review article prevalence of splanchnic vein thrombosis in...

Review ArticlePrevalence of Splanchnic Vein Thrombosis in Pancreatitis:A Systematic Review and Meta-Analysis of Observational Studies

Wenda Xu,1 Xingshun Qi,2 Jiang Chen,2 Chunping Su,3 and Xiaozhong Guo2

1The 251st Hospital of PLA, Zhangjiakou 075000, China2Department of Gastroenterology, Shenyang General Hospital of PLA, Shenyang 110840, China3Library of Fourth Military Medical University, Xi’an 710032, China

Correspondence should be addressed to Xiaozhong Guo; [email protected]

Received 18 October 2014; Accepted 24 November 2014

Academic Editor: Valerio De Stefano

Copyright © 2015 Wenda Xu et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Splanchnic vein thrombosis (SVT) may be negatively associated with the prognosis of pancreatitis. We performed a systematicreview and meta-analysis of literatures to explore the prevalence of SVT in pancreatitis. All observational studies regarding theprevalence of SVT in pancreatitis were identified via PubMed and EMBASE databases. The prevalence of SVT was pooled in thetotal of patients with pancreatitis. And it was also pooled in the subgroup analyses according to the stage and causes of pancreatitis,location of SVT, and regions where the studies were performed. After the review of 714 studies, 44 studies fulfilled the inclusioncriteria. Meta-analyses showed a pooled prevalence of SVT of 13.6% in pancreatitis. According to the stage of pancreatitis, thepooled prevalence of SVT was 16.6% and 11.6% in patients with acute and chronic pancreatitis, respectively. According to thecauses of pancreatitis, the pooled prevalence of SVT was 12.2% and 14.6% in patients with hereditary and autoimmune pancreatitis.According to the location of SVT, the pooled prevalence of portal vein, splenic vein, and mesenteric vein thrombosis was 6.2%,11.2%, and 2.7% in pancreatitis. The prevalence of SVT in pancreatitis was 16.9%, 11.5%, and 8.5% in Europe, America, and Asia,respectively.

1. Introduction

Splanchnic vein thrombosis (SVT) is one such vascular com-plication of pancreatitis. SVT involves the portal vein (PV),splenic vein (SplV), and mesenteric vein (MV) with theoccurrence in combination or separately [1]. The conse-quence of pancreatitis-induced SVT may generate a local-ized form of portal hypertension and then splenoportal orgastroepiploic systems burden following localized venoushypertension and lead to gastric, oesophageal, or colonicvarices. Itmay also cause the liver failure, bowel ischemia, andgastrointestinal bleeding [2]. Patients suffer from great painand potentially lethal threaten. The limited literature cannotacquire an exact prevalence of SVT in pancreatitis. The aimof the present systematic review and meta-analysis is toobtain the prevalence of SVT in pancreatitis by resolving thefollowing three questions. (1) What is the prevalence of SVTin pancreatitis, including PVT, SplVT, and MVT? (2) Whatis the prevalence of SVT in different types of pancreatitis?

(3) What is the prevalence of SVT in pancreatitis in differentregions? This study is conducted according to the guidelinesfor the reporting of meta-analysis of observational studies,which were published by the Meta-analysis of ObservationalStudies in Epidemiology Group in 2000 [3].

2. Methods

As a systematic review and meta-analysis were planned, wereviewed standard guidelines to conduct meta-analysis stud-ies according to a protocol determined before the study,including study objectives, prespecified eligibility criteria,and methods of statistical analysis.

2.1. Eligibility Criteria

(1) The participants of any age were diagnosed with pan-creatitis, including acute pancreatitis (AP), chronic

Hindawi Publishing CorporationGastroenterology Research and PracticeVolume 2015, Article ID 245460, 23 pageshttp://dx.doi.org/10.1155/2015/245460

2 Gastroenterology Research and Practice

Articles screened on basis of

Studies retrieved for more detailed

Potentially appropriate studies to be

Studies included in meta-analysis

title and abstract (n = 714)

information (n = 51)

included in the meta-analysis (n = 48)

(n = 44): full text (n = 29),abstract (n = 15)

Excluded (n = 663)∙ Case reports (n = 294)∙ Other basic studies (n = 186)∙ Reviews (n = 152)∙ Comments or editorials (n = 12)∙ Animal study (n = 15)∙ Letter (n = 4)

Excluded (n = 7)∙ Number of patients <10 (n = 1)∙ Duplicate study (n = 6)

Included (n = 3)

∙ Comment source (n = 1)∙ Reference source (n = 2)

Literature search on pancreatitis associatedwith splanchnic venous thrombosis (SVT)

Excluded (n = 3)∙ All included cases were diagnosedwith both pancreatitis and SVT (n = 3)

Figure 1: Flow diagram of study selection.

