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Venous Thrombosis in Acute Pancreatitis: What to and Not to Do?

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Abstract

Acute pancreatitis is an acute inflammatory condition of the pancreas that has not only local but systemic effects as well. Venous thrombosis is one such complication which can give rise to thrombosis of the peripheral vasculature in the form of deep vein thrombosis, pulmonary embolism, and splanchnic vein thrombosis. The prevalence of these complications increases with the severity of the disease and adds to the adverse outcomes profile. With better imaging and awareness, more cases are being detected, although many at times it can be an incidental finding. However, it remains understudied and strangely, most of the guidelines on the management of acute pancreatitis are silent on this aspect. This review offers an overview of the incidence, pathophysiology, symptomatology, diagnostic work-up, and management of venous thrombosis that develops in AP.

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References

  1. Samanta J, Dhaka N, Gupta P et al. Comparative study of the outcome between alcohol and gallstone pancreatitis in a high-volume tertiary care center. JGH Open 2019;3:338–343.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review. Jama 2021;325:382–390.

    CAS  PubMed  Google Scholar 

  3. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet 2015;386:85–96.

    Article  PubMed  Google Scholar 

  4. Boxhoorn L, Voermans RP, Bouwense SA et al. Acute pancreatitis. Lancet 2020;396:726–734.

    Article  PubMed  Google Scholar 

  5. Samanta J, Dhar J, Birda CL et al. Dynamics of Serum Procalcitonin Can Predict Outcome in Patients of Infected Pancreatic Necrosis: A Prospective Analysis. Dig Dis Sci 2023;68:2080–2089.https://doi.org/10.1007/s10620-022-07758-4

    Article  CAS  PubMed  Google Scholar 

  6. Mallick IH, Winslet MC. Vascular complications of pancreatitis. Jop 2004;5:328–337.

    PubMed  Google Scholar 

  7. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:e1–15.

  8. Practice guidance for diagnosis and treatment of pancreatitis-related splanchnic vein thrombosis (Shenyang, 2020). J Dig Dis 2021;22:2–8.

  9. Maatman TK, McGuire SP, Lewellen KA et al. Prospective Analysis of the Mechanisms Underlying Ineffective Deep Vein Thrombosis Prophylaxis in Necrotizing Pancreatitis. J Am Coll Surg 2021;232:91–100.

    Article  PubMed  Google Scholar 

  10. Roch AM, Maatman TK, Carr RA et al. Venous Thromboembolism in Necrotizing Pancreatitis: an Underappreciated Risk. J Gastrointest Surg 2019;23:2430–2438.

    Article  PubMed  Google Scholar 

  11. Dorffel T, Wruck T, Ruckert RI et al. Vascular complications in acute pancreatitis assessed by color duplex ultrasonography. Pancreas 2000;21:126–133.

    Article  CAS  PubMed  Google Scholar 

  12. Harris S, Nadkarni NA, Naina HV et al. Splanchnic vein thrombosis in acute pancreatitis: a single-center experience. Pancreas 2013;42:1251–1254.

    Article  PubMed  Google Scholar 

  13. Mortele KJ, Mergo PJ, Taylor HM et al. Peripancreatic vascular abnormalities complicating acute pancreatitis: contrast-enhanced helical CT findings. Eur J Radiol 2004;52:67–72.

    Article  PubMed  Google Scholar 

  14. Easler J, Muddana V, Furlan A et al. Portosplenomesenteric venous thrombosis in patients with acute pancreatitis is associated with pancreatic necrosis and usually has a benign course. Clin Gastroenterol Hepatol 2014;12:854–862.

    Article  PubMed  Google Scholar 

  15. Butler JR, Eckert GJ, Zyromski NJ et al. Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. HPB (Oxford) 2011;13:839–845.

    Article  PubMed  Google Scholar 

  16. Xu W, Qi X, Chen J et al. Prevalence of Splanchnic Vein Thrombosis in Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies. Gastroenterol Res Pract 2015;2015:245460.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Sissingh NJ, Groen JV, Koole D et al. Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A systematic review and meta-analysis. Pancreatology 2022;22:235–243.

    Article  CAS  PubMed  Google Scholar 

  18. Stein PD, Beemath A, Olson RE. Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients. Am J Cardiol 2005;95:1525–1526.

    Article  PubMed  Google Scholar 

  19. Ahmad DS, Mansoor E, Alikhan MM et al. Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study. Pancreas 2021;50:71–76.

    Article  PubMed  Google Scholar 

  20. Trikudanathan G, Umapathy C, Munigala S et al. Venous Thromboembolism Is Associated With Adverse Outcomes in Hospitalized Patients With Acute Pancreatitis: A Population-Based Cohort Study. Pancreas 2017;46:1165–1172.

