Optimal treatment strategies for hepatic portal venous gas:A retrospective assessment

BACKGROUND Hepatic portal venous gas(HPVG)generally indicates poor prognoses in patients with serious intestinal damage.Although surgical removal of the damaged portion is effective,some patients can recover with conservative treatments.AIM To establish an optimal treatment strategy for HPVG,we attempted to generate computed tomography(CT)-based criteria for determining surgical indication,and explored reliable prognostic factors in non-surgical cases.METHODS Thirty-four cases of HPVG(patients aged 34-99 years)were included.Necessity for surgery had been determined mainly by CT findings(i.e.free-air,embolism,lack of contrast enhancement of the intestinal wall,and intestinal pneumatosis).The clinical data,including treatment outcomes,were analyzed separately for the surgical cases and non-surgical cases.RESULTS Laparotomy was performed in eight cases(surgical cases).Seven patients(87.5%)survived but one(12.5%)died.In each case,severe intestinal damage was confirmed during surgery,and the necrotic portion,if present,was removed.Non-occlusive mesenteric ischemia was the most common cause(n=4).Twentysix cases were treated conservatively(non-surgical cases).Surgical treatments had been required for twelve but were abandoned because of the patients’poor general conditions.Surprisingly,however,three(25%)of the twelve inoperable patients survived.The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments,and only one patient(7%)died.Comparative analyses of the fatal(n=10)and recovery(n=16)cases revealed that ascites,peritoneal irritation signs,and shock were significantly more frequent in the fatal cases.The mortality was 90%if two or all of these three clinical findings were detected.CONCLUSION HPVG related to intestinal necrosis requires surgery,and our CT-based criteria are probably useful to determine the surgical indication.In non-surgical cases,ascites,peritoneal irritation signs and shock were closely associated with poor prognoses,and are applicable as predictors of patients’prognoses.

Changing common sense:Anti-platelet/coagulation therapy against cirrhosis

Until recently,anti-platelet/coagulation therapy had not been recommended for patients with cirrhosis.Although venous thrombosis is one of the representative complications of cirrhosis and ischemic disorders associated with atherosclerosis are not infrequent in cirrhotic patients,many clinicians have tended to hesitate to introduce anti-platelet/coagulation therapy to their patients.Undoubtedly,this is due to the increased risk of hemorrhagic diathesis in cirrhotic patients.However,accumulating evidence has revealed the benefits of anti-platelet/coagulation therapy for cirrhotic patients.In addition to the safety of the therapy carried out against cardiovascular diseases in cirrhotic patients,some clinical data have indicated its preventive effect on venous thrombosis.Moreover,the efficacy of antiplatelet/coagulation therapy against cirrhosis itself has been demonstrated both clinically and experimentally.The conceptual basis for application of anti-platelet/coagulation therapy against cirrhosis was constructed through two pathologic studies on intrahepatic thrombosis in cirrhotic livers.It may be better to use thrombopoietinreceptor agonists,which have been tested as a treatment for cirrhosis-related thrombocytopenia,in combination with anti-platelet drugs to reduce the risk of venous thrombosis.During the last decade,the World Journal of Gastroenterology,a sister journal of World Journal of Hepatology,has been one of the main platforms of active discussion of this theme.