Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study

Splanchnic vein thrombosis in patients with pancreatitis: Outcome and impact of anticoagulation

INTRODUCTION

Splanchnic venous thrombosis (SVT) is a frequent complication of acute pancreatitis (AP) and may worsen the prognosis. There are no definite recommendations for the management of SVT. Our objectives were to analyze the recanalization rate and short and long-term complications of SVT.

PATIENTS AND METHODS

Single-center retrospective cohort study, which included patients hospitalized for AP complicated by SVT within the first 30 days. The primary endpoint was venous recanalization. Secondary endpoints were portal hypertension, gastrointestinal bleeding, complications of anticoagulation, and mortality.

RESULTS

Between 2014 and 2018, 711 patients were hospitalized with AP; 121 (17 %) developed SVT and 88 were included in the analysis. Venous thrombosis involved the portal vein (27 %), splenic vein (21 %), superior mesenteric vein (16 %), 2 sites (19 %) or 3 sites (14 %). Of them, 78 % of patients received anticoagulation. After a median follow-up of 30 months, thrombosed vessel(s) got recanalized in 42 % of patients within a median of 7 months. Thrombosis extension was observed in 18 % of patients. The only factor associated with non-recanalization was portal vein or multi-site involvement (p = 0.004). Anticoagulation treatment was not associated with a higher rate of recanalization. Portal hypertension developed in 56 % of patients and varices rupture occurred in 9 % of patients. The only predictive factor of portal hypertension was non-recanalization of the thrombosed vessel (p < 0,001).

CONCLUSION

Recanalization was observed in 42 % of patients with SVT complicating in AP. Non-recanalization was the only risk for portal hypertension. Our study suggests an absence of benefit of anticoagulation.

Venous Thromboembolism Occurrence and Association with Gastrointestinal Disorders in Children with Cystic Fibrosis: An Analysis from the TriNetX Research Network Global Multicenter Real-World Dataset

The purpose of this study is to (1) estimate and compare the prevalence of venous thromboembolism (VTE) in children (age 0 to ≤21) with versus without cystic fibrosis (CF); (2) investigate putative associations between specific gastrointestinal (GI) manifestations and the development of VTE among children with CF. This was a multicenter case-control analysis among patients aged 0 to ≤ 21 years between 2010 and 2020, using the TriNetX Research Network. Data queries included ICD-9/10 (International Classification of Diseases-9th/10th Revision) diagnosis codes. Bivariate associations with VTE among CF patients were compared using Chi-square testing for categorical variables and Student's t-test for continuous variables. We used multivariable logistic regression to test for independent associations of GI manifestations with VTE among children with CF, with adjustment for other salient covariates. There was a total of 7,689 children with and 22,327,660 without CF. The frequency of occurrence of VTE was increased nearly 20-fold among those with, as compared with without CF (130 vs. 7 per 10,000 patients). Acute pancreatitis (adjusted odd ratio [aOR] = 3.80, [95% confidence interval, CI: 2.00-7.22]), biliary disease (aOR = 2.17 [95% CI: 1.17-4.03]), gastrostomy status (aOR = 2.01 [95% CI: 1.27-3.18]), and malabsorption/malnutrition (aOR = 2.41 [95% CI: 1.52-3.82]) were each associated with a higher likelihood of VTE among children with CF. In conclusion, we found a significantly increased frequency of VTE occurrence and association of specific GI diseases as independent risk factors for VTE among children with CF compared with those without.

Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk.

METHODS

The German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005-2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated.

RESULTS

Overall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0-71.0] years), 39.2 % females) were detected in Germany 2005-2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513-1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854-4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619-1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684-4.181], P < 0.001).

CONCLUSIONS

VTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.

