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Splanchnic Vein Thrombosis in Cirrhosis - Areas Still in the Shadow

Gîrleanu, Irina1; Trifan, Anca1; Sfarti, Cãtãlin1

Clinical and Translational Gastroenterology: December 2018 - Volume 9 - Issue 12 - p e211
doi: 10.1038/s41424-018-0079-3
CORRESPONDENCE Open Access
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1 Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, “St. Spiridon” University Hospital, Gastroenterology and Hepatology Institute, 16 Universitãtii St, 700115 Iasi, Romania

Correspondence: Anca Trifan (ancatrifan@yahoo.com)

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Competing interests

Conflict of interest The authors declare that they have no conflict of interest.

Guarantor of article: Anca Trifan, MD.

Specific author contributions: Gîrleanu I., Sfarti C., and Trifan A. conceived and design the letter; Gîrleanu I. and Sfarti C. wrote and revised the manuscript; Trifan A. critically revised the manuscript for important intellectual content and gave the final approval of the version to be published; all authors approved the final version of the manuscript.

Financial support: Non-financial.

Potential competing interests: None.

Received: 12 September 2018 Revised: 8 October 2018 Accepted: 22 October 2018

Published online: 07 December 2018

Dear Editor:

We read with great interest the recent article by Senzolo et al.1 aiming to describe the clinical presentation, bleeding incidence, thrombotic events, and mortality in cirrhotic patients with splanchnic vein thrombosis (SVT).

This is a complete study on splanchnic vein thrombosis in cirrhotic patients and the largest of its kind, shedding light on a very debated subject matter regarding the longterm clinical outcomes of SVT and the safety and the efficacy of the anticoagulant treatment in cirrhotic patients.

Although this is a very well conducted multicenter study, we would like to address some issues that deserve further consideration.

Firstly, the study was centred on Child-Pugh A and B patients, with only 10.2% Child-Pugh C patients. We think that it is very important to make a clear distinction between patients with compensated and decompensated liver cirrhosis, as the influence of each risk factor in the development of SVT could be different, with an immediate effect on the therapeutic approach and patient outcome. New studies including Child-Pugh C population are needed in order to establish the best therapeutic approach in this difficult to treat (special) population.

Secondly, the authors reported that only 25% and 33.7% of the patients received beta-blockers prophylaxis or endoscopic treatment, respectively. Although, this could be considered an inappropriate variceal bleeding prophylaxis, the rate of variceal bleeding events in the treated group is maintained low, which could be explained by the beneficial effects of anticoagulant treatment on portal hypertension, as it has already been demonstrated by Villa et al.2

Finally, with regard to acute portal vein thrombosis, we are still missing a clear definition. Until now the definitions proposed were based on anatomic findings only, lacking any clinically significant consequences of portal vein thrombotic occlusion such as portal hypertension and ascites. In our view, it is important to have a description of PVT pattern of evolution (spontaneous recanalization, extended or stable) with or without anticoagulant treatment, and the status of the liver cirrhosis (compensated or decompensated) in order to achieve a personalized therapeutic approach.

To conclude, the study by Senzolo et al.1 provides the opportunity to highlight some aspects regarding SVT in cirrhotic patients, though the subject remains a matter of debate in the scientific community and should be cautiously considered, primarily because the definitions of acute/chronic thrombosis are not clearly stated3–5 and, until now the anticoagulant treatment is not strongly support by randomized control clinical trials6.

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References

1. Senzolo, M. et al. Long Term Outcome of Splanchnic Vein Thrombosis in Cirrhosis. Clin. Transl. Gastroenterol. 9, 176 (2018).
2. Villa, E. et al. Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis. Gastroenterology 143, 1253-1260 (2012).
3. Garcia-Pagan JC, et al. EASL Clinical Practice Guidelines: Vascular diseases of the liver. J. Hepatol. 64, 179-202 (2016).
4. DeLeve, L. D., Valla, D. C. & Garcia-Tsao, G. Vascular disorders of the liver. Hepatology 49, 1729-1764 (2009).
5. de Franchis, R. & Baveno, V. I. Faculty. Expanding consensus in portal hypertension: Report the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J. Hepatol. 63, 743-752 (2015).
6. Loffredo, L. et al. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: a systematic review and meta-analysis. Gastroenterology 153, 480-487.e1 (2017).
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