الفهرس 
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Abstract
It has now been proven that a state of hypercoagulability can coexist with cirrhosis. This state manifests in micro vascular and macro vascular thrombosis which is rarely attributed to this condition. Parallel to these findings it has been postulated that the coagulation system in cirrhotic patients is in a state of “rebalance”. The tests that are normally used to evaluate coagulation balances are centered on the procoagulant abnormalities, they do not show this“rebalance”and should be not considered useful tools for the prediction of bleeding or other thrombotic complications. Contrast-enhanced abdominal CT is the diagnostic test of choice for MVT and may allow identification of MVT before intestinal infarction and at a time when anticoagulation may obviate severe ischemic damage. In this study we reported our experience regarding the risk factors and management of acute MVT in cirrhotic patients. We reported thirty patients who had liver cirrhosis and presented with acute MVT in the surgical department, National Liver Institute, Menoufiya University from January 2010 to March 2015. They were 22 males (73.3%) & 8 females (26.6%) ,with mean age 54 ± 12.85 (range 13 - 72 years). The causes of liver cirrhosis were: HCV in 22 patients (73.33%), HBV in 2 patients (6.66% ), HCV &HBV in 2 patients (6.66%), and data wasn’t available in 4 patients. 13 patients (43.3%) were Child B, and 12 patients (40%) were Child A, 5patients (16.6%) were Child C .
Summary
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Seventeen patients (56.6% ) presented with normal count of platelets , while 3 patients (10%) presented with thrombocytosis and 10 patients (33.3%) presented with thrombocytopenia. There were 12 patients (40%) with INR from 1.2 to 1.7, two patients (6.6%) had their INR from 1.7 to 2.5, and 3 patients (10%) had INR above 2.5. Protein C was measured in 15 patients; 11 patients (73.3%) had levels which are below normal ( n=70-160%) . And the other 4 patients (26.6%) were within normal range. Triphasic CT abdomen and pelvis was done in 18 patients (60%). It revealed; six patients (30%) had thrombosis in SMV, SV and PV , seven patients (30%) had thrombosed SMV and PV, while five patients (16.6%) had thrombosis of SMV only. CT scan revealed congested and edematous loops of small intestine in nine patients (50%), and gangrenous loops in nine patients (50%). Nine patients (30%) underwent conservative treatment. Twenty one patients (70%) were explored surgically; resection and primary anastomosis was done in 19 patients (90%), while ileostomy was done in one patient (4.7%) due to infection, as the bowel was perforated and abdomen was full of pus and intestinal content, and one patient (4.7%) had only congested bowel loop that underwent conservative treatment without resection The length of resected gangrenous loops was 76.7 ±119cm (range 20 - 250 cm). Two patients underwent second look, and none of them needed more resection. All patients whether underwent conservative or surgical treatment received LMWH during hospital stay, and discharged on oral anticoagulant for 6 months.
Summary
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Thirteen patients (62%) had early post operative complications -out of
21patient who underwent surgical exploration- cases: Four patients (19%) had
Systemic Inflammatory Response Syndrome (SIRS) and sepsis, Five patients
(23%) had septic shock , two patients (10%) had severe chest infections, Eleven
patients (52%) suffered from hepatic decompensation; two patients (10%) had
hepatic encephalopathy, and three patients (14%) had hematemesis and melena.
One patient (5%) had splenic abscess.
The mean hospital stay for the surgical group was 11.5±7 (range 6-25
days). While hospital stay for the conservatively treated group was 10± 6 (range 7-
17days).
Two patients ( 6.6%) had recurrent symptoms of acute MVT, and they were
readmitted and one of them was managed conservatively and the other one was
explored surgically, and underwent resection.
The overall mortality was 12 patients (40%) due to acute MVT. Seven
patients (23.3%) died during the hospital course. While 5 patients (16.6%) died
early after discharge.
The 1- , 2- , and 3-year total survival rates were 60%. The 1-,2-, and 3-year
survival rates of patients who underwent conservative treatment (9 patients)
were 55.6%. The perioperative mortality was 6 patients (28.5%) out of 21
patients who underwent surgical exploration, and the 1-, 2-, and 3-year survival
rates of patients who underwent surgical treatment were 61.9%.
Factors that affectd patients’ survival were; Child and MELD scores, INR,
low protein C level, leukocytosis, metabolic acidosis, and bleeding per rectum
and /or melena at presentation.
Conclusions and Recommendations
115
Conclusions and Recommendations -The cirrhotic patient might have hypercoagulable states, and the usual laboratory tests for coagulation don’t accurately assess the coagulation status of the cirrhotic patient, and for thus further studies should be directed towards diagnosis of the actual defect in the coagulation system. - Mesenteric venous thrombosis is a very challenging surgical condition regarding diagnosis and management. - The diagnosis of MVT is often overlooked and delayed, and one key to its prompt diagnosis is clinical suspicion, so Physicians must be aware of MVT in their differential diagnosis in order not to miss this serious condition. -CT scan with portal phase or MRI are the gold standard diagnostic modalities for MVT; it can give information about the level of thrombus as well as the status of bowel loops. -Early diagnosis can give a better chance for conservative treatment and improves the outcome. - Conservative treatment by early anticoagulant therapy, to prevent further propagation of thrombosis, is planned for patients without signs of peritonitis and no evidence of bowel gangrene by CT scan. - Close follow up to the patients who undergo conservative treatment is necessary, and when any peritoneal signs or radiological findings that suggest infarction are present, we can proceed to surgical exploration for the patient. -The aim of surgery is to conserve as much bowel as we can, for fear of further ischemia and resection to prevent short bowel syndrome.
Conclusions and Recommendations
116
-The second look is not a routine after first exploration, and it should be done only when needed, guided by clinical, laboratory, and the images findings of the patient after the exploration. -Early post operative anticoagulation is mandatory. It decreases the incidence of recurrent attack of acute MVT, and it should be for at least 6 months postoperative with adjusted level of INR. -MVT still has a high perioperative mortality rate especially in cirrhotic patients. The Child and MELD scores, low protein C level, metabolic acidosis, and leukocytosis are risk factors for survival in cirrhotic patients with MVT. -Further studies should be done about feasibility of endovascular treatment in patients with early MVT. - Giving anti oxidants to patients with acute mesenteric ischemia before reperfusion, should be considered. - We should consider team work approach (there is no ” I ” in team work)