Background: Nonmalignant portal vein thrombosis is a significant event in the course of cirrhosis that can contraindicate liver transplantation and even impact survival after the surgical procedure. Risk factors are not completely known or validated and are still debated. Aim: To identify in patients with cirrhosis the risk factors for portal vein thrombosis that are assessable in clinical practice. Methods: Between January 2014 and February 2017, 108 outpatients with cirrhosis and no portal vein thrombosis (78% Child A) were enrolled. Doppler ultrasound was performed every 3 or 6 months, for a median follow up of 19 months. Results: Portal vein thrombosis developed in 11 patients. Nonselective beta-blockade (hazard ratio [HR] 10.56; 95% confidence interval [CI]: 1.35-82.73; P = 0.025),and medium or large-sized oesophageal varices (HR 5.67; 95% CI: 1.49-21.63; P = 0.011) at baseline were associated with portal vein thrombosis development.Although heart rate (P < 0.001) and portal blood flow velocity at baseline (P = 0.005) were significantly reduced by nonselective beta-blockers, they were not related to portal vein thrombosis development. Conclusions:Our findings confirm an association between portal vein thrombosis development and oesophageal varices at baseline, but suggest that the association could be explained by exposure to nonselective beta-blockers, independently from effects on heart rate and portal blood flow velocity. The mechanisms that explain portal vein thrombosis development in patients on nonselective beta-blockers require elucidation in order to optimise targeting of nonselective beta-blockade in patients with cirrhosis.Authors' complete affiliations are listed in Appendix section.

In acute portal vein thrombosis (APVT) unrelated to cirrhosis, anticoagulant therapy is classically started with low molecular weight heparin or vitamin K antagonists. New direct-acting oral anticoagulants (DOACs) are used in the treatment of venous thrombosis outside the splanchnic vascular bed, but not in the latter. We report a young female with APVT occurring in a non-cirrhotic liver linked to heterozygosity of factor V-Leiden and prothrombin G20210A gene mutations. Rivaroxaban was started, with total recanalization of the left and partial recanalization of the right portal vein branches, without complications. New DOACs do not need daily subcutaneous injections nor routinely blood coagulation control tests, making its use attractive, eventually increasing patient’s compliance. If proved to be safe and effective in the future studies, its use may be extended to PVT treatment. This case shows that rivaroxaban was safe, not only prevented the extension of thrombosis in the portal tract, but also resolved PVT, at least partially.

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Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide and one of the fastest growing causes of cancer-related mortality, being mostly diagnosed in patients with cirrhosis. Despite the recent efforts regarding an earlier diagnosis, the majority of patients are at advanced stages at first presentation, when the potential for institution of curative strategies is scarce. This tumor is remarkable because it occurs mostly superimposed on chronic liver diseases, which entails the need to take special attention to liver function preservation and hepatotoxicity prevention when choosing a specific therapy. Major changes had occurred in the management of HCC in the last decade. The decision-making process must be based on an accurate staging of the patient, using the Barcelona Clinic Liver Cancer (BCLC) staging system, updated knowledge of the new therapeutic options, their contraindications and the potential local or systemic complications. The authors start from 4 clinical different scenarios, in order to objectively discuss the therapeutic options available and the decision-making-process based on the staging system.