Systemic thrombolysis of portal vein thrombosis in cirrhotic patients: a pilot study.

BACKGROUND: Portal vein thrombosis is a frequent complication in liver cirrhosis. Encouraging reports of systemic thrombolysis in non-cirrhotic patients suffering from acute portal vein thrombosis led us to start a pilot study on the efficacy and safety of systemic low dose recombinant tissue plasminogen activator (Actilyse, Boheringer Ingelheim, Florence, Italy). PATIENTS: Nine cirrhotic patients (6 males and 3 females) with recent portal vein thrombosis were enrolled. Exclusion criteria were portal cavernomatosis, recent (30 days) surgery, active bleeding, hepatocellular carcinoma and cancer in other sites. METHODS: All cases were treated for a maximum of 7 days by continuous i.v. infusion of 0.25mg/kg/die of r-tPA plus subcutaneous low molecular weight heparin. Efficacy was evaluated by colour doppler sonography monitoring and confirmed by contrast enhanced computerized tomography. RESULTS: The combined r-tPA/LMWH treatment was well tolerated without clinically significant side effects. Complete resolution of thrombosis occurred in 4 cases, partial regression in 4 and none in 1. Retreatment of a complete recurrence in 1 patient was successful. Variceal pressure dropped from 30.7+/-4.5 mmHg to 21.2+/-6.6 mmHg (p=0.012). CONCLUSIONS: Our preliminary data demonstrate that thrombolytic treatment of recent portal vein thrombosis with i.v. r-tPA and LMWH in patients with cirrhosis appears to be safe and effective and can significantly reduce pressure in oesophageal varices.

[Treatment for Helicobacter pylori: current criteria]. / Terapia dell'infezione da Helicobacter pylori. Attuali criteri.

H. pylori eradication following standard triple therapies is decreasing worldwide, mainly due to an increased prevalence of bacterial resistance against antibiotics. Therefore, to cure such an infection remains a challenge for clinicians. This paper aimed to review the currently available therapeutic approaches, for which large and consistent data exist in literature, in order to update H. pylori management in the clinical practice. According to the updated European Guidelines, the first-line therapy should be chosen based on the prevalence of clarithromycin resistance. A 7-day triple therapy should be employed if clarithromycin resistance is lower than 15-20%, whilst this regimen should be prolonged to 14 days where resistance is higher. A 7-day quadruple therapy is suggested as second-line treatment. However, quadruple therapy is no more available in Italy. According to the forthcoming Italian Guidelines, a new "therapeutic package" could be used, including a 10-day sequential regimen as first-line therapy and a 10-day levofloxacin-based regimen as re-treatment. The sequential regimen (5-day dual plus 5-day triple therapy) achieved an eradication rate constantly >90% in several Italian studies, being more effective than standard triple therapy, even in patients with clarithromycin resistant strains.

Evaluation of D-dimer and factor VIII in cirrhotic patients with asymptomatic portal venous thrombosis.

D-dimer and factor VIII levels raise in advanced cirrhosis. We investigated the behavior and the diagnostic usefulness of D-dimer and factor VIII in cirrhotic patients with asymptomatic portal venous thrombosis. Factor VIII coagulant and D-dimer values were measured in 136 consecutive outpatients with stable cirrhosis divided according to Child-Pugh (CP) classification, who underwent color/power ultrasonography to detect portal thrombosis. Portal thrombosis was found in 33 patients (24.2%). In patients without thrombosis, factor VIII was significantly higher in CP class C compared with class A and B. Conversely, class C patients with portal thrombosis had lower factor VIII levels than those without thrombosis. In both groups, D-dimer was significantly increased in class C compared with class A and B. In class C, thrombotic patients showed higher D-dimer values than did patients without thrombosis. In class C, a D-dimer value > or = 0.55 microg/mL provided a sensitivity and a negative predictive value for portal thrombosis of 100%, and a factor VIII coagulant level < or = 80% showed a specificity and a negative predictive value of 76% and 84%, respectively. In class B, a D-dimer value > or = 0.225 microg/mL had a sensitivity of 89% and a negative predictive value of 82%. In conclusion, our study shows that factor VIII values increase in severe cirrhosis but significantly decrease in the presence of concomitant portal thrombosis, likely because of consumption during thrombosis; D-dimer is enhanced by both liver failure and portal thrombosis; in severe cirrhosis, normal D-dimer and factor VIII values may safely exclude the presence of asymptomatic portal thrombosis.