Partial splenic embolization for the treatment of severe thrombocytopenia in HCV-related cirrhosis

Öz

Thrombocytopenia can be found in patients with liver cirrhosis related to hepatitis C virus. Both hypersplenism and increased platelet autoantibodies have been hypothesized as mechanisms responsible for thrombocytopenia. A 55-year-old man with hepatic cirrhosis secondary to hepatitis C and documented portal hypertension was admitted with hypersplenism, severe thrombocytopenia (900/μL) and gingival bleeding, which were refractory to corticosteroid therapy. Partial splenic embolization was performed radiologically by injection of polyvinyl alcohol particles. Splenic volume decreased 45% following the embolization. Over 10 days following the procedure, the platelet count increased progressively from 4,450 to 89,700/μL. Postembolization syndrome was the main side effect, but no life-threatening complications were detected. In conclusion, partial splenic embolization can be a safe and effective therapy for hypersplenism in cirrhosis.

Anahtar Kelimeler

• Partial splenic embolization, thrombocytopenia, cirrhosis

HCV’ye sekonder sirozda fliddetli trombositopeni tedavisinde parsiyel splenik embolizasyon

Öz

Thrombositopeni hepatit C virüsüne sekonder karaciğer sirozlu hastalarda karşılaşılabilen bir durumdur. Bu hastalardaki trombositopeniden sorumlu mekanizmalar olarak hipersplenizm ve dolaşımda artmış platelet otoantikorları gösterilmektedir. Hepatit C virüsüne sekonder siroz ve dökümante edilmiş portal hipertansiyon ve hipersplenizmi olduğu bilinen 55 yaşında erkek hasta şiddetli trombositopeni (900/microL) ve diş eti kanaması nedeniyle başvurdu. Kortikosteroid tedavisine cevap vermeyen hastaya radyolojik olarak polyvinyl alkol partikülleri ile parsiyel splenik embolizasyon yapıldı. Embolizasyonu takiben dalak volumu %45 azaltıldı. İşlemi takip eden 10 gün içinde platelet sayısı progressif olarak 4,450 den 89,700/ microL'ye kadar yükseldi. Postembolizasyon sendromu olarak hayati tehlike yaratmayan bazı yan etkiler görüldü. Sonuç olarak parsiyel splenik embolizasyon sirotik hastalardaki hipersplenizm tedavisinde güvenli ve etkili bir tedavi yöntemidir.

Anahtar Kelimeler

• Parsiyel splenik embolizasyon, trombositopeni, siroz

Kaynakça

1. Grossmann RJ, de Franchis R. Portal hypertension. In: Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff’s Disease of the Liver ED 8. Philadelphia: Lippincott-Raven, 1999: 387-442.
2. Nagamine T, Ohtuka T, Takehara K, et al. Thrombocytopenia associated with hepatitis C viral infection. J Hepatol 1996; 24: 135-40.
3. Aoki Y, Hirai K, Tanikawa K. Mechanism of thrombocytopenia in liver cirrhosis: Kinetics of indium-111 tropolone labelled platelets. Eur J Nucl Med 1993; 20: 123-9.
4. Aster RH. Pooling of platelets in the spleen: role in the pathogenesis of hypersplenic thrombocytopenia. J Clin Invest 1966; 45: 645-57.
5. Carr JM. Disseminated intravascular coagulation in cirrhosis. Hepatology 1989; 10: 103-10.
6. Sangro B, Bilbao I, Herrero I, et al. Partial splenic embolization for the treatment of hypersplenism in cirrhosis. Hepatology 1993; 18: 309-14.
7. Yanaga K, Tzakis AG, Shimada M, et al. Reversal of hypersplenism following orthotopic liver transplantation. Ann Surg 1989; 210: 180-3.
8. De Gabriele G, Penington DG. Regulation of platelet production: hypersplenism in the experimental animal. Br J Haematol 1967; 13: 384-93.

9. Penny R, Rozenberg MC, Firkin BG. The splenic platelet pool. Blood 1966; 27: 1-16.
10. Kajiwara E, Akagi K, Azuma K, et al. Evidence for an immunological basis of thrombocytopenia in chronic liver disease. Am J Gastroenterol 1995; 90: 962-6.
11. Lopez Morante AJ, Saez-Royuela F, Casanova Valero F, et al. Immune thrombocytopenia after alpha-interferon therapy in a patient with chronic hepatitis C. Am J Gastroenterol 1992; 87: 809-10.
12. Feistauer SM, Penner E, Mayr WR, Panser S. Target platelet antigens of autoantibodies in patients with primary biliary cirrhosis. Hepatology 1997; 25: 1343-5.
13. Young NS,. Flaviviruses and bone marrow failure. JAMA 1990; 263: 3065-8.
14. Hoofnagle JH. Thrombocytopenia during interferon alpha therapy. JAMA 1991; 266: 849.
15. Realdi G, Fattovich G, Hadziyannis S, et al. Survival and prognostic factors in 366 patients with compansated cirrhosis type B: a multi-center study. The investigators of the European Concerted Action on Viral Hepatitis (EUROHEP). J Hepatol 1994; 21: 656-66.
16. Cabrera J, Maynar M, Granados R, et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology 1996; 110: 832-9.
17. Goulis J, Armonis A, Patch D, et al. Bacterial infection is indepently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology 1998; 27: 1207-12.
18. Basili S, Ferro D, Leo R, et al. Bleeding time does not predict gastrointestinal bleeding in patients with cirrhosis. The CALC Group. (Coagulation Abnormalities in Liver Cirrhosis). J Hepatol 1996; 24: 574-80.
19. Clavien PA, Camargo CA Jr, Croxford R, et al. Definition and classification of negative outcomes in solid organ transplantation. Application in liver transplantation. Ann Surg 1994; 220: 109-20.
20. Pockros PJ, Duchini A, McMillan R, et al. Immune thrombocytopenic purpura in patients with chronic hepatitis C virus infection. Am J Gastroenterol 2002; 97: 2040-5.
21. Hernandez F, Blanguer A, Linares M, et al. Autoimmune thrombocytopenia associated with hepatitis C virus infection. Acta Haematol 1998; 99: 217-20.
22. Bauder F, Marty F, Larrouy M, Ducout L. Immunologic thrombocytopenic purpura as presenting symptom of hepatitis C infection. Am J Hematol 1998; 57: 338-40.
23. Peck-Radosavljevic M. Hypersplenism. Eur J Gastroenterol Hepatol 2001; 13: 317-23.
24. Palsson B, Hallen M, Forsberg AM, Alwmark A. Partial splenic embolization: long-term outcome. Langenbecks Arc Surg 2003; 387: 421-6.
25. Sockrider CS, Boykin KN, Gren J, et al. Partial splenic embolization for hypersplenism before and after liver transplantation. Clin Transplant 2002; 16 (Suppl 7): 59-61.