Does a patient with acute pancreatitis and partial splenic vein thrombus, currently on twice-daily Clexane (enoxaparin), require further investigation during admission?

From the Guidelines

Yes, a patient with acute pancreatitis and partial splenic vein thrombus on twice-daily enoxaparin (Clexane) requires further investigation during admission. The patient's current anticoagulation therapy with Clexane is a crucial aspect of management, as it aims to prevent further thrombus formation and potential complications such as gastric varices and portal hypertension 1. Given the patient's condition, it is essential to monitor the thrombus and adjust the anticoagulation therapy as needed.

Key Considerations

• The patient should undergo regular abdominal imaging, preferably with contrast-enhanced CT or MRI, to monitor thrombus progression or resolution before discharge.
• A comprehensive thrombophilia workup, including protein C and S levels, antithrombin III, factor V Leiden mutation, prothrombin gene mutation, and antiphospholipid antibodies, should be considered to guide anticoagulation management.
• Hematology consultation is recommended to determine the optimal duration of anticoagulation therapy, which typically ranges from 3-6 months depending on thrombus resolution and underlying risk factors.
• The patient's renal function should be monitored regularly, with dose adjustments of enoxaparin as needed, typically 1mg/kg twice daily with normal renal function.

Rationale

The presence of a partial splenic vein thrombus in a patient with acute pancreatitis necessitates close monitoring and management to prevent complications. The British Society of Gastroenterology guidelines emphasize the importance of ongoing reassessment and monitoring for life-threatening complications in patients with acute pancreatitis 1. In this context, further investigation during admission is crucial to ensure optimal management and prevent potential complications.

From the Research

Patient Management

• The patient is currently on twice-daily Clexane (enoxaparin) for partial splenic vein thrombus associated with acute pancreatitis 2.
• The use of anticoagulation in patients with acute pancreatitis and splanchnic vein thrombosis (SVT) is not universally agreed upon, with some studies suggesting that it may increase the risk of bleeding complications 3, 4.
• A study published in the ANZ journal of surgery found that the rate of anticoagulation use was lowest in isolated splenic vein thrombus (23%), suggesting that anticoagulation may not be necessary in these cases 2.

Investigation and Treatment

• The patient's CTAP was poorly visualized, and an ultrasound may be necessary to further investigate the partial splenic vein thrombus.
• A study published in the World journal of gastroenterology reported a case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum, which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis 3.
• Another study published in the Journal of medical case reports found that deep vein thrombosis with pulmonary embolism is a rare but life-threatening complication of acute pancreatitis, and early treatment with intravenous heparin or thrombolysis is effective 4.

Outcome and Prognosis

• A study published in HPB found that recanalization of splanchnic vein thrombosis was observed in almost a third of patients, irrespective of whether or not they received systemic anticoagulation 5.
• A study published in Gastroenterology research found that anticoagulation does not affect outcomes of SVT, but a subset of patients may benefit from anticoagulation 6.
• The patient's outcome and prognosis will depend on various factors, including the severity of the acute pancreatitis, the extent of the splanchnic vein thrombosis, and the effectiveness of treatment.