Malkowski Piotr, Pawlak Jacek, Michalowicz Bogdan, Szczerban Jerzy, Wroblewski Tadeusz, Leowska Elzbieta, Krawczyk Marek
Department of General & Liver Surgery Medical University of Warsaw, Banacha St. 1A., 02-097 Warsaw, Poland.
Hepatogastroenterology. 2003 Nov-Dec;50(54):2098-100.
BACKGROUND/AIMS: The authors present their experience with thrombolytic treatment of "acute" portal thrombosis.
Since 1980, portal thrombosis has been diagnosed in 305 patients treated in our Department. Portal thrombosis, mostly chronic, was associated with liver cirrhosis, Budd-Chiari syndrome, inflammatory and malignant liver tumors, as well as hypercoagulation conditions. In half of the patients the etiology of portal thrombosis remained obscure. Herewith, the authors present a retrospective review of 33 cases of rapidly developing portal thrombosis. Abdominal pain, ascites and jaundice were the most frequent initial symptoms. Time interval from the first symptoms appearance to hospitalization ranged from 8 to 60 days. The acute form of portal thrombosis was confirmed by Doppler sonography, spiral computed tomography and angiography. Sixteen female patients were regularly using oral contraceptives, in 8--portal thrombosis coexisted with the Budd-Chiari syndrome, in another 8--with polycythemia or myeloproliferative disorders and in 1 was observed during acute liver failure following paracetamol ingestion.
Conservative treatment was unsuccessful in the first 5 cases: all of them died from esophageal variceal bleeding and liver failure. The next 28 patients received fibrinolytic treatment with streptokinase (3 cases) or recombinated tissue plasminogen activator. The results of therapy were evaluated on the basis of clinical picture and Doppler sonography monitoring. Rapid improvement of general condition, with Doppler sonography signs of the portal vein recanalization was noted in 10 patients, in all of whom the history of the disease did not exceed 14 days. In 13 patients with the longer history, partial portal vein occlusion persisted, but restored hepatopetal flow was sufficient to assure normal liver function. In the remaining 5 patients, with the history of the disease lasting longer than 30-40 days, the treatment failed and no clinical or Doppler sonography evidence of restoring of the portal flow were demonstrated. Four patients died: 2 from portal rethrombosis, 1 from liver failure and 1 from cerebral stroke (12, 16 months, 3 months and 4 years after therapy, respectively). Twenty-four patients are alive, the time of follow-up ranging from 9 months to 6 years. In 8 cases, five years after portal system recanalization the first symptoms of portal hypertension occurred.
Thrombolytic treatment of acute portal thrombosis, if administered promptly, appears to be the only way to improve, or even restore, the portal system patency.
背景/目的：作者介绍他们对“急性”门静脉血栓形成进行溶栓治疗的经验。
自1980年以来，在我们科室接受治疗的305例患者中诊断出门静脉血栓形成。门静脉血栓形成大多为慢性，与肝硬化、布加综合征、肝脏炎性和恶性肿瘤以及高凝状态有关。半数患者门静脉血栓形成的病因仍不清楚。在此，作者对33例快速进展的门静脉血栓形成病例进行回顾性分析。腹痛、腹水和黄疸是最常见的初始症状。从首次出现症状到住院的时间间隔为8至60天。门静脉血栓形成的急性形式通过多普勒超声、螺旋计算机断层扫描和血管造影得以证实。16例女性患者经常服用口服避孕药，8例门静脉血栓形成与布加综合征并存，另外8例与红细胞增多症或骨髓增殖性疾病并存，1例在服用对乙酰氨基酚后急性肝衰竭期间被观察到。
前5例保守治疗失败：所有患者均死于食管静脉曲张破裂出血和肝衰竭。接下来的28例患者接受了链激酶（3例）或重组组织型纤溶酶原激活剂的溶栓治疗。根据临床表现和多普勒超声监测评估治疗结果。10例患者全身状况迅速改善，多普勒超声显示门静脉再通迹象，所有这些患者的病程均不超过14天。13例病程较长的患者，门静脉部分闭塞持续存在，但恢复的向肝血流足以保证肝功能正常。其余5例病程超过30 - 40天的患者，治疗失败，未显示出门静脉血流恢复的临床或多普勒超声证据。4例患者死亡：2例死于门静脉再血栓形成，1例死于肝衰竭，1例死于脑卒中（分别在治疗后12个月、16个月、3个月和4年）。24例患者存活，随访时间为9个月至6年。8例患者在门静脉系统再通5年后出现门静脉高压的首发症状。
急性门静脉血栓形成的溶栓治疗，如果及时给药，似乎是改善甚至恢复门静脉系统通畅的唯一方法。