Acute Venous Thromboembolism Is Common Following Acute Necrotizing Pancreatitis and Is Associated With Worse Clinical Outcomes

OBJECTIVES

Although splanchnic vein thrombosis (SVT) is a well-known local complication of acute pancreatitis, extrasplanchnic venous thromboembolism (ESVT) is inadequately studied. Here, we aim to explore the incidence of venous thromboembolism (VTE) in acute necrotizing pancreatitis (ANP) and the associated mortality.

METHODS

Adults with a diagnosis of ANP from January 2017 to December 2022 were identified using appropriate International Classification of Diseases, 10th Revision, Clinical Modification codes. The primary outcome was development of acute ESVT within 1 month of ANP. Secondary outcomes were 90-day mortality, 30-day rehospitalization, and oral anticoagulant (OAC) use in patients with ESVT. Propensity score matching (1:1) was performed for baseline characteristics and common comorbidities.

RESULTS

During the study period, 17,942 (7.11%) patients were diagnosed with ANP, and about 10% (1,737) of them had a diagnosis of ESVT. Of all VTEs, 61% were ESVT with or without SVT, and 63% (n = 1799) were SVT. Ninety-day mortality (16.3% vs 5.7%; risk ratio [RR], 2.86; 95% confidence interval, 2.29-3.56) and 30-day rehospitalization (31% vs 19%; RR, 1.63; 95% confidence interval, 1.49-1.79) were higher in patients with ESVT compared with non-VTE patients. Sixty percent of patients with ESVT were on OAC, and OAC use was associated with lower 90-day mortality (8.9% vs 19.4%; RR, 0.46) without increased risk of adverse events (acute gastrointestinal bleeding, intracranial bleeding, or need for transfusion).

CONCLUSIONS

Systemic VTE is common in patients with ANP and may contribute to increased mortality and risk of readmissions. Prospective studies can confirm our findings and explore the role of aggressive VTE prophylaxis in patients with ANP during hospital stay and in the immediate ambulatory period.

Incidence and risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) in acute necrotizing pancreatitis (ANP) - A single center experience

INTRODUCTION

Inflammation-induced dysregulation of the coagulation cascade and vascular stasis in hospitalized patients with acute necrotizing pancreatitis (ANP) serve as a milieu for venous thromboembolism (VTE). Deep vein thrombosis (DVT) and pulmonary embolism (PE) are often underrecognized. We evaluated the incidence and risk factors for VTE in a cohort of patients with ANP.

METHODS

All adult patients with ANP at our center between 2009 and 2022 were followed for three months after index hospitalization and categorized into cases and controls based on development of VTE. Demographic, clinical, and radiologic characteristics during admission were compared. A multivariable analysis was done to identify independent predictors for VTE. A p value of <0.05 was taken as significant.

RESULTS

Among 643 ANP patients, 512 [males-350, median age-52 years] were eligible for inclusion. VTE developed in 64 (12.5 %) patients - 28 DVT (5 %), 22 PE (4 %) and both in 14 (3 %) after a median 16 days from the diagnosis of ANP. Significant independent predictors for VTE on multivariable analysis were age ≥60 years (OR 1.91; 95 % CI 1.04-3.53), peri-pancreatic extent of necrosis (OR 7.61; 95 % CI 3.94-14.70), infected necrosis (OR 2.26; 95 % CI 1.13-4.50) and total length of stay ≥14 days (OR 4.08; 95 % CI 1.75-9.50).

CONCLUSIONS

The overall incidence of VTE in our cohort of patients with ANP was 12.5 %, which was usually diagnosed within one month of hospitalization. High-risk patients can be stratified based on clinical and imaging characteristics and may benefit from intensive DVT screening and prophylaxis during hospitalization and following discharge.

Venous Thrombosis in Acute Pancreatitis: What to and Not to Do?

