Testing for thrombophilia in mesenteric venous thrombosis - Retrospective original study and systematic review

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis

OBJECTIVE

Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis.

METHODS

All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease).

RESULTS

Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival.

CONCLUSIONS

Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

Mesenteric venous thrombosis

Mesenteric vein thrombosis (MVT) is a rare condition that can present acutely, subacutely, or chronically. MVT can be isolated or within a splanchnic thrombosis (spleno-porto-mesenteric). Symptomatic cases usually present as nonspecific abdominal pain, with or without signs of intestinal ischemia, and the diagnosis is usually made by imaging test (abdominal CT or MRI) in patients with high clinical suspicion. An early clinical-surgical approach is recommended to screen those patients with warning signs and who benefit from an exploratory laparotomy in addition to anticoagulant treatment, which is the cornerstone of medical treatment. MVT is usually associated with prothrombotic states, with hematological disorders (myeloproliferative syndromes and/or JAK2 gene mutations) being of special clinical relevance. On the other hand, the 5-year survival rate is 70-82% and early overall 30-day mortality from MVT can reach 20-32%.

Cancer-Associated Splanchnic Vein Thrombosis

Splanchnic vein thrombosis (SVT), which includes portal, mesenteric, and splenic vein thrombosis and the Budd-Chiari syndrome, is an infrequent manifestation of venous thromboembolism (VTE). Like typical site VTE, SVT is also frequently associated with cancer, particularly intra-abdominal solid malignancies and myeloproliferative neoplasms (MPNs). The clinical presentation of SVT is nonspecific. Symptoms may be related to the underlying malignancy, and thrombosis is incidentally diagnosed by imaging studies for cancer staging or follow-up in a substantial proportion of cases. The occurrence of SVT predicts worse prognosis in patients with liver or pancreatic cancer and, not uncommonly, SVT may precede the diagnosis of cancer. Therefore, the occurrence of an apparently unprovoked SVT should prompt careful patient evaluation for the presence of an underlying malignancy or MPN. Cancer patients carry a high risk of VTE extension and recurrence and long-term anticoagulant treatment is suggested in the absence of high risk of bleeding. Either LMWH or direct oral anticoagulants (DOACs) are suggested for the treatment of patients with cancer-related SVT, although limited experience is available on the use of DOACs in these settings. Vitamin K antagonists (VKAs) are suggested for the short and long-term treatment of SVT associated with MPN. This review outlines the epidemiological aspects, pathogenesis, risk factors, and diagnosis of cancer-associated SVT, and addresses questions regarding the management of this challenging condition.

Predictors and risk factors for intestinal necrosis in patients with mesenteric ischemia

Background

Mesenteric ischemia results in blood flow that is insufficient to meet metabolic demands and subsequent dysfunction of visceral organs, including arterial obstruction and venous thrombosis. Sustained mesenteric ischemia exhausts the ability of capillaries to provide oxygen and initiate an inflammatory reaction, and eventually leads to intestinal mucosal necrosis, a serious and potentially life-threatening condition. Therefore, it is essential that the predictors and risk factors for intestinal necrosis in patients with mesenteric thrombus are explored.

Methods

This study retrospectively enrolled 41 patients with mesenteric ischemia (including mesenteric vein embolism, mesenteric artery thrombosis, and portal vein thrombosis) who were admitted to the Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital between May 2016 and October 2019; of the patients, 18 were further diagnosed with intestinal necrosis. Comparisons of symptoms, computed tomography angiography (CTA) features, and laboratory examination results were performed between mesenteric ischemia patients with and without intestinal necrosis.

Results

White blood cell count showed an excellent predictive ability for intestinal necrosis in patients with mesenteric ischemia, with an area under the receiver operating characteristic (ROC) curve of 0.772 (P=0.009). The four CTA features [pneumatosis (P=0.016), intestinal swelling (P=0.006), ascitic fluid (P<0.001), and decreased intestinal wall enhancement (P=0.004)] differed significantly between patients with and without intestinal necrosis. Peritonitis showed a strong association with intestinal necrosis (P=0.006) in the univariate analysis, and multivariate analysis further showed their association [odds ratio (OR): 8.53; 95%CI: 1.46-49.81; P=0.017].

