Cirrhosis splenomegaly, tube or whatever? Director on liver disease

Author: Tan Youwen Zhenjiang Third Hospital affiliated to Jiangsu University

This article is authorized by the author to be published by Yimaitong, please do not reprint
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A common complication of liver cirrhosis splenomegaly, which can subsequently cause hypersplenism, resulting in a decline in blood cells commonly seen in the clinic, platelets, white blood cells and anemia, so the very common clinical treatment principle is splenectomy (including partial splenectomy, splenic artery embolism, etc.
), but what is the effect, is it pros or cons? There has been clinical controversy
.
The author will briefly discuss
a case.

This is a patient with post-hepatitis B cirrhosis with a history of gastrointestinal bleeding, and was admitted in 2018 with splenomegaly, hypersplenism, and low platelets, with a minimum of 32×10⁹/L
.
The doctor believes that low platelets are the cause of bleeding, and recommends partial splenic artery embolization, and in early 2019, partial splenic artery embolization was performed twice, and warfarin and low molecular weight heparin anticoagulation were not given after surgery, and only aspirin was orally treated for one month
.
The patient developed embolism of the right branch and main blood of the portal vein after six months, underwent low molecular weight heparin anticoagulation, and was re-examined one year later, and there was no obvious change
in portal vein thrombosis.
In 2020, there was another
major gastrointestinal bleeding.

Fig.
1 Changes before and after splenic artery embolization

Fig.
2 The patient had two obvious leukocyte emergency reactions before and after surgery, and no obvious leukocytosis
was seen after surgery.

Fig.
3 The obvious low platelet value before surgery, which increased after surgery, rose slowly for one year, and then gradually decreased
again.

The spleen is the largest lymphoid organ in the human body, with the functions of storing blood, making blood, removing senescent red blood cells, and carrying out immune responses.

1.
T cells and B cells settle the site: The spleen is the site of mature lymphocytes to settle, of which B cells account for about 60% of the total number of splenic lymphocytes and T cells account for about 40%.

2.
Where the immune response occurs: As a peripheral immune organ, the main difference between the spleen and the lymph node is that the spleen is the main place for the primary immune response to bloodborne antibodies, while the lymph nodes mainly respond
to antigens that drain lymph.

3
.
Synthesis of bioactive substances: The spleen can synthesize and secrete certain important active substances, such as complement components and cytokines.

4.
Filtration: About 90% of the circulating blood in the body flows through the spleen, which can purify
the blood.

Splenomegaly and hypersplenism are common
in patients with cirrhosis.
However, the two are not directly related, as patients with a normal spleen size may have hypersplenism, while patients with a large spleen may not
.
For example, in one report, 24% of patients with cirrhosis had splenomegaly, while 64% had thrombocytopenia
.
This difference reflects the fact that factors other than an enlarged splenoid cause cytopenia in patients with cirrhosis
.

The prevalence of leukopenia (<3500/L) in patients with cirrhosis is approximately 5%, no different from
that in patients without cirrhosis.
In contrast, thrombocytopenia is more common
in patients with cirrhosis than in patients without cirrhosis.
In patients with cirrhosis, more than 50% to 75% have low platelet counts (< 150,000/L), but only 1% to 11% of patients with cirrhosis have platelet counts below 50,000/L
.

Table 1 Severity and frequency of thrombocytopenia in patients with cirrhosis and non-cirrhosis liver disease

According to reports in patients with immune thrombocytopenia, minor post-traumatic bleeding is usually not present until the platelet count is less than 20,000-30,000/L, and internal bleeding
usually occurs when the count is less than 5000/L.
Given the mild to moderate severity of thrombocytopenia in cirrhosis, there is little increase
in the risk of bleeding from varicose veins or other causes.

It is worth noting that the presence of thrombocytopenia and leukopenia may indicate undesirable results
observed over a long period of time.
One report observed an increased
risk of death or decompensation within 5 years in patients found thrombocytopenia and leukopenia compared to patients with normal counts.
In the second group of patients with severe hypersplenism (platelet < 75000/L or blood count <2000/L), there is no good evidence that splenectomy improves the prognosis
of these patients with cirrhosis.

