosis along with peripancreatic fluid collection extending into the mesentery. The patient was managed with a multidisciplinary approach involving endocrinology, gastroenterology, and critical care teams. Her abdominal pain initially improved, followed by worsening around the sixth hospital day. She underwent an MRI of her abdomen which revealed a new splenic vein thrombosis. Given the risk of bleeding from the peri-pancreatic fluid collection and non-occlusive nature of the thrombosis, clinical monitoring was preferred over anticoagulation. Extensive workup did not reveal an etiology of the pancreatitis, and it was deemed idiopathic. The patient became insulin dependent from her pancreatitis. She had a prolonged hospital course and was eventually discharged after three weeks of presentation with appropriate outpatient follow-up. Discussion: The incidence of diabetes mellitus after acute pancreatitis depends on the severity of pancreatic necrosis; the degree of insulin deficiency being directly proportional to the extent of necrosis.[1] The pathophysiology of splenic vein thrombosis revolves around necrosis, venous stasis, and activation of coagulation cascade, all in the background of the inflammatory state.[2] Anticoagulation in splenic vein thrombosis secondary to pancreatitis thus remains controversial, given the increased risk of hemorrhage and formation of pseudoaneurysms. Interestingly, therapeutic anticoagulation might prevent thrombosis progression by reducing portal pressure and thereby decreasing the risk of hemorrhage. Lower rates of hemorrhage have been documented in literature in patients receiving anticoagulation in this subset of patients, versus untreated cases.[3] Thus, an individual risk-benefit analysis is needed before initiating anticoagulation.

Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience

Background Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis. Methods A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients’ data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort. Results Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm ‘Y’–shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm ‘Y’–shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5–21.0 months). The median follow-up time was 12.2 months (3.0–45 months). Conclusions During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with ‘Y’–shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.

Pancreatic cancer near the splenic hilum has a higher likelihood of splenic vessel invasion and unfavorable survival.

This study aimed to investigate whether clinical outcomes varied based on the tumor location within the pancreatic body and tail in patients with pancreatic cancer (PC). Ninety-five patients who had undergone a distal pancreatectomy for resectable (R) or borderline resectable (BR) PC within the pancreatic body or tail region were retrospectively investigated and divided into four groups (three subgroups of R-PC according to tumor location, and BR-PC): R-PC in the pancreatic body region (group A, n = 24), R-PC on the right side of the pancreatic tail region (group B, n = 17), R-PC on the left side of the pancreatic tail region (group C, n = 29), and BR-PC located in any region within the pancreatic body and tail (group BR, n = 25). Group C patients showed a higher incidence of pretreatment splenic artery and vein involvement than group A and B patients (splenic artery: 8.3/11.8/41.4%, p < 0.010; splenic vein: 25.0/23.5/79.3%, p < 0.010, in groups A/B/C, respectively). The overall survival of group C patients was significantly unfavorable compared to that of group A and B patients (median: 3.9/4.2/2.3years in groups A/B/C, p = 0.029, respectively). Pretreatment clinical factors were comparable between group C and group BR. Median survival rates were comparable between group C and BR patients (2.3 and 2.0years, respectively) (p = 0.93). Differences in anatomical location within the pancreatic body and tail characterize the unfavorable outcomes of PC near the splenic hilum.

Paroxysmal Nocturnal Hemoglobinuria: A Case Report in a Pandemic Environment

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal, rare, complement-mediated hemolytic anemia. PNH can be associated with marrow failure and thrombophilia. We present a clinical report of splenic vein thrombosis in a patient with classic PNH. A 41-year-old male with classic PNH, naïve to complement inhibitor therapy, developed splenic vein thrombosis as a major adverse effect after vaccination protocol to prevent meningococcal disease. We also report anticoagulant and eculizumab treatment outcomes. In PNH patients, vaccination should be monitored to prevent major outcome events, like vaccine-induced thrombosis. Eculizumab proves effective for treating intravascular hemolysis and preventing more thrombotic events. The potential protective role of eculizumab on controlling complement activity and consequent inflammation may help the patient to not experience breakthrough hemolysis when infected with SARS-CoV-2. Extravascular hemolysis remains present, but new molecules are being studied to inhibit proximal complement and there is a good health prospective for PNH patients.

Direct oral anticoagulants for the treatment of splanchnic vein thrombosis: A state of art.

