Refractory ascites due to portal vein thrombosis in liver cirrhosis--report of two cases

Portal vein thrombosis as a complication of liver cirrhosis has been reported to be extremely rare in Japan, as compared with European countries. There are few reports discussing the correlation of portal vein thrombosis with refractory ascites. Between January 1994 and December 1995, 20 cases (91%) of 22 patients with liver cirrhosis with ascites admitted to our hospital responded well within 2 months to a combination therapy of diuretics and albumin infusion, and the other two cases (9%) with refractory ascites were associated with portal vein thrombosis. The ascites in the first patient continued for 1 year, despite diuretics and albumin infusion therapy, and portal vein thrombosis was confirmed by autopsy. The ascites in the other patient continued for more than 4 months, and portal vein thrombosis was detected by ultrasound. Portal vein thrombosis was not found in the other 20 cirrhotic patients with ascites. These two cases suggest that portal vein thrombosis may be a contributing factor to refractory ascites in patients with decompensated liver cirrhosis.     

Post-traumatic thrombosis of the portal vein

Blunt trauma to the abdomen is an exceptional cause of portal vein thrombosis. To our knowledge, 8 cases have been reported in the literature. When thrombosis of the portal vein occurs, a complete search for all the known main causes must be carried out before entertaining this diagnosis. Other causes may be cirrhosis, tumors and inflammation of the abdomen, coagulation disorders and hematologic diseases including latent myeloproliferative syndrome. We report a case in a 25-year-old man with an uneventful past history who presented with thrombosis of the portal vein after a violent blunt trauma which occurred during a rugby play. In this young man, none of the other potential causes was found, in particular bone marrow culture on medium with low growth-factor concentration allowed us to eliminate a latent myeloproliferative syndrome. The only triggering factor remaining was the recent abdominal trauma. After an 18-month follow-up, no other element has been observed which could have caused thrombosis of the portal vein.     

Thickening of the wall of the bile duct due to intramural collaterals in three patients with portal vein thrombosis

OBJECTIVE: We report three cases of a rare form of cavernoma developed within the wall of the common bile duct. CONCLUSION: To our knowledge, this kind of portal cavernoma has not been described in the literature. Because the cavernoma may be easily confused with other causes of bile duct wall thickening, color Doppler sonography is mandatory for a correct diagnosis.     

Risk factors influencing the outcome of portal and mesenteric vein thrombosis

BACKGROUND/AIMS: This study analyzes risk factors that influence the course and outcome of portal and superior mesenteric vein thrombosis (PMVT). METHODOLOGY: We retrospectively reviewed 45 patients who were admitted to our institution over a 17-year period with a diagnosis of PMVT. Patients were classified according to three etiological groups, namely: cirrhosis (47%), pancreatitis (22%), and other causes (33%), with 1 patient belonging to two different groups. RESULTS: Over the course of the disease, rupture of gastric or esophageal varices was more frequent (p<0.005) in cirrhotics (75%) than non-cirrhotics (17%). Sclerotherapy was always the first treatment for variceal bleeding, with a success rate of 73% but a rate of recurrence of 56%. Surgical procedures were performed on 22% of patients. Actuarial survival was 43% at 5 years, but survival was significantly increased for idiopathic cases (p=0.005) and decreased in the presence of cirrhosis (p<0.001), malignancy (p<0.0001) or hematemesis (p<0.005). Gastrointestinal bleeding and terminal malignancies were responsible for 50% of deaths. CONCLUSIONS: Cirrhotic patients experience a detrimental outcome with an increased risk of gastrointestinal bleeding, which is the first cause of mortality in PMVT. Non-cirrhotic patients, especially idiopathic cases, enjoy a longer survival rate and seldom bleed, which allows for the use of anticoagulative therapy.     

Partial portal vein and mesenteric vein thrombosis in familial protein S deficiency

Protein S, a vitamin-K dependent glycoprotein is a cofactor of protein-C system, which acts as an inhibitor of the plasmatic coagulation. Protein-S congenital deficiency results in recurrent venous thromboses, atypical locations in portal and mesenteric veins are possible. In our patient the partial thrombosis of the portal vein was diagnosed by computed tomography and angiography. Small bowel ischaemia due to mesenteric vein thrombosis required segmental resection. Post-operatively the patient was heparinized and later phenprocoumon was applied to a long-term therapy.     

Study of hemostasis in pediatric patients with portal vein thrombosis

We describe the behavior of hemostatic variables in children with portal vein thrombosis (PVT) and in a control pediatric population. Hereditary protein C (PC) or protein S (PS) deficiency was not a etiologic factor for PVT in children. Minor signs of consumption of coagulation factors II, V, fibrinogen and hyperfibrinolysis were detected. One child had lupus anticoagulant (LA).     