At present, there are many ways to treat splenomegaly and hypersplenism, and the efficacy and completeness are summarized as follows:

Table 2 Summary of methods for the treatment of splenomegaly and hypersplenism

PVT: portal vein thrombosis; TIPS: Percutaneous jugular hepatic venous shunt

1.
Risk of infection

The risk of infection is greatest after splenectomy, which has the highest incidence of infection in the first two years after splenectomy, but the risk persists for life.
In longitudinal studies, 50% to 75% of postsplenectomy infections occurred within the first two years, with an average interval of 22.
6 months
.
The risk of partial splenectomy may be lower when splenectomy is performed for blood disorders compared with post-traumatic splenectomy when splenectomy is performed on a shorter mean interval between infections (20 months versus 50 months), and the risk of partial splenectomy may be lower
.

2.
Risk of blood clots

Patients with cirrhosis have a significantly increased risk of portal vein thrombosis after treatment of hypersplenism, ranging from 17% to 36%.

For splenectomy and arterial embolization, effective therapeutic anticoagulation is now recommended to prevent portal vein thrombosis, first with heparin followed by warfarin for 3 to 6 months, resulting in complete resolution of thrombus in 67% of patients and partial resolution in 13% of cases
.
However, 20% of patients present with persistent portal vein obstruction with portal hypertension and cavernous hemangioma
.

3.
Tumor risk

A 1995 study showed that the risk of cancer may increase after splenectomy for non-invasive
indications.
A 2014 study that rekindled the debate by comparing long-term follow-up results in 8149 U.
S.
military veterans who underwent splenectomy for benign disease with an average follow-up of 12.
6 years (up to 27 years); this study confirmed the long-term follow-up of 8149 U.
S.
military veterans who underwent splenectomy for benign disease and confirmed complications due to infection [pneumonia, meningitis, and sepsis (relative risk between 1.
9 and 3.
4)], deep vein thrombosis and pulmonary embolism (relative risk: 2.
2), and solid tumors (upper respiratory digestive tract, lungs, colon, pancreas, liver, and prostate, relative risk between 1.
3 and 1.
9), as well as hematologic malignancies (mainly various types of lymphoma and leukemia, relative risk between 1.
8 and 6.
0).

In this study, regardless of the type (solid tumor, lymphoma, or leukemia), the risk of death from infections, pulmonary embolism, coronary artery disease, and cancer was also increased
.
This additional risk persisted more than a decade after splenectomy and was also observed
in a subgroup of patients who underwent splenectomy for trauma.

Splenomegaly and hypersplenism are common in patients with cirrhosis, but the clinical consequences of these abnormalities are small
.
The current literature has focused heavily on the short-term effects of various treatment techniques on splenomegaly and hypersplenism, but there is a lack of observation of long-term effects, especially on patient survival
.
Most patients with splenomegaly and hypersplenism should be treated
conservatively.
If operative, invasive surgery is required, the use of medications appears to be the best approach, as complication rates are low and effective
in addressing hypersplenism or improving platelet counts.

References (swipe down):

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Prevalence of peripheral blood cytopenias (hypersplenism) in patients with nonalcoholic chronic liver disease.
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2.
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Hypersplenism.
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5.
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8.
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9.
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Surg Today 2013; 43: 521–5.

10.
El-Khishen MA, Henderson JM, Millikan WR Jr, Kutner MH, Warren WD.
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11.
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Eltrombopag for thrombocytopenia in patients with cirrhosis associated with hepatitis C.
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12.
Moussa MM, Mowafy N.
Preoperative use of romiplostim in thrombocytopenic patients with chronic hepatitis C and liver cirrhosis.
J Gastroenterol Hepatol 2013; 28: 335–41.

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Tan Youwen

Chief physician Dr

Master tutor of Jiangsu University

Director of the Department of Hepatology, Zhenjiang Third Hospital, Jiangsu University

Columnist of Medical Pulse Communication