Splanchnic vein thrombosis (SVT) is a manifestation of venous thromboembolism in an unusual site. Portal, mesenteric, and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis, although non-cirrhotic patients could be affected as well. Thrombosis of hepatic veins, also known as Budd-Chiari syndrome, is another manifestation of SVT. Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications. Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases. However, recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants (DOACs) in this setting. Available results are mainly based on retrospective studies with small sample size, but first clinical trials have been published in the last years. This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.

Quantitative analysis of the structure of the portal vein of the liver and splenic vein in people with different somatotypes in portal hypertension

BACKGROUND: HeathCarter somatotyping using bioimpedance analysis is one of the most common methods of somatotyping because of its non-invasiveness, portability, comparative reliability of the data, and ease of use. Knowledge of the relationship between portal hypertension and somatotype may lead to the development of effective approaches to the diagnosis, treatment, and prevention of this disease.&#x0D; AIM: To examine the frequency of various somatotypes in people with portal hypertension.&#x0D; MATERIALS AND METHODS: The study included 46 patients with cirrhosis of the liver who were treated at the University Clinical Hospital N 2 Sechenov University. The calculation of endo- (ENDO) and mesomorphy (MESO) scores, assessment of the somatotype by HeathCarter, and data visualization on the somatogram were carried out using the ABC-01 MEDASS software (STC MEDASS, Russia). Portal hypertension was diagnosed by ultrasonography of the abdominal cavity and retroperitoneal space.&#x0D; RESULTS: The diameter of the splenic vein was 7 mm in 17/18 men and 23/28 women. The diameter of the portal vein was 13 mm in 8/18 men and 12/28 women. The mesoendomorphic somatotype was the most common among women and endomesomorphic among men. More than half (n=9; 52.9%) of men had splenic vein diameter large than normal and the endomesomorphic somatotype, whereas the predominant part of women (n=18; 78.3%) had the mesoendomorphic somatotype. Similar results were obtained in patients with portal vein diameter larger than normal, and the endomesomorphic somatotype prevailed among men (n=5; 62.5%) and mesoendomorphic among women (n=10; 83.3%).&#x0D; CONCLUSIONS: The frequency of portal hypertension in patients with different somatotypes varied. It was higher in patients with a pronounced endomorphic component than in those with other somatotypes. In general, our results underline the complexity of the association of portal hypertension with somatotypes and indicate the need for a deeper analysis of this problem and further research. Future studies should include larger numbers of both healthy individuals and patients with chronic liver disease, different age groups, and a broader set of parameters for analysis. Understanding the relationship between portal hypertension and somatotypes can help develop more effective strategies for the prevention and treatment of this syndrome.

Comparison of prevention and treatment of portal vein thrombosis between proximal splenic vein ligation followed by postoperative transcatheter anticoagulant therapy and systemic anticoagulant therapy in patients with cirrhotic portal hypertension

AbstractAimsSplenectomy combined with pericardial devascularization is one of the important methods to treat hypersplenism, gastrointestinal bleeding, and other complications caused by liver cirrhosis; however, it is accompanied by a high risk of portal vein thrombosis (PVT). This study aimed to explore the preventive and therapeutic effects of proximal splenic vein ligation (PSVL) with postoperative transcatheter anticoagulant therapy (TCAT) on PVT.MethodsThis study retrospectively selected 143 patients with liver cirrhosis and portal hypertension, who received splenectomy combined with pericardial devascularization from June 30, 2018 to June 30, 2021. According to computed tomography photography, within 1 week before the operation, the patients were divided into a prevention group (without preoperative PVT, n = 112) and a treatment group (preoperative PVT, n = 31). Then, each group was subdivided based on the treatment and prevention measures into PSVL + TCAT (n = 70) and systemic anticoagulant therapy (SAT) subgroups (n = 73). The preventive and therapeutic effects of PSVL followed by TCAT on PVT were analyzed.ResultsThe operation time in the PSVL + TCAT subgroups was longer than that in the SAT subgroups (185 ± 76 min vs. 161 ± 55 min; p &lt; 0.01). There was no difference between the two subgroups in terms of operative bleeding (345 ± 82 mL vs. 336 ± 65 mL; p &gt; 0.50). There was no operative death, and all patients recovered uneventfully. In the prevention group, procedure‐related complications occurred in two patients in the PSVL + TCAT subgroup (3.7% [2/54]), including one patient with slight pancreatitis and one patient with chylous leakage, owing to mobilization of the pancreas. The PVT incidence in the prevention group was significantly different between the two subgroups at postoperative 7th day, 3rd month, and 6th month (PSVL + TCAT: 0%, 11.1%, and 5.6% vs. SAT: 39.7%, 31.0%, and 20.7%, respectively; all p &lt; 0.05). In the treatment group, the thrombus regression rate at postoperative 7th day and disappearance rates at the 3rd month and the 6th month of the PSVL + TCAT subgroup were significantly higher than those in the SAT subgroup after anticoagulant and thrombolysis therapy (PSVL + TCAT: 75.0%, 68.8%, and 87.5% vs. SAT: 20.0%, 26.7%, and 40.0%; all p &lt; 0.05).ConclusionsPSVL + TCAT reduces the risk of PVT after splenectomy and is safe and effective in treating PVT during surgery for portal hypertension.

