DAY 3 - Acute and Chronic Vascular Disorders of the Liver – Role of Anticoagulation

Updated recommendations are changing how doctors manage hepatic vascular diseases. At the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting in Philadelphia, Pennsylvania, Dr. Simona Jakab, Chief of Klatskin Liver Inpatient Service at Yale New Haven Health, presented updated guideline-based recommendations for the diagnosis and management of portal vein thrombosis (PVT), Budd-Chiari syndrome, and veno-occlusive diseases. Dr. Jakab stated, "I will discuss the role of anticoagulation for the most common acute and chronic vascular disorders that you can encounter in your practice. Hopefully, by the end of the presentation, you will have a better idea of implementing guideline-based recommendations for managing these disorders."

She focused on what gastroenterologists need to know about the critical role of various factors in diagnosing these three vascular diseases. Dr. Jakab explained why traditional laboratory measures such as Prothrombin Time, Partial Thromboplastin Time, and platelet count do not adequately capture hemostatic changes in cirrhosis. She discussed the choice of anticoagulants for patients with and without cirrhosis, as well as the duration of anticoagulant therapy.

"Ten years ago, we were quite reluctant to anticoagulate some liver cirrhosis patients, but now, as you can see, there are many nuances in treatment, and anticoagulation will be recommended in most patients," Dr. Jakab noted. 

Regarding screening for PVT in cirrhosis, Dr. Jakab explained that it remains an ongoing topic of discussion. While the American Association for the Study of Liver Diseases (AASLD) recommends monitoring portal vein thrombosis, especially in liver transplant candidates, the American Gastroenterological Association (AGA) considers its clinical benefit uncertain. "But if you choose to monitor for portal vein thrombosis, we are better off with cross-sectional imaging as ultrasound has a very high false positive rate," advised Dr. Jakab.

For Budd-Chiari syndrome, Dr. Jakab stated, "Budd-Chiari syndrome should be suspected if acute or chronic liver disease occurs without an obvious cause." She presented a patient study illustrating key aspects of disease presentation, imaging, evaluation, and stepwise management, outlining a treatment approach beginning with systemic anticoagulation, followed by interventional radiology angioplasty or transjugular intrahepatic portosystemic shunt if medical therapy fails.

Regarding veno-occlusive disease, Dr. Jakab introduced its new nomenclature: sinusoidal obstruction syndrome (SOS), caused by high-dose myeloablative chemotherapy regimens used before hematopoietic stem cell transplantation. She emphasized the importance of identifying high-risk patients in collaboration with hematologists, as prophylaxis can help decrease the occurrence of SOS. Crucially, Dr. Jakab clarified, "In terms of treatment, there is really no role for anticoagulation, and defibrotide is what is considered for these patients."

This comprehensive presentation offered practical guidance for clinicians dealing with these challenging hepatic vascular disorders.