Conclusions

White blood cell count is a potential predictor of intestinal necrosis. Peritonitis is a possible risk factor for intestinal necrosis in patients with mesenteric ischemia. A multi-center prospective study with a larger sample size needs to be performed to further investigate these findings.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

The Natural History, Treatments, and Outcomes of Portal Vein Thrombosis in Patients With Inflammatory Bowel Disease

BACKGROUND

Portal vein thrombosis (PVT) is a poorly described complication of inflammatory bowel disease (IBD). We sought to better characterize presentations, compare treatments, and assess outcomes in IBD-related PVT.

METHODS

We conducted a retrospective investigation of IBD-related PVT at our institution. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios across treatments.

RESULTS

Sixty-three patients with IBD-related PVT (26 with Crohn disease, 37 with ulcerative colitis) were followed for a median 21 months (interquartile ratio [IQR] = 9-52). Major risk factors included intra-abdominal surgery (60%), IBD flare (33%), and intra-abdominal infection (13%). Primary hematologic thrombophilias were rare and did not impact management. Presentations were generally nonspecific, and diagnosis was incidental. Ninety-two percent of patients (58/63) received anticoagulation (AC), including 23 who received direct oral anticoagulants (DOACs), 22 who received warfarin, and 13 who received enoxaparin. All anticoagulated patients started AC within 3 days of diagnosis. Complete radiographic resolution (CRR) of PVT occurred in 71% of patients. We found that DOACs were associated with higher CRR rates (22/23; 96%) relative to warfarin (12/22; 55%): the hazard ratio of DOACs to warfarin was 4.04 (1.83-8.93; P = 0.0006)). Patients receiving DOACs required shorter courses of AC (median 3.9 months; IQR = 2.7-6.1) than those receiving warfarin (median 8.5 months; IQR = 3.9-NA; P = 0.0190). Incidence of gut ischemia (n = 3), symptomatic portal hypertension (n = 3), major bleeding (n = 4), and death (n = 2) were rare, and no patients receiving DOACs experienced these adverse outcomes.

CONCLUSIONS

We show that early and aggressive use of AC can lead to excellent outcomes in IBD-associated PVT and that DOACs are associated with particularly favorable outcomes in this setting.

The role of anticoagulation in pylephlebitis: a retrospective examination of characteristics and outcomes

Pylephlebitis, or suppurative thrombophlebitis of the portal vein, typically occurs in the context of an intraabdominal infection or abdominal sepsis. Antibiotics are the mainstay of treatment. The role of anticoagulation in the management of pylephlebitis is controversial, and data regarding its impact on outcomes is limited. The records of 67 consecutive patients with pylephlebitis treated at our institution over a 19 year period were retrospectively reviewed. Data was gathered regarding their baseline characteristics, presentations, management, and outcomes. Patients who did and did not receive anticoagulation were compared. Outcomes of interest included survival, portal vein thrombosis (PVT) resolution, development of chronic symptomatic portal hypertension, and major bleeding. Forty-seven patients received anticoagulation and 20 did not. The anticoagulated and non-anticoagulated groups did not differ significantly with respect to potential covariates or confounders. Anticoagulated patients had significantly higher rates of PVT resolution than non-anticoagulated patients (58% vs. 21%, p = 0.0201). This translated to lower rates of future chronic portal hypertensive symptoms among anticoagulated patients (11% vs. 47%, p = 0.0034). Anticoagulated patients had a trend toward improved survival however this improvement was not significant on multivariable analysis. There was no significant difference in rates of major bleeding between groups. Thrombophilia testing was common in this cohort however the occurrence of meaningful positive results was exceedingly low. Anticoagulation significantly improves the rate of PVT resolution, and significantly reduces the rate of chronic symptomatic portal hypertension, among patients with pylephlebitis. Treatment of pylephlebitis should incorporate the use of systemic anticoagulation whenever possible.

Management of Acute Mesenteric Venous Thrombosis: A Systematic Review of Contemporary Studies

Background and Aims:

Acute mesenteric venous thrombosis accounts for up to 20% of all patients with acute mesenteric ischemia in high-income countries. Acute mesenteric venous thrombosis is nowadays relatively more often diagnosed with intravenous contrast-enhanced computed tomography in the portal phase than at explorative laparotomy No high-quality comparative studies between anticoagulation alone, endovascular therapy, or surgery exists. The aim of the present systematic review was to offer a contemporary overview on management.

