Splanchnic Vein Thrombosis In Patients With Severe Acute Pancreatitis And Risk Factors Together With Predictive Model For Sinistral Portal Hypertension

Nowadays,severe acute pancreatitis onset suddenly,condition critically,progress rapidly,with lots complications.Splanchnic vein thrombosis is one of the vascular complications of severe acute pancreatitis,moreover,patients with severe acute pancreatitis complicated by splanchnic venous thrombosis are more seriously and have a higher mortality rate.Severe acute pancreatitis-related splanchnic venous thrombosis mostly occurs in the late stage of acute pancreatitis.In recent years,with the advancement of medical technology,more and more splanchnic venous thrombosis has been detected in the early stage of acute pancreatitis,although,radiology diagnosis plays an important role in its diagnosis there are few related studies.Due to the special adjacent relationship between the splenic vein and the pancreas,splanchnic vein thrombosis caused by acute pancreatitis mainly involves the splenic vein.Splenic vein thrombosis will further block the passage of splenic blood back to the portal vein,resulting in sinistral portal hypertension.Sinistral portal hypertension has a certain risk of fatal gastrointestinal bleeding and is one of the important predisposing factors for the death of patients with acute pancreatitis.However,there are still many unsolved questions.First,previous studies have mostly focused on the relationship between clinical and laboratory results of patients with severe pancreatitis and splanchnic venous thrombosis,while a large number of clinical imaging data have not been fully studied.Whether the imaging features of patients with severe pancreatitis are associated with early splanchnic venous thrombosis remains unclear.Second,due to the intentional or unintentional neglect of early splanchnic vein thrombosis in clinical work,patients with severe pancreatitis are often complicated with sinistral portal hypertension and collateral varices in the late course of the disease.How the veins are involved and how they change dynamically is still unclear.Third,some patients with severe acute pancreatitis complicated by sinistral portal hypertension may die due to gastrointestinal bleeding.It is feasible to establish a predictive model to predict the occurrence of sinistral portal hypertension.Fourth,for asymptomatic pancreatic portal hypertension,there is no unified clinical management plan for the management of patients with portal hypertension at present.Whether we can provide safe and effective management suggestions.In view of the above problems,the purpose of this paper is to clinically predict the early splanchnic venous thrombosis and the formation of sinistral portal hypertension in patients with severe pancreatitis,and to intervene and control the risk factors as early as possible.This essay was divided into the following two parts.Part 1:Image features and risk factors of splanchnic vein thrombosis in patients with early-stage severe acute pancreatitisObjective: To investigate the incidence and risk factors of splanchnic vein thrombosis(SVT)in the early stage of severe acute pancreatitis(SAP).Methods: Patients with SAP in The First Affiliated Hospital of Nanchang University from January 1,2014 to December 31,2016 were retrospectively reviewed.All contrast-enhanced computed tomography(CECT)studies were reassessed and reviewed by a senior doctor who is expert in subspecialty of digestive diseases.Clinical outcome measures were compared between SAP patients with and without SVT in the early stage of the disease.Univariate and multivariate logistic regression analyses were sequentially performed to assess potential risk factors for the development of SVT in SAP patients.A receiver operating characteristic(ROC)curve was generated for the qualifying independent risk factors.Results: Twenty-five of the one hundred and forty(17.86%)SAP patients developed SVT 6.19 ± 2.43 d after acute pancreatitis(AP)onset.Multivariate stepwise logistic regression analyses showed that Balthazar’s CT severity index(CTSI)scores [odds ratio(OR): 2.742;95% confidence interval(CI): 1.664-4.519;P < 0.001],gastrointestinal wall thickening(OR: 4.367,95%CI: 1.218-15.658;P=0.024)and hypoalbuminemia(serum albumin level<25 g/L)(OR: 32.573;95%CI:2.711-391.353;P=0.006)were independent risk factors for SVT developed in patients with SAP.The area under the ROC curve for Balthazar’s CTSI scores was 0.777(P<0.001),the sensitivity was 52%,and the specificity was 93% at a cut-off value of 5.5.Conclusion: High Balthazar’s CTSI scores,gastrointestinal wall thickening and hypoalbuminemia are independent risk factors for SVT developed in the early stage of SAP.Part 2:Dynamic changes and nomogram prediction for sinistral portal hypertension in moderate and severe acute pancreatitisObjectives: To investigate the dynamic changes in gastric varices in patients with acute pancreatitis(AP)and to develop a novel nomogram for the early prediction of sinistral portal hypertension(SPH).Methods: This was a retrospective,case-control study.Patients with moderate severe acute pancreatitis and severe acute pancreatitis in The First Affiliated Hospital of Nanchang University from January 1,2015 to October 31,2019 were retrospectively reviewed.All contrast-enhanced computed tomography(CECT)studies were reassessed in order to clarify involvement and dynamic changes of collateral varices in SPH patients.Patients with and without SPH were matched 1:1for age.Multivariate logistic regression was employed to determine the independent risk factors for SPH,furthermore to establish a nomogram for predicting SPH.Results: The SPH group(n=94)and non-SPH group(n=94)were matched for age.The dynamic changes showed an increasing trend in the diameter of gastric fundus,short gastric,gastric coronary,and gastroepiploic varices,which did not recover during the one-year follow-up.Multivariate analysis showed that male(adjusted odds ratio(adj OR),8.71;95% confidence interval(CI),2.86-26.53;P<0.001),body mass index ≥27.5 kg/m2(adj OR,5.49;95% CI,1.85-16.29;P=0.002),prothrombin time ≥12.6 seconds(adj OR,2.82;95% CI,1.11-7.17;P=0.03),and the patency of splenic vein(stenosis(adj OR,8.48;95% CI,2.13-33.71;P=0.002),and occlusion(adj OR,34.57;95% CI,10.87-110.00;P < 0.001)were independently associated with the development of SPH.The nomogram incorporating these factors demonstrated good discrimination,calibration and clinical utility.The area under the curve(AUC)was as high as 0.92(95% CI,0.87-0.95).Conclusions: CECT can reflect the dynamic changes of SPH collateral varices objectively,which is helpful for early and accurate diagnosis of SPH.The dynamic changes in collateral varices in SPH are long-term and slowly progressing,and a simple nomogram tool helps in the early,accurate prediction of SPH.A flexible follow-up plan with radiology examination is suggested in males and in obese patients with abnormal splenic veins and coagulopathies.