An Unusual Presentation ofSCAD ina Young Male Soldier.

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction and sudden cardiac death in young individuals without significant cardiovascular risk factors. The etiology of SCAD appears to be multifactorial and is often precipitated by physical and emotional stress superimposed on underlying arteriopathy, connective tissue disorders, systemic inflammatory disorders, genetic factors, and hormonal influences. There are no current societal guidelines to stratify young soldiers' risk of developing SCAD. Diagnosis typically requires invasive coronary artery angiography which is largely unavailable in stations with limited medical resources. Furthermore, young patients with SCAD often present with atypical cardiac symptoms, such as heartburn leading to the misdiagnosis of gastroesophageal reflux disease and a delay in diagnosis and management. We present a 21-year-old active duty male who was transferred from Okinawa, Japan to a tertiary military medical center for evaluation of hypercoagulable conditions after CT revealed non-obstructing portal venous thrombosis extending to right hepatic vein, splenic vein thrombosis with splenic infarct, and bilateral wedge-shaped renal infarct. Extensive work-up ultimately revealed mid-left anterior descending spiral dissection with transmural infarct of inferior, anteroseptal, and inferoseptal wall resulting in the formation of left ventricular thrombus, subsequently causing thromboembolism to multiple organs. This case demonstrates the ramifications of SCAD when diagnosis and management are delayed and serve as a poignant reminder for all providers to include SCAD in the differential diagnosis for young soldiers with atypical chest pain.

Domestic researchers who have made important contributions to the study of digestive system diseases: images in art. Maks Moiseyevich Gubergrits

A few main directions can be distinguished in the scientific and practical activities of M. M. Gubergrits. Even his first studies contributed to the history of the development of domestic cardiology. He continued the work started by V. P. Obraztsov on the III normal heart sound, studied changes in heart tones and the formation of a gallop rhythm, the rhythm of a neurasthenic quail, was one of the first to evaluate the clinical significance of the electrocardiographic technique, and tried to use it for better understanding the effect of certain drugs on the heart. He described disorders of the cardiovascular system in severe infectious diseases (epidemic typhus, relapsing fever, and typhoid fever) and thrombosis of the splenic vein. An important part of the scientific activity of M. M. Gubergrits was the pain problem. An outstanding humanist scientist could not ignore this human suffering from various diseases. He was interested not only in the origin of pain in diseases of the heart, liver, and kidneys but also in pain as a general problem of physiology and pathology. However, he most clearly revealed himself as a talented clinician in gastroenterology by constantly combining thoughtful observation at the patient’s bedside with clinical and physiological experimentation. Back in 1929, in his work on the mechanism of gastric secretion, he established the effect of mechanical irritation of the gastric mucosa on the secretion of gastric juice. He described a unique palpatory symptom of a bigastric stomach (changes in the position of the lower border of the stomach, re‑determined by splashing noise). He had a keen interest in peptic ulcer disease. His studies on pancreatic physiology and pathology have retained their value to the present day: data on excretory function, the adaptability of exocrine function to different diets, the possibility of a partial violation of this function (dyspancreatism), as well as the organ’s functional study technique developed in his clinic. M. M. Gubergrits described the pain zone in the pathology of the head and body of the pancreas. In addition, he described concomitant diseases of the liver and pancreas and the liver’s involvement in the pathological process in gastric, duodenal, and large intestinal diseases. The studies by M. M. Gubergrits on the clinical picture of pancreatic diseases played a significant role in the further research. To a large extent, his statements on the diagnosis of pancreatitis have retained their significance. He emphasized the importance of such symptoms as pathological hunger, thirst, polyuria, weight loss, pain in the epigastric area, sometimes jaundice, diarrhea with creatorrhea and steatorrhea, and changes in the blood and urine.