Proportion meta-analysis plot (random effects)

0.0 0.2 0.4 0.6 0.8Combined 0.1358 (0.1016, 0.1740)Gross 1958 0.0160 (0.0019, 0.0566)

McElroy and Christiansen 1972 0.1923 (0.0655, 0.3935)Sibert 1978 0.0694 (0.0229, 0.1547)

Roesch et al. 1981 0.0508 (0.0338, 0.0731)Hofer et al. 1987 0.2200 (0.1153, 0.3596)

Rogers and Klatt 1989 0.1528 (0.0788, 0.2569)Nordback et al. 1989 0.0047 (0.0017, 0.0103)Bernades et al. 1992 0.1316 (0.0934, 0.1782)

Lin et al. 1997 0.0556 (0.0183, 0.1249)Friess et al. 1997 0.0529 (0.0330, 0.0797)

Takase et al. 1997 0.4167 (0.1517, 0.7233)Tsushima et al. 1999 0.0400 (0.0010, 0.2035)

Arotcarena et al. 1999 0.1478 (0.1177, 0.1822)Sakorafas et al. 2000 0.0702 (0.0491, 0.0968)

Dörffel et al. 2000 0.2381 (0.1793, 0.3053)0.1900 (0.1184, 0.2807)

Malíková et al. 2002 0.3250 (0.1857, 0.4913)Pimentel et al. 2003 0.0313 (0.0038, 0.1084)

Makowiec et al. 2004 0.2203 (0.1616, 0.2887)0.4600 (0.3598, 0.5626)

Agarwal et al. 2008 0.2166 (0.1549, 0.2893)Keck et al. 2009 0.1505 (0.0848, 0.2397)

Raina et al. 2009 0.1538 (0.0436, 0.3487)Pribramska et al. 2009 0.0433 (0.0323, 0.0567)

Chooklin and Hranat 2009 0.2000 (0.0573, 0.4366)Chowdhury et al. 2011 0.0548 (0.0151, 0.1344)

Huggett et al. 2011 0.1346 (0.0559, 0.2579)Shalimar et al. 2011 0.0398 (0.0184, 0.0742)Gonzelez et al. 2011 0.1575 (0.0989, 0.2327)Rebours et al. 2012 0.3445 (0.2598, 0.4372)

Muddana et al. 2012 0.1633 (0.1198, 0.2150)Vyas et al. 2012 0.2529 (0.1658, 0.3575)

De León et al. 2012 0.2500 (0.0727, 0.5238)Sisman et al. 2012 0.1719 (0.0890, 0.2868)

Ishikawa et al. 2012 0.0185 (0.0005, 0.0989)Harris et al. 2013 0.0183 (0.0134, 0.0245)

Jakchairoongruang and Arjhansiri 2013 0.0139 (0.0004, 0.0750)Marra-López et al. 2013 0.1059 (0.0496, 0.1915)

Suero et al. 2013 0.2400 (0.0936, 0.4513)0.0298 (0.0097, 0.0681)

Easler et al. 2014 0.1358 (0.0871, 0.1984)Talukdar et al. 2014 0.0736 (0.0386, 0.1251)

Britton et al. 2014 0.6207 (0.5364, 0.6999)Sisman et al. 2014 0.2000 (0.1110, 0.3177)

Proportion (95% confidence interval)

Mortelé et al. 2004


Castineira-Alvarino et al. 2013

Figure 2: Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in pancreatitis.

Gastroenterology Research and Practice 3

Proportion meta-analysis plot (fixed effects)

0.0 0.2 0.4 0.6 0.8

Combined 0.0161 (0.0132, 0.0193)McElroy and Christiansen 1972 0.1154 (0.0245, 0.3015)

Sibert 1978 0.0278 (0.0034, 0.0968)Nordback et al. 1989 0.0016 (0.0002, 0.0057)Bernades et al. 1992 0.0376 (0.0182, 0.0680)

0.0582 (0.0294, 0.1017)0.0500 (0.0061, 0.1692)0.1300 (0.0711, 0.2120)

Pribramska et al. 2009 0.0026 (0.0005, 0.0076)Gonzelez et al. 2011 0.0787 (0.0384, 0.1400)Rebours et al. 2012 0.1176 (0.0658, 0.1895)Ishikawa et al. 2012 0.0185 (0.0005, 0.0989)

0.0081 (0.0050, 0.0126)0.0298 (0.0097, 0.0681)


Britton et al. 2014 0.6207 (0.5364, 0.6999)


Castineira-Alvarino et al. 2013Harris et al. 2013

Mortelé et al. 2004Malíková et al. 2002

Dörffel et al. 2000

(a)


0.0 0.2 0.4 0.6 0.8

Combined 0.1121 (0.0815, 0.1470)Gross 1958 0.0080 (0.0002, 0.0438)

McElroy and Christiansen 1972 0.0769 (0.0095, 0.2513)Sibert et al. 1978 0.0417 (0.0087, 0.1170)


0.1528 (0.0788, 0.2569)Nordback et al. 1989 0.0016 (0.0002, 0.0057)Bernades et al. 1992 0.0827 (0.0526, 0.1225)

Lin et al. 1997 0.0556 (0.0183, 0.1249)Takase et al. 1997 0.4167 (0.1517, 0.7233)

Tsushima et al. 1999 0