Improved results of liver transplantation in patients with portal vein thrombosis

OBJECTIVE: To analyze the impact of preexisting portal vein thrombosis (PVT) on the operative management and outcome of liver transplantation. DESIGN: Retrospective review of 1423 patients who received transplants over 11 years. SETTING: Tertiary referral center. PATIENTS OR OTHER PARTICIPANTS: Seventy patients who underwent liver transplantation who had preexisting PVT. INTERVENTIONS: Portal vein thromboendovenectomy, vein grafting, or use of portal collateral veins for inflow during liver transplantation. MAIN OUTCOME MEASURES: Postoperative PVT, intraoperative transfusion, retransplantation rate, 30-day and 1-year actuarial survival rates. RESULTS: Operative management consisted of thromboendovenectomy in 61 cases, vein graft to the superior mesenteric vein in 6 cases, and vein graft to other mesenteric veins in 3 cases. The incidence of posttransplant PVT was 3% (n = 2). The mean +/- SD transfusion requirement was 23 +/- 18 U. The 1-year actuarial survival rate was 74% but improved from 66% in the first 35 cases to 82% in the latter 35 cases. CONCLUSIONS: Thromboendovenectomy is the procedure of choice for PVT. Results of liver transplantation in patients with PVT improve significantly with experience gained and are equivalent to results in patients without PVT.     

The middle colic vein: an alternative source of portal inflow in orthotopic liver transplantation complicated by portal vein thrombosis

BACKGROUND: Portal vein thrombosis (PVT) was previously considered a contraindication to orthotopic liver transplantation (OLT) since adequate portal blood supply is mandatory for graft function and patient survival. Improvements in surgical technique, however, have meant that this problem now can be circumvented in most instances. Nevertheless portal vein thrombosis remains an obstacle in OLT and is associated with increased incidence of primary non-function and long-term liver failure. METHODS: A 55-yr-old patient underwent OLT for secondary biliary cirrhosis associated with hepatitis C infection and complicated by long standing PVT. Involvement of the portal, mesenteric, and splenic veins prevented standard portal venous reconstruction. Portal inflow was accomplished by a side-to-end anastomosis between the middle colic vein and the donor portal vein. RESULTS: Hepatic reperfusion and subsequent liver function were excellent. Portal blood flow, as measured by color-enhanced Doppler ultrasound, was normal following surgery until discharge. The post-operative course was complicated by abdominal wound dehiscence and recurrent cytomegalovirus (CMV) infection. The patient was discharged in good clinical condition, with excellent liver function and patent portal vein 89 d after OLT. CONCLUSIONS: The middle colic vein is a novel, not previously described, source of portal venous inflow for OLT complicated by extensive splanchnic venous inflow thrombosis.     

Factor V Leiden is not common in children with portal vein thrombosis

Portal vein thrombosis (PVT) is a rare condition affecting both children and adults, and occurs in association with a wide variety of clinical situations. On the other hand, the development of PVT in patients under these situations indicates that other contributing factors could be involved. Recently a missense mutation in the factor V gene (1691G-->A), known as factor V Leiden, has been identified and results in abnormal factor V product, resistant to proteolytic inactivation by activated protein C and thus predisposes to thrombosis. This study was carried out to verify if children with PVT have an increase in frequency of factor V Leiden. Allele-specific restriction analysis and single strand conformational polymorphism (SSCP) were used to test for factor V Leiden in 20 children with PVT and 64 normal children. None of the PVT children were heterozygous or homozygous for the factor V Leiden, and one control child was heterozygous. This study demonstrates that factor V Leiden is not common in children with PVT, and is not a prerequisite for this thrombotic event.     

Frequent factor II G20210A mutation in idiopathic portal vein thrombosis

OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) in post-Billroth II (BII) gastrectomy is more difficult due to anatomical changes. The difficulties include entrance to the afferent loop and selective cannulation. Our aim here is to report the success rate and special manipulations and techniques of this procedure. METHODS: A retrospective review of 56 ERCP procedures in post-BII gastrectomy patients was performed. There were 43 male and 13 female patients with a mean age of 63 yr (range, 32-78 yr). All cases were tried with forward-viewing endoscope first. Of the failed cases, 10 were retried by side-view duodenoscope. The entrance to the afferent loop was attempted by starting from the upper opening at the anastomosis site and, if this failed, then using the lower opening; presence of bile; and air-contrasted afferent loop under fluoroscopy. If failure of afferent loop entrance resulted, hand compression over the mid-abdomen, or polypectomy snare in the working channel of the endoscope, was tried. For failure of common bile duct cannulation with straight catheters, techniques of pushing the catheter against the duodenal wall and bending the tip of the endoscope or guidewire were used. RESULTS: The success rate of afferent loop entrance was 76.7% (43 of 56 cases). The afferent loop was identified in the upper orifice of the anastomosis in 93% (40 of 43) of the cases. Eight cases of afferent loop entrance could be facilitated by hand compression, and three by polypectomy snare in the working channel of the endoscope. The success rate of ERCP cannulation in those successful afferent loop intubation cases was 81.3% (35/43 cases). Most of the selective common bile duct (CBD) cannulation was achieved by straight (new) catheter and an additional six cases were successful using the techniques mentioned. No serious complications were encountered, except three cases of submucosal hemorrhage. CONCLUSION: The overall success rate of BII ERCP was 62.5% (35 of 56 cases). The special manipulations mentioned in BII ERCP can be helpful in certain cases.     

