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19 October 2018 at 16h03 #2109Audrey DillonParticipant
I would like to ask your opinion on a particularly contentious case we currently have as to the best method of anticoagulation.
We have a young woman in her late twenties, with a longstanding diagnosis of portal hypertension following childhood treatment for leukaemia, with fibrosis but not cirrhosis on biopsy as a teenager. She had variceal bleeding 5 years ago, and was well up to last year when developed ascites post-partum associated with an acute portal vein thrombosis.
We therapeutically anticoagulated her for a year with LMWH and then reduced to prophylactic LMWH on advice of haematology as low platelets (range 40-50).
Our haematologists now don’t want her even on prophylactic LMWH and only want her given prophylactic LMWH at times of high risk eg when admitted unwell, in pregnancy again etc.
Her imaging shows stable size of thrombosis, and we are concerned that no anticoagulation could render her untransplantable in the future if her thrombosis extends.
We have reached a stalemate with our haematology colleagues, who have advised the patient that any anticoagulation is too unsafe for her. Our hepatology team are in agreement that not anticoagulating is unsafe!
I was wondering what your local practice is to manage concerns about low platelets and anticoagulation? Her low platelets have no other cause (has been investigated) and a negative thrombophilia screen.
Previously, we have given warfarin and LMWH both therapeutically and prophylactic doses in this situation, but our haematology colleagues have begun to question these decisions as very unsafe.
19 October 2018 at 16h25 #2110Xingshun QiParticipant
An interesting case.
According to your words, this patient may be diagnosed with INCPH complicated with PVT and hypersplenism (PLT 40-50). You want to balance the benefit and risk of anticoagulation for such a patient. Some details should be further given before an effective discussion.
First, despite you said that the size of thrombosis was unchanged, could you please tell us the detailed extension and grade of PVT? The severity of PVT is an important factor for determining long-term anticoagulation or not.
Second, INCPH often has a good liver function and prognosis. Liver transplantation is not necessary in most of INCPH cases. Could you please tell us the detailed liver function.
Third, we do not have any evidence that PVT increases the mortality of INCPH. Similarly, we do not have any evidence that anticoagulation increases the survival of INCPH.
20 October 2018 at 13h15 #2111Markus Peck-RadosavljevicParticipant
I think there is enough evidence to show that anticoagulation is safe in patients with thrombocytopenia and liver disease (mostly cirrhosis but I do not see why this should be different in your patient).
We would continue her on anticoagulation, either warfarin, LMWH, or DOAK’s (here you should not be too aggressive with the dose). I would not worry about bleeding complications, even if she would have varices. My main concern also would be the risk to develop progressive thrombosis of the splanchnic venous bed.
22 October 2018 at 12h52 #2112Audrey DillonParticipant
Thank you, our main concern is the risk of progression of thrombus, and while I agree that transplant is not necessary for many in this NCPH; we want to ensure that she does not end up non-transplantable due to our inaction, as she is only 25.
She has a 5cm non-occlusive thrombus in the portal vein that stops just above the confluence.
She has a normal bilirubin and albumin, INR 1.2. Her US 2 weeks ago showed no ascites on Spironolactone 200mg.
22 October 2018 at 13h44 #2113Xingshun QiParticipant
Thank you for your further information.
Supporting point for long-term anticoagulation is an occlusive PVT. Spontaneous recanalization is difficult. I remember a case report by Prof. Garcia-Pagan in J Hepatol showing a complete recanalization for CTPV after long-term anticogulation.
Opposing points for long-term anticoagulation are negative thrombophilia, without mesenteric vein involvment, non-LT listed, and a low PLT. Indeed, you can find that a majority of patients included in published studies regarding anticoagulation for PVT do not have a low PLT. So your hematologist’ considerations are reasonable.
Generally, no high-level evidence has been provided, especially in INCPH. Regardless of your final decision, a close monitoring is very necessary. For anticoagulation, please monitor the bleeding risk. For non-anticoagulation, please monitor thrombus progression.
23 October 2018 at 9h10 #2115Andrea De GottardiParticipant
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!
27 October 2018 at 16h19 #2116Pierre-Emmanuel RautouModerator
Dear Audrey, dear colleagues,
We have here a patient with INCPH and a thrombus that occurred at a period well known to be procoagulant (postpartum). She has been treated with anticoagulation for 1 year. At the stage we are now, there is no data supporting one attitude (no anticoagulation) or the other (anticoagulation). In situations at risk (pregnancy, hospitalization, etc) anticoagulaion is likely needed.
If anticoagulation is discontinued, I would personally (extrapolating on data from Delgato CGH 2012 obtained in cirrhosis and our local experience on PVT) propose an ultrasonography at 1 and 3 months and a CT scan at 6 month. I thrombosis recurs, then anticoagulation is clearly needed on the long term.
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