Disorders of Hepatic and Mesenteric Circulation

Patient Guideline Summary

Publication Date: January 1, 2020

Objective

Objective

This patient summary means to discuss key recommendations from the American College of Gastroenterology (ACG) for Disorders of the Hepatic and Mesenteric Circulation. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Overview

  • Blood supply to digestive organs can affect many liver diseases since blood from the stomach and intestines passes through the liver on its way back to the heart. These diseases include liver failure, chronic liver diseases, cirrhosis, and cancer.
  • This patient summary focuses primarily on
    • thrombotic (blood clotting) and bleeding risk in cirrhosis
    • portal and hepatic venous thrombosis (blood clots)
    • hereditary hemorrhagic telangiectasia (tiny, fragile, swollen blood vessels) (HHT) involving the liver
    • mesenteric arterial aneurysms (ballooning and weakening of arteries).

Cirrhosis

Cirrhosis

  • “Cirrhosis” means hardening due to scar tissue. Since scar tissue is replacing normal liver tissue, liver function is impaired. The liver makes necessary chemicals for blood clotting. Therefore, bleeding risk throughout the body increases.
  • Hardening also constricts blood vessels in the liver, leading to increased back pressure in gut blood vessels. More blood bypasses the liver through fragile blood vessels around the stomach that may subsequently bleed.

Treatment
  • Blood clotting factors can be given to replace those not made by a sick liver or depleted by other conditions, but the several methods of treatment either do not work or may increase the bleeding risk for complex reasons. Therefore, the ACG does not recommend fresh frozen plasma and cautions against the use of platelet transfusions and drugs that enhance clotting.

Blood Clots

Blood Clots

Diagnosis
  • The ACG recommends imaging to evaluate blood clots. Ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI) will be chosen depending on your unique circumstances.
Treatment
  • You may be treated with anticoagulation (drugs that prevent further clotting). At least 6 months of treatment is recommended. Several different anticoagulant drugs are available.
  • You may be treated with drugs that dissolve existing clots.
  • The choice and duration of treatment depend on all the accompanying conditions that affect your liver, blood circulation, and your general health.

Bleeding Varices

Bleeding Varices

(large, swollen, fragile blood vessels in the lower esophagus)

Treatment
  • The ACG prefers drug treatment of bleeding esophageal varices but notes that an endoscopic procedure may have to be performed. The drugs used are beta-blockers that reduce the blood pressure in the varices.

Mesenteric Artery Aneurysms

Mesenteric Artery Aneurysms

  • Surgical repair is the usual treatment choice for all aneurysms over 2 cm in size. Many smaller mesenteric artery aneurysms are also repaired if they are in critical areas or in younger women, accompany liver transplant, or are causing symptoms.
  • If surgery is not performed, follow-up imaging is recommended once or twice a year because they tend to enlarge.

Hereditary Hemorrhagic Telangiectasia (HHT)

Hereditary Hemorrhagic Telangiectasia (HHT)

Diagnosis
  • HHT is a rare genetic overgrowth of blood vessels that may be present in several family members. It may not cause problems, but it should be evaluated by imaging to determine the risk it poses.
    • Imaging choices include US, CT, and MRI.
  • HHT may cause heart failure, liver dysfunction, bleeding, anemia from bleeding, and other problems.
Treatment
  • Medication like bevacizumab that suppresses blood vessel growth may be helpful.
  • Other treatments include plugging up or tying off the target blood vessel and liver transplantation.

Abbreviations

  • ACG: American College Of Gastroenterology
  • CT: Computed Tomography
  • HHT: Hereditary Hemorrhagic Telangiectasia Syndrome
  • MRI: Magnetic Resonance Imaging
  • US: Ultrasound

Source Citation

Simonetto, Douglas A. MD; Singal, Ashwani K. MD, MS, FACG; Garcia-Tsao, Guadalupe MD, FACG; Caldwell, Stephen H. MD; Ahn, Joseph MD, MS, MBA, FACG; Kamath, Patrick S. MD. ACG Clinical Guideline, The American Journal of Gastroenterology: January 2020 - Volume 115 - Issue 1 - p 18-40 doi: 10.14309/ajg.0000000000000486

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.