Breast abscess due to Corynebacterium striatum

Corynebacterium striatum, a normal constituent of the skin flora, is rarely pathogenic. Previous reports of infection are few, and are mainly confined to immunosuppressed patients or those with indwelling prosthetic devices. We report a case in which the organism caused a recurrent breast abscess in a woman with normal immune function. The only previous reports of Corynebacterium striatum mastitis have been in cows.     

Chiasmal syndrome due to intrasellar abscess

A 43-year-old woman had diabetes insipidus and amenorrhea. There was panhypopituitarism on endocrine testing and visual field examination showed inexorably progressive loss to bitemporal hemianopsia. All radiographic findings were normal, but craniotomy disclosed the cause of this chiasmal syndrome to be an intrasellar abscess which, on culture, grew a Gram-positive anaerobe, Peptococcus. Intrasellar or pituitary abscess is rare, but it must always be considered in the differential diagnosis of the chiasmal syndrome, since loss of pituitary and visual function may occur much more rapidly than with the tumors most often responsible for this syndrome and since surgical cure is possible.     

Intraoperative placement of a Wallstent for portal vein stenosis and thrombosis after liver transplantation

We report a case of orthotopic liver transplantation, in which portal vein thrombosis developed in the immediate postoperative period. Surgical thrombectomy and intraoperative placement of a large caliber Wallstent resulted in long-term patency. The unique feature of this case is the intraoperative placement of the stent via the inferior mesenteric vein under fluoroscopic guidance. The use of a large caliber (16 mm) stent obviated the need for postoperative anticoagulation.     

Tuberculous thrombophlebitis of the portal vein

The myelin sheath and axon areas in the sciatic nerve of 20 adult rats were studied using the video-point-counting method (Quantimet). This automatic measurement procedure allows an exact and rapid determination of the above mentioned areas as a result of the differing intensities of the structures. The electron-microscopic pictures are projected at a magnification of 3500 onto the monitor through a lens system from a Vidikon-TV-tube, objective 32 mm. The areas of single nerve cross-sections, myelin sheath areas and total area are then measured. These area values are stated in picture points which can be calculated to absolute values. The statistical evaluation of both parameters shows a linear regression with a correlation coefficient of 0.94. These values are compared with the results obtained using the conventional manual methods of other authors, e.g. determination of lamellae number or myelin sheath thickness as well as axon circumference or axon diameter. The special advantages of this procedure are thereby pointed out.     

Spontaneous erythroid colony formation as the clue to an underlying myeloproliferative disorder in patients with Budd-Chiari syndrome or portal vein thrombosis

Results from this laboratory have shown that bone metabolism is directly related to extracellular pH and that high concentrations of tobramycin released from impregnated polymethylmethacryrate (PMMA) beads has pH-dependent toxic effects on bone. In the present study, beneficial effects of calcium hydroxide-impregnated PMMA were investigated regarding tobramycin toxicity and bone metabolism in chick embryo tibiae in vitro. Also using Ca(OH)2 as a pH regulator, the antibiotic efficacy of tobramycin-impregnated PMMA was evaluated with respect to inhibition of Staphylococcus aureus growth. When Ca(OH)2 was added to PMMA beads containing tobramycin, the beads released hydroxyl and calcium ions into the culture medium and released more antibiotic than beads containing only tobramycin. Bone metabolism (glycolysis, total protein synthesis, and collagen synthesis) was enhanced by Ca(OH)2-impregnated beads with or without tobramycin. Additionally, bacterial growth was inhibited more strongly when S. aureus was incubated with tobramycin- and Ca(OH)2-impregnated PMMA disks than with disks containing only tobramycin. This study demonstrates the feasibility of adding Ca(OH)2 to tobramycin-impregnated PMMA beads as a regulator of local pH and a promoter of bone metabolism for protection of bone when high concentrations of tobramycin are used to treat osteomyelitis. It also suggests that lower concentrations of antibiotic may be effective if Ca(OH)2 and tobramycin are administered simultaneously.