    Article  PubMed  Google Scholar 

  21. Chung WS, Lin CL. Association between venous thromboembolism and acute pancreatitis: An analysis from the nationwide inpatient sample. Clin Respir J 2020;14:320–327.

    Article  PubMed  Google Scholar 

  22. Fumery M, Xiaocang C, Dauchet L et al. Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: a meta-analysis of observational studies. J Crohns Colitis 2014;8:469–479.

    Article  PubMed  Google Scholar 

  23. Chaudhry H, Sohal A, Bains K et al. Incidence and factors associated with portal vein thrombosis in patients with acute pancreatitis: A United States national retrospective study. Pancreatology 2023;23:350–357.

    Article  PubMed  Google Scholar 

  24. Fei Y, Gao K, Hu J et al. Predicting the incidence of portosplenomesenteric vein thrombosis in patients with acute pancreatitis using classification and regression tree algorithm. J Crit Care 2017;39:124–130.

    Article  PubMed  Google Scholar 

  25. Garg R, Mohammed A, Singh A et al. Mortality Trends, Outcomes, and Predictors of Portal Vein Thrombosis in Acute Pancreatitis Patients: A Propensity-Matched National Study. Dig Dis Sci 2023;68:2674–2682. https://doi.org/10.1007/s10620-023-07945-x

    Article  PubMed  Google Scholar 

  26. Toque L, Hamy A, Hamel JF et al. Predictive factors of splanchnic vein thrombosis in acute pancreatitis: A 6-year single-center experience. J Dig Dis 2015;16:734–740.

    Article  CAS  PubMed  Google Scholar 

  27. Garg PK, Singh VP. Organ Failure Due to Systemic Injury in Acute Pancreatitis. Gastroenterology 2019;156:2008–2023.

    Article  PubMed  Google Scholar 

  28. Samanta J, Singh S, Arora S et al. Cytokine profile in prediction of acute lung injury in patients with acute pancreatitis. Pancreatology 2018;18:878–884.

    Article  CAS  PubMed  Google Scholar 

  29. Dumnicka P, Maduzia D, Ceranowicz P, et al. The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications. Int J Mol Sci 2017;18.

  30. Esmon CT. Crosstalk between inflammation and thrombosis. Maturitas 2004;47:305–314.

    Article  CAS  PubMed  Google Scholar 

  31. Cuthbertson CM, Christophi C. Disturbances of the microcirculation in acute pancreatitis. Br J Surg 2006;93:518–530.

    Article  CAS  PubMed  Google Scholar 

  32. Foitzik T, Eibl G, Hotz B et al. Persistent multiple organ microcirculatory disorders in severe acute pancreatitis: experimental findings and clinical implications. Dig Dis Sci 2002;47:130–138. https://doi.org/10.1023/A:1013284008219

    Article  CAS  PubMed  Google Scholar 

  33. Zhou ZG, Chen YD. Influencing factors of pancreatic microcirculatory impairment in acute panceatitis. World J Gastroenterol 2002;8:406–412.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Lasson A, Ohlsson K. Consumptive coagulopathy, fibrinolysis and protease-antiprotease interactions during acute human pancreatitis. Thromb Res 1986;41:167–183.

    Article  CAS  PubMed  Google Scholar 

  35. Ranson JH, Lackner H, Berman IR et al. The relationship of coagulation factors to clinical complications of acute pancreatitis. Surgery 1977;81:502–511.

    CAS  PubMed  Google Scholar 

  36. Thatipelli MR, McBane RD, Hodge DO et al. Survival and recurrence in patients with splanchnic vein thromboses. Clin Gastroenterol Hepatol 2010;8:200–205.

    Article  PubMed  Google Scholar 

  37. Samanta J, Rana A, Dhaka N et al. Ascites in acute pancreatitis: not a silent bystander. Pancreatology 2019;19:646–652.

    Article  PubMed  Google Scholar 

  38. Connor S, Alexakis N, Raraty MG et al. Early and late complications after pancreatic necrosectomy. Surgery 2005;137:499–505.

    Article  CAS  PubMed  Google Scholar 

  39. Gonzelez HJ, Sahay SJ, Samadi B et al. Splanchnic vein thrombosis in severe acute pancreatitis: a 2-year, single-institution experience. HPB (Oxford) 2011;13:860–864.

    Article  PubMed  Google Scholar 

  40. Geersing GJ, Zuithoff NP, Kearon C et al. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. Bmj 2014;348:g1340.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Hendriksen JM, Geersing GJ, Lucassen WA et al. Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care. BMJ 2015;351:h4438.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Lucassen W, Geersing GJ, Erkens PM et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011;155:448–460.