Materials and Methods:

Eleven relevant published original studies with series of at least ten patients were retrieved from a Pub Med search between 2015 and 2020 using the Medical Subject Heading term “mesenteric venous thrombosis.”

Results:

When MVT is diagnosed early, immediate anticoagulation with either unfractionated heparin or subcutaneous low-molecular-weight heparin should commence. Surgeons need to be aware of the importance to scrutinize the computed tomography images themselves for assessment of secondary intestinal abnormalities to mesenteric venous thrombosis and the risk of bowel resection and worse prognosis. Progression toward peritonitis is an indication for explorative laparotomy and assessment of bowel viability. Frank transmural small bowel necrosis should be resected and bowel anastomosis may be delayed for several days until second look. Meanwhile, intravenous full-dose unfractionated heparin should be given at the end of the first operation. Postoperative major intra-abdominal or gastrointestinal bleeding occurs rarely, but the heparin effect can instantaneously be reversed by protamine sulfate. Patients who do not improve during conservative therapy with anticoagulation alone but without developing peritonitis may be subjected to endovascular therapy in expert centers. When the patient’s intestinal function has recovered, with or without bowel resection, switch from parenteral unfractionated heparin or low-molecular-weight heparin therapy to oral anticoagulation can be performed. There is a trend that direct oral anticoagulants are increasingly used instead of vitamin K antagonists. Up to now, direct oral anticoagulants have been shown to be equally effective with the same rate of bleeding complications. Patients with no strong permanent trigger factor for mesenteric venous thrombosis such as intra-abdominal cancer should undergo blood screening for inherited and acquired thrombophilia.

Conclusion:

Early diagnosis with emergency computed tomography with intravenous contrast-enhancement and imaging in the portal phase and anticoagulation therapy is necessary to be able to have a succesful non-operative succesful course.

The utility of thrombophilia testing in patients with newly diagnosed portal vein thrombosis

: Thrombophilia testing is frequently performed in both seemingly provoked and unprovoked portal vein thrombosis (PVT), yet the clinical implications of these expensive laboratory tests are unknown. We investigated the frequency of clinical management changes in patients with newly diagnosed PVT. This is a retrospective analysis of adult patients with a newly diagnosed PVT at a single institution. The primary outcome is change in clinical management, defined as documented change in choice, dose, or duration of anticoagulation, future thromboprophylaxis, or counseling of asymptomatic family members. Five-hundred and forty-four patients with PVT were identified, 438 (80.5%) of whom had an identifiable pretesting provoking factor, most commonly cirrhosis (39.2%). Two-hundred ninety-one patients (53.5%) had at least one hypercoagulable laboratory test performed. The most frequently positive test was PAI-1 polymorphism, followed by elevated homocysteine and MTHFR mutational analysis. However, the only test that was frequently positive and consistently altered management was JAK2 mutational analysis (15.3%). Factor V Leiden was commonly positive but rarely changed clinical decision-making (1.5%), as was flow cytometric testing for paroxysmal nocturnal hemoglobinuria (0.8%), and antiphospholipid antibodies (0.7%). Patients with cirrhosis rarely had thrombophilia testing results that were clinically significant. A rough cost estimate was dramatically reduced from $231 000 to $76 000 if only clinically meaningful tests were employed in the hypercoagulable work-up. These results highlight the need for focused thrombophilia testing in patients with PVT.

Comparison between thrombophilic gene polymorphisms among high risk patients

Introduction. The purpose of this study was to compare the role of the thrombophilic variants among two groups of high risk patients with vascular disorders and recurrent pregnancy loss.

Methods. 200 patients, including 76 with thrombotic accidents and 124 with two or more idiopathic recurrent miscarriage during the first trimester, were tested for the presence of Factor V (F V) Leiden G1691A, Factor II (F II) G20210A, plasminogen activator inhibitor (PAI) 4G/5G, and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphisms using Real time polymerase chain reaction (RT – PCR) in the Laboratory of Medical Genetics, Varna, Bulgaria between June 2016 and May 2019. Frequencies of thrombophilic gene polymorphisms were compared among the two populations and to the expected genotype frequencies.

