Portal system thrombosis is one of the complications of portal hypertension in hepatic sclerosis, with an incidence of 6.6% as reported by Japanese scholars; 5.2% (12/233) as shown by Wu Zhiyong in China.
The incidence of portal vein system thrombosis is more likely to occur after splenectomy in patients with portal hypertension, with an incidence of 37.5%-43.5% reported in the domestic literature.
Portal vein system thrombosis refers to thrombosis in the main portal vein, superior mesenteric vein, inferior mesenteric vein or splenic vein. It is not easy to diagnose portal vein system thrombosis before surgery because of its insidious onset and lack of typical clinical symptoms. Most patients must be diagnosed intraoperatively after peritonitis due to upper gastrointestinal bleeding or intestinal strangulation and necrosis.
The portal vein is a branch of.
1. Superior mesenteric vein
2.Inferior mesenteric vein
3.Gastric omental right vein
4.Gastric short vein
5.Spleen vein
6.Coronary vein
7.Superior gastroduodenal vein
8.Inferior gastroduodenal vein
9.Parapancreatic vein
10.Hilar vein
11.Right trunk of portal vein
12.Left trunk of portal vein
13.Mid-colonic vein
Portal hypertension portal venous system is prone to thrombosis due to the following factors.
1.Slowed blood flow, stagnation and even reflux in portal vein.
2.Sclerosis and limited thickening of portal vein wall.
3.The content of pro-coagulant substances such as D-dimer, endotoxin and adhesion substance P-selectin are significantly increased.
4.Decreased anticoagulant substances.
After splenectomy or combined flow dissection surgery, many factors can contribute to portal thrombosis
1. Slower blood flow.
2.Short-term sharp increase in platelet count as well as elevated red blood cells and persistent increase in whole blood and plasma viscosity.
3.Short-term sharp increase in platelet count as well as elevated red blood cells and persistent increase in whole blood and plasma viscosity.
4.The content of coagulation factor VIII and factor VIII-related antigen started to increase on the second day after splenectomy and continued to increase until the eighth day after surgery, while the antithrombin activity decreased on the second to fifth day after surgery and returned to normal on the eighth day, indicating that the blood was in a hypercoagulable state from the second to the eighth day after splenectomy, which was conducive to thrombosis.
5. Splenic vein intima injury.
Clinical manifestations of portal vein system thrombosis
Irregular or persistent fever of unknown origin, nausea, vomiting, epigastric distension, severe abdominal pain. Signs of peritonitis; bloody ascites on abdominal puncture; X-ray examination, pneumatization in the intestinal cavity.
Diagnosis of portal vein system thrombosis
1.Abdominal color Doppler ultrasound
2.CT on portal vein thrombosis and collateral veins
3.Portal venography can make a clear diagnosis.
4. Mesenteric arteriogram
Portal vein system thrombosis treatment
1.Systemic anticoagulation and thrombolytic therapy: It is suitable for incomplete or acute portal vein thrombosis in the early stage (within 1~2 days), but it often requires longer time of medication, and once thrombolytic therapy fails to turn to surgery, it can bring serious bleeding;
Our experience.
Urokinase 200,000 U + 5% GS250 Bid for 3 to 5 days, followed by
100,000U+5% GS250 Bid 3~5 days
Low molecular heparin calcium 4000UΘ Bid
Earth kinase 3 tablets Tid
Enteric aspirin 0.30 Qd
Pansentin 50mg Tid
2.Interventional treatment technique, “endovascular thrombectomy” for portal vein thrombosis by TIPS.
3.Surgical thrombectomy.
Mesenteric vein thrombosis
Early thrombectomy is feasible, late intestinal necrosis must be operated.
Platelets and other coagulation factors are destroyed in a large amount in the enlarged spleen, and the synthesis of coagulation factors by the liver is reduced, so that patients with hepatic sclerosis and hypersplenism often show bleeding tendency, while the portal venous system is in the coagulation state.
Prevention of portal vein system thrombosis
l. Improvement of surgical methods: secondary splenic tissues should be disconnected, and large ligated tissues should be avoided, i.e., branches of splenic tissues should be ligated one by one, and splenic tissues should not be blocked by clamps.
2. Postoperative patients should be closely monitored for changes in platelets and blood rheology, platelets should be rechecked every other day and blood rheology should be checked once a week. In our recent clinical practice, for postoperative platelets over 300,000, namely, heparin subcutaneous injection and other comprehensive anticoagulation therapy (except for patients after ITP).
3. If platelets exceed 300,000/ml, portal vein ultrasound examination ;
4, post-operative hemostatic drug application restrictions: only for the day of surgery or the first post-operative day cirrhotic patients usually have a bleeding tendency, but the portal venous system shows a tendency to clot.