Treatment of acute exacerbation of liver-cirrhosis-associated portal vein thrombosis with direct-acting oral anticoagulant, edoxaban, used as an initial treatment in the early postoperative period after abdominal surgery: a case report

Abstract

Background: Cirrhosis-associated portal vein thrombosis (CA-PVT) has been reportedly observed in 5-30% of cirrhotic patients. Moreover, the acute exacerbation of CA-PVT is likely to occur after certain situations, such as a status after abdominal surgery. Safety and efficacy of the direct-acting oral anticoagulant (DOAC) used for cirrhotic patients have been being confirmed. However, use of the DOAC as an initial treatment for CA-PVT appears still challenging especially in the early postoperative period after major surgery in terms of unestablished efficacy and safety in such occasion.

Case presentation: We herein report a case of the acute exacerbation of CA-PVT in the early postoperative period after abdominal surgery, which was successfully treated with DOAC, edoxaban used as an initial treatment. The patient was a 79-year-old Japanese male with alcoholic cirrhosis. The patient suffered choledocholithiasis and had a mural chronic CA-PVT extending from the superior mesenteric vein to the portal trunk. He underwent open cholecystectomy and choledochotomy. Early postoperative clinical course was uneventful except for abdominal distension due to ascites diagnosed on postoperative day (POD)7 when hospital discharge was planned. Contrast enhancement computed tomography (CE-CT) taken on POD 7 revealed the exacerbation of the CA-PVT. Despite recommendation for extension of hospital admission with low molecular weight heparin treatment, the patient strongly hoped to be discharged. Unwillingly, we selected DOAC, edoxaban, as an initial treatment, which was commenced the day after discharge (POD8). As a result, the remarkable improvement of the exacerbated CA-PVT was confirmed by the CE-CT taken on POD21. Any bleeding complications were not observed. Although a slight residue of the CA-PVT remains, the patient is currently doing well 4 years after surgery and is still receiving edoxaban. Any adverse effects of edoxaban have not been observed for 4 years.

Conclusions: A case of successful treatment of the acute exacerbation of CA-PVT with edoxaban was reported. Moreover, edoxaban has been safely administered in a cirrhotic patient for 4 years. The findings obtained from the present case suggest that DOAC can be used as an initial treatment for CA-PVT even in early postoperative period after major abdominal surgery.

Keywords: Direct-acting oral anticoagulant; Early postoperative period after major abdominal surgery; Edoxaban; Liver cirrhosis; Portal vein thrombosis.

Fig. 1

Findings of preoperative abdominal contrast-enhanced computed tomography regarding the choledocholithiasis and the endoscopically inserted biliary drainage tube. Several gallstones existed in the gallbladder and common bile duct (CBD). Maximum stone with 3cm in diameter was observed in CBD (White arrows). Furthermore, distal end of the endoscopically inserted biliary drainage tube penetrated through the duodenum to the cecum (White arrowheads). (Ce cecum; and Du duodenum)

Fig. 2

Findings of the portal vein thrombosis in the preoperative period. The portal vein thrombosis (PVT) (White arrowheads) extended from the superior mesenteric vein (d) to the portal trunk (b). Although the PVT caused considerable stenosis at the level of the confluence of the superior mesenteric vein and the splenic vein (c), it did not reach the bifurcation of the right and left portal veins (a)

Fig. 3

Findings of the portal vein thrombosis on postoperative day 8. Exacerbation of the portal vein thrombosis (PVT) (White arrowheads) was noticed with the findings of contrast-enhanced computed tomography taken on postoperative day 7. The PVT extended cephalically beyond the bifurcation of the right and left portal veins (a). The stenosis caused by the PVT was deteriorated either in the portal trunk (b) or in the confluence of the superior mesenteric vein and the splenic vein (c). Furthermore, the PVT extended much more caudally compared to the preoperative period (d). (CHD common hepatic duct; and CBD common bile duct)

Fig. 4

Findings of the portal vein thrombosis 20 days after the initiation of edoxaban. The portal vein thrombosis (PVT) (White arrowheads) was markedly shrunk. The cephalic end of the PVT was no longer observed in the right or left portal vein although very small residue was observed in the left portal vein (a). The stenosis caused by the PVT was markedly improved either in the portal trunk (b) or in the confluence of the superior mesenteric vein and the splenic vein (c). Furthermore, the caudal end of the PVT was markedly withdrawn cephalically compared to the prior evaluation (d). (CHD common hepatic duct; and CBD common bile duct)