    Article  PubMed  Google Scholar 

  43. Silveira PC, Ip IK, Goldhaber SZ et al. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med 2015;175:1112–1117.

    Article  PubMed  Google Scholar 

  44. Chopard R, Albertsen IE, Piazza G. Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review. JAMA 2020;324:1765–1776.

    Article  PubMed  Google Scholar 

  45. Riva N, Ageno W, Schulman S et al. Clinical history and antithrombotic treatment of incidentally detected splanchnic vein thrombosis: a multicentre, international prospective registry. Lancet Haematol 2016;3:e267–e275.

    Article  PubMed  Google Scholar 

  46. Zhang DL, Hao JY, Yang N. Value of D-dimer and protein S for diagnosis of portal vein thrombosis in patients with liver cirrhosis. J Int Med Res 2013;41:664–672.

    Article  CAS  PubMed  Google Scholar 

  47. Cudnik MT, Darbha S, Jones J et al. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med 2013;20:1087–1100.

    Article  PubMed  Google Scholar 

  48. Bala M, Catena F, Kashuk J et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022;17:54.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Alpern MB, Rubin JM, Williams DM et al. Porta hepatis: duplex Doppler US with angiographic correlation. Radiology 1987;162:53–56.

    Article  CAS  PubMed  Google Scholar 

  50. Finn JP, Kane RA, Edelman RR et al. Imaging of the portal venous system in patients with cirrhosis: MR angiography vs duplex Doppler sonography. AJR Am J Roentgenol 1993;161:989–994.

    Article  CAS  PubMed  Google Scholar 

  51. Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–111.

    Article  PubMed  Google Scholar 

  52. Gupta P, Kamat R, Samanta J et al. Computed Tomography Findings in Intraabdominal Hypertension in Patients with Acute Pancreatitis. Indian J Radiol Imaging 2021;31:150–156.

    PubMed  PubMed Central  Google Scholar 

  53. Harward TR, Green D, Bergan JJ et al. Mesenteric venous thrombosis. J Vasc Surg 1989;9:328–333.

    Article  CAS  PubMed  Google Scholar 

  54. Vogelzang RL, Gore RM, Anschuetz SL et al. Thrombosis of the splanchnic veins: CT diagnosis. AJR Am J Roentgenol 1988;150:93–96.

    Article  CAS  PubMed  Google Scholar 

  55. Schieda N, Fasih N, Shabana W. Triphasic CT in the diagnosis of acute mesenteric ischaemia. Eur Radiol 2013;23:1891–1900.

    Article  PubMed  Google Scholar 

  56. Srisajjakul S, Prapaisilp P, Bangchokdee S. Comprehensive review of acute small bowel ischemia: CT imaging findings, pearls, and pitfalls. Emerg Radiol 2022;29:531–544.

    Article  PubMed  Google Scholar 

  57. Bradbury MS, Kavanagh PV, Bechtold RE et al. Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics 2002;22:527–541.

    Article  PubMed  Google Scholar 

  58. Yano T, Kodama T, Suzuki Y et al. Gadolinium-enhanced 3D time-of-flight MR angiography. Experimental and clinical evaluation. Acta Radiol 1997;38:47–54.

    CAS  PubMed  Google Scholar 

  59. Cakmak O, Elmas N, Tamsel S et al. Role of contrast-enhanced 3D magnetic resonance portography in evaluating portal venous system compared with color Doppler ultrasonography. Abdom Imaging 2008;33:65–71.

    Article  PubMed  Google Scholar 

  60. Caletti G, Brocchi E, Baraldini M et al. Assessment of portal hypertension by endoscopic ultrasonography. Gastrointest Endosc 1990;36:S21–S27.

    Article  CAS  PubMed  Google Scholar 

  61. Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023;15:216–239.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Samanta J, Dhar J, Muktesh G et al. Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis. Expert Rev Gastroenterol Hepatol 2022;16:297–305.

    Article  CAS  PubMed  Google Scholar 

  63. Samanta J, Nabi Z, Facciorusso A et al. EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis. Liver Int 2023;43:1783–1792.

    Article  CAS  PubMed  Google Scholar 

  64. Besselink MG. Splanchnic vein thrombosis complicating severe acute pancreatitis. HPB (Oxford) 2011;13:831–832.

    Article  PubMed  Google Scholar 

  65. Leppäniemi A, Tolonen M, Tarasconi A et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019;14:27.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Pezzilli R, Zerbi A, Campra D et al. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis 2015;47:532–543.

    Article  PubMed  Google Scholar 

  67. Garcia-Pagán JC, Hernández-Guerra M, Bosch J. Extrahepatic portal vein thrombosis. Semin Liver Dis 2008;28:282–292.

    Article  PubMed  Google Scholar 

  68. Hall TC, Garcea G, Metcalfe M et al. Management of acute non-cirrhotic and non-malignant portal vein thrombosis: a systematic review. World J Surg 2011;35:2510–2520.

