Reply To: Anticoagulation options with platelets

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Andrea De Gottardi

Dear Audrey and colleagues,

This young patient already developed complications related to her non-cirrhotic (yet fibrotic) liver disease in terms of clinically significant portal hypertension with variceal bleeding and PVT.

In this situation, prevention of variceal re-bleeding should be performed according to the Baveno recommendations, while prevention of extension of the PVT remains a question mark. Although there is no solid evidence, anticoagulation in prophylactic dose, either with LMWH (enoxaparin 40 mg/day) or DOAC (apixaban 2.5 mg twice/day or rivaroxaban 10 mg once/day) should be considered. Thrombocytopenia is neither protective against thrombosis, nor a risk factor for variceal bleeding in this range.

What’s more is that sevearal questions remain open: what about her risk of rebleeding? if we do not decrease portal hypertension, will her thrombocytopenia progressively worsen? what about covert HE in this case? More and more transjugular or transplenic interventions successfully aimed at recanalysing the cavernoma are reported. Discuss!