Acute pancreatitis is an acute inflammatory condition of the pancreas that has not only local but systemic effects as well. Venous thrombosis is one such complication which can give rise to thrombosis of the peripheral vasculature in the form of deep vein thrombosis, pulmonary embolism, and splanchnic vein thrombosis. The prevalence of these complications increases with the severity of the disease and adds to the adverse outcomes profile. With better imaging and awareness, more cases are being detected, although many at times it can be an incidental finding. However, it remains understudied and strangely, most of the guidelines on the management of acute pancreatitis are silent on this aspect. This review offers an overview of the incidence, pathophysiology, symptomatology, diagnostic work-up, and management of venous thrombosis that develops in AP.

Long-term risk of venous thromboembolism among patients with gastrointestinal non-neoplastic and neoplastic diseases: A prospective cohort study of 484 211 individuals

We conducted a prospective cohort study to examine the associations of 21 gastrointestinal diseases with the risk of incident venous thromboembolism (VTE). The study included 485 936 UK Biobank participants free of baseline VTE. The gastrointestinal diseases were defined by the International Classification of Disease (ICD)-9 and 10 codes with data from the nationwide inpatient data set, the primary care data set, and the cancer registries. Incident VTE cases were defined by ICD-9 and 10 codes with data from the nationwide inpatient data set. Cox proportional hazards regression was used to estimate the associations of baseline gastrointestinal diseases with incident VTE risk. During a median follow-up of 12.0 years, 13 646 incident VTE cases were diagnosed. Eleven gastrointestinal diseases (nine non-neoplastic and two neoplastic) were associated with an increased risk of incident VTE after Bonferroni corrections. The risk of VTE was >50% higher among patients with gallbladder and biliary tract cancer (hazard ratio [HR] 3.15, 95% confidence interval [CI] 95% CI 1.74-5.70), pancreatic cancer (HR 2.84, 95% CI 1.65-4.91), cirrhosis (HR 2.34, 95% CI 1.96-2.79), Crohn's disease (HR 1.61, 95% CI 1.33-1.95), or pancreatitis (HR 1.57, 95% CI 1.31-1.88) compared with individuals without each of these diseases. We observed multiplicative interactions of age, sex, and body mass index with some gastrointestinal diseases (p < .05). A more pronounced, increased risk of VTE was found among younger, female, or obese patients. The study suggests a 50% higher risk of developing VTE among patients with gallbladder and biliary tract cancer, pancreatic cancer, cirrhosis, Crohn's disease, or pancreatitis.

Determinants and impact of splanchnic vein thrombosis in acute pancreatitis

BACKGROUND

Splanchnic vein thrombosis (SVT) is a well-recognised though little-studied complication in acute pancreatitis (AP). SVT risk factors, its clinical consequences and the role of anticoagulation (AC) therapy is scarce.

AIMS

To evaluate the incidence and natural history of SVT in AP.

METHODS

Post hoc analysis of a prospective multicentre cohort study involving 23 hospitals in Spain. AP complications were identified by computer tomography, and patients with SVT were re-evaluated after two years.

RESULTS

A total of 1655 patients with AP were included. The overall incidence of SVT was 3.6%. SVT was significantly associated with male gender, younger age and alcoholic aetiology. Every local complication increased SVT incidence, and this risk rose gradually with larger extension and infection of necrosis. These patients had a longer hospital stay and underwent a greater number of invasive treatments, regardless of AP severity. Forty-six patients with SVT were followed up. SVT resolution rate was 54.5% in the AC group and 30.8% in the non-AC group with lower thrombotic complications in the SVT resolution group (83.3% vs 22.7%; p<0.001). No AC-related adverse events occurred.

CONCLUSION

This study identifies the risk factors and negative clinical impact of SVT in AP. Our results justify future trials to demonstrate the role of AC in this clinical scenario.

Acute pancreatitis induces a transient hypercoagulable state in murine models

BACKGROUND/OBJECTIVES

Although understudied, risk of venous thromboembolism (VTE) appears to be increased during acute pancreatitis (AP). We aimed to further characterize a hypercoagulable state associated with AP utilizing thromboelastography (TEG), a readily available, point of care test.