    Article  CAS  PubMed  Google Scholar 

  69. Valeriani E, Di Nisio M, Riva N et al. Anticoagulant therapy for splanchnic vein thrombosis: a systematic review and meta-analysis. Blood 2021;137:1233–1240.

    Article  CAS  PubMed  Google Scholar 

  70. Norton W, Lazaraviciute G, Ramsay G et al. Current practice of anticoagulant in the treatment of splanchnic vein thrombosis secondary to acute pancreatitis. Hepatobiliary Pancreat Dis Int 2020;19:116–121.

    Article  CAS  PubMed  Google Scholar 

  71. Hajibandeh S, Hajibandeh S, Agrawal S et al. Anticoagulation Versus No Anticoagulation for Splanchnic Venous Thrombosis Secondary to Acute Pancreatitis: Do We Really Need to Treat the Incidental Findings? Pancreas 2020;49:e84–e85.

    Article  CAS  PubMed  Google Scholar 

  72. Garret C, Péron M, Reignier J et al. Risk factors and outcomes of infected pancreatic necrosis: Retrospective cohort of 148 patients admitted to the ICU for acute pancreatitis. United European Gastroenterol J 2018;6:910–918.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Pagliari D, Cianci R, Brizi MG et al. Anticoagulant therapy in the treatment of splanchnic vein thrombosis associated to acute pancreatitis: a 3-year single-centre experience. Intern Emerg Med 2020;15:1021–1029.

    Article  PubMed  Google Scholar 

  74. Junare PR, Udgirkar S, Nair S et al. Splanchnic Venous Thrombosis in Acute Pancreatitis: Does Anticoagulation Affect Outcome? Gastroenterology Res 2020;13:25–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. K T, Chan SJ, Varghese C, et al. A selective anticoagulation policy for splanchnic vein thrombosis in acute pancreatitis is associated with favourable outcomes: experience from a UK tertiary referral centre. HPB (Oxford) 2022;24:1937–1943.

  76. Al-Azzawi Y, Mahmoud M, Holzwanger EA, et al. The Predictor Factors of Portal Vein Thrombosis in Pancreatitis Patients: 15. Official journal of the American College of Gastroenterology| ACG 2017;112:S8-S9.

  77. Anderson W, Niccum B, Chitnavis M, et al. Outcomes of anticoagulation for portal and/or splenic vein thrombosis in setting of acute pancreatitis: 11. Official journal of the American College of Gastroenterology| ACG 2017;112:S6.

  78. Robbins AJ, Lusczek E, Bellin MD et al. Thromboembolic Complications in the First Year After Acute Pancreatitis Diagnosis. Pancreas 2021;50:751–755.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Sogaard KK, Astrup LB, Vilstrup H et al. Portal vein thrombosis; risk factors, clinical presentation and treatment. BMC Gastroenterol 2007;7:34.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Ageno W, Riva N, Schulman S et al. Long-term Clinical Outcomes of Splanchnic Vein Thrombosis: Results of an International Registry. JAMA Intern Med 2015;175:1474–1480.

    Article  PubMed  Google Scholar 

  81. De Gottardi A, Trebicka J, Klinger C et al. Antithrombotic treatment with direct-acting oral anticoagulants in patients with splanchnic vein thrombosis and cirrhosis. Liver Int 2017;37:694–699.

    Article  PubMed  Google Scholar 

  82. Haage P, Krings T, Schmitz-Rode T. Nontraumatic vascular emergencies: imaging and intervention in acute venous occlusion. Eur Radiol 2002;12:2627–2643.

    Article  PubMed  Google Scholar 

  83. Di Nisio M, van Es N, Büller HR. Deep vein thrombosis and pulmonary embolism. Lancet 2016;388:3060–3073.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Gastroenterology, Post Graduate Institute of Medical College and Research, Chandigarh, India

    Jayanta Samanta & Rakesh Kochhar

  2. Department of Gastroenterology, Sohana Hospital, Mohali, Punjab, India

    Jahnvi Dhar

  3. Department of Radiodiagnosis, Post Graduate Institute of Medical College and Research, Chandigarh, India

    Pankaj Gupta

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JS contributed toward conception and data search, interpretation of the data, drafting the work, and final approval. JD and PG contributed toward data acquisition, interpretation of the data, review of the manuscript, and final approval. RK contributed toward conception and design, interpretation of the data, review of the manuscript, and final approval.

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Correspondence to Rakesh Kochhar.

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Samanta, J., Dhar, J., Gupta, P. et al. Venous Thrombosis in Acute Pancreatitis: What to and Not to Do?. Dig Dis Sci (2024). https://doi.org/10.1007/s10620-024-08418-5

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