Vascular liver disorders are common in clinical practice, and general practitioners, gastroenterologists, and hepatologists may benefit from expert guidance in managing patients with these conditions, according to a recent guideline from the American College of Gastroenterology.
The guideline includes key concepts as well as specific recommendations. The key concepts include the following:
- Abdominal pain disproportionate to physical findings of an abdominal examination should raise suspicion for portal vein thrombosis (PVT) and mesenteric vein thrombosis (MVT).
- In patients with PVT or MVT, physicians should suspect intestinal ischemia when they see fever, ascites, rebound abdominal tenderness, leukocytosis, and elevated serum lactate levels.
- In patients with new diagnoses of cirrhosis, onset of portal hypertension, or hepatic decompensation, physicians should conduct Doppler ultrasound of the hepatic vasculature.
- Endoscopic evaluation should be performed in patients with chronic PVT to assess for esophageal or gastric varices.
The recommendations include the following:
- Doppler ultrasound is the initial noninvasive modality to diagnose PVT. Contrast-enhanced CT or MRI is recommended to assess extension of thrombus into the mesenteric veins and to exclude tumor thrombus among patients with cirrhosis who develop new portal and/or mesenteric vein thrombus (strong recommendation, very low level of evidence).
- Use anticoagulation for all patients without cirrhosis who have acute symptomatic PVT or MVT in the absence of any contraindication (strong recommendation, low level of evidence). Use anticoagulation for patients with chronic PVT if there is evidence of inherited or acquired thrombophilia, progression of thrombus into the mesenteric veins, or current or previous evidence of bowel ischemia (conditional recommendation, very low level of evidence).
- Follow up with at least six months of anticoagulation in patients with PVT or MVT without a demonstrable thrombophilia and when the cause of the thrombosis is reversible. Indefinite anticoagulation is recommended in patients with PVT or MVT and thrombophilia (conditional recommendation, very low level of evidence).
- Once a decision is made to begin anticoagulation for treatment of PVT or MVT, unfractionated heparin or low-molecular-weight heparin (LMWH) is suggested after consideration of the risks and benefits (conditional recommendation, very low level of evidence).
- LMWH or warfarin is suggested for maintenance, since experience with direct oral anticoagulants is currently limited. The guideline recommended some monitoring of therapy because absorption of these agents may be limited in the presence of intestinal edema, noting that a normal thrombin time and activated partial thromboplastin time for dabigatran and a normal prothrombin time or anti-Xa activity for apixaban and rivaroxaban rule out substantial drug effect. Pros and cons of all approaches, including availability of reversal agents, should be considered before deciding on the specific regimen, the guideline said (conditional recommendation, very low level of evidence).
The guideline was published in the January American Journal of Gastroenterology.