METHODS

AP was induced in C57/Bl6 mice using l-arginine and caerulein. TEG was performed with citrated native samples. The maximum amplitude (MA) and coagulation index (CI), a composite marker of coagulability, were evaluated. Platelet aggregation was assessed using whole blood collagen-activated platelet impedance aggregometry. Circulating tissue factor (TF), the initiator of extrinsic coagulation, was measured with ELISA. A VTE model using IVC ligation followed by measurement of clot size and weight was evaluated. After IRB approval and consent, blood samples from patients hospitalized with a diagnosis of AP were evaluated by TEG.

RESULTS

Mice with AP displayed a significant increase in MA and CI, consistent with hypercoagulability. Hypercoagulability peaked at 24 h after induction of pancreatitis, then returned to baseline by 72 h. AP resulted in significantly increased platelet aggregation and elevated circulating TF. Increased clot formation with AP was observed in an in vivo model of deep vein thrombosis. In a proof of concept, correlative study, over two thirds of patients with AP demonstrated an elevated MA and CI compared to the normal range, consistent with hypercoagulability.

CONCLUSIONS

Murine acute pancreatitis results in a transient hypercoagulable state that can be assessed by TEG. Correlative evidence for hypercoagulability was also demonstrated in human pancreatitis. Further study to correlate coagulation measures to incidence of VTE in AP is warranted.

Deep Venous Thrombosis in Acute Pancreatitis Is Associated with High Mortality: A Prospective Study

BACKGROUND

Incidence and risk factors for the development of extremity deep vein thrombosis (eDVT) in admitted patients of acute pancreatitis have been rarely explored.

AIMS

To identify the incidence of eDVT and to explore role of clinical scores for predicting eDVT in admitted patients of acute pancreatitis.

METHODS

We prospectively enrolled admitted patients of acute pancreatitis and performed a weekly eDVT screen for the duration of their admission. Well's score and Padua's score were also calculated weekly. The incidence of venous thrombosis (eDVT and splanchnic thrombosis based on contrast-enhanced CT scan abdomen) was noted, and the risk factors were determined using multivariate analysis. The correlation between Well's score, Padua's score, and development of DVT was calculated using Pearson's correlation.

RESULTS

Of the 102 patients of acute pancreatitis enrolled, 73.5% of patients had necrotizing pancreatitis. Total of 46 patients (45.1%) developed thrombosis: 43 patients had splanchnic vein thrombosis; 5 patients had eDVT; and 1 patient had pulmonary embolism. Patients with eDVT had higher BISAP score (2.6 ± 0.9 vs 1.7 ± 0.8; p = 0.039), requirement of mechanical ventilation (60% vs 8.2%; p = 0.008), and mortality (60% vs 12.4%; p = 0.022). Well's score of ≥ 2 had sensitivity and specificity of 80% and 96.9% for prediction of eDVT and it had better correlation with the development of eDVT compared to Pauda's score.

CONCLUSION

Incidence of DVT is 5% in patients with acute pancreatitis requiring admission. It is associated with higher disease severity and mortality. The Well's score is useful to predict the development of eDVT in routine clinical practice.

Contemporary Surgical Management of Pancreatic Necrosis

Importance

For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach.

Observations

This review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome.

Conclusions and Relevance

The treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.

Necrotizing Pancreatitis: To Anticoagulate or Not to Anticoagulate?

Necrotizing pancreatitis is an inflammatory process that poses a strong risk of systemic venous thromboembolism. However, it is often challenging to opt for systemic anticoagulation since the disease is also associated with an increased risk of hemorrhage. Given these opposing complications, a risk versus benefit analysis has to be employed in the management of necrotizing pancreatitis on a case-by-case basis. We discuss a case where the team was faced with a dilemma regarding anticoagulation in a patient with newly developed atrial fibrillation in the setting of necrotizing pancreatitis. We found that there is a lack of guidelines that address the time of initiation and the type of systemic anticoagulation that should be administered in such patients.