Results. Individuals with a history of vascular disorders had a significantly higher frequency of F V Leiden variant compared to women with recurrent miscariage. There was no statistical difference between the analyzed patients for the other three thrombophilic polymorphisms. The allelic frequencies and the expected genotype frequencies of the F V, F II and MTHFR polymorphisms were calculated according to Hardy-Weinberg equilibrium. The percentages of the homozygotes for F V and F II were higher than expected in the two groups of patients. For the MTHFR there was no difference.

Conclusion. F V Leiden remains the strongest risk factor for vascular disorders and recurrent pregnancy loss. Screening for this variant should be recommended to patients with thrombotic accidents and women with repeated miscarriage. The role of F II, PAI and MTHFR remains controversial.

Acute mesenteric ischaemia secondary to portal, splenic and superior mesenteric vein thrombosis

Mesenteric ischaemia represents an uncommon complication of splanchnic vein thrombosis which requires a high level of suspicion to diagnose in a timely manner. This report discusses a case of portal, splenic and superior mesenteric vein thrombosis leading to mesenteric ischaemia and infarct in a 79-year-old man. The diagnosis of acute mesenteric ischaemia and splanchnic vein thrombosis remains difficult due to the non-specific symptoms of these conditions. As diagnosis does continue to improve, treatment of acute mesenteric ischaemia using medical management has become increasingly possible before ischaemia advances to the point at which surgical resection is required.

Clinical implications of different risk factor profiles in patients with mesenteric venous thrombosis and systemic venous thromboembolism: a population-based study

It is unknown whether the risk factor profile for mesenteric venous thrombosis (MVT) is different from systemic venous thromboembolism (VTE). The aim of the present population-based study was to compare acquired and inherited risk factors in MVT versus VTE. Identification of all MVT patients at Skåne University Hospital between 2000 and 2015 was performed in patient records and AuriculA (Swedish anticoagulation registry). VTE patients were retrieved from the Malmö Thrombophilia Study (MATS), including 1465 consecutive unselected VTE patients between 1998 and 2008. Patients with MVT (n = 120) were younger (p < 0.001), had higher glomerular filtration rate (p < 0.001), lower smoking rate (p < 0.001), and had less often undergone recent surgery (p = 0.025). The prevalence of solid cancer (19.2% in MVT versus 12.1% in VTE; p = 0.026) and intra-abdominal cancer (16.7% versus 2.3%; p < 0.001) were higher in MVT. The prevalence of factor V Leiden mutation without presence of cancer was lower in MVT compared to VTE (26.6% versus 38.9%; p = 0.031). Thirty-day mortality was higher in the MVT group (9.2% versus 0.6%; p < 0.001), but did not differ at long-term follow-up according to Kaplan–Meier analysis (p = 0.73). Patients with MVT have a higher prevalence of cancer and lower prevalence of factor V Leiden mutation than those with systemic VTE. Intra-abdominal cancer should be excluded in MVT patients, and the high prevalence of factor V Leiden mutation in patients without cancer in both groups suggests that screening for thrombophilia in patients without cancer should be considered in this population for both groups.

Evaluation of direct oral anticoagulants and vitamin K antagonists in mesenteric venous thrombosis

BACKGROUND/AIM

Mesenteric venous thrombosis is a rare lethal disease. The main aim of the present study was to evaluate clinical efficacy and safety of direct oral anticoagulants and vitamin K antagonists in mesenteric venous thrombosis patients.

METHODS

Retrospective study of 102 mesenteric venous thrombosis patients treated between 2004 and 2017 at a center with a conservative medical first approach. Median clinical follow-up was 4 years.

RESULTS

Computed tomography showed successful recanalization of thrombosis in 71% of patients on vitamin K antagonists and 69% of patients on direct oral anticoagulants ( p = 0.88). Overall major and esophageal variceal bleeding rate was 14.7% and 2.9%, respectively. No difference in major bleeding ( p = 0.54) was found between vitamin K antagonists and direct oral anticoagulants. No mesenteric venous thrombosis recurrence occurred during follow-up, and one venous thromboembolism occurred after cessation of anticoagulation.

CONCLUSION

Anticoagulation with direct oral anticoagulants and vitamin K antagonists was efficient in patients with mesenteric venous thrombosis. Bleeding complications was a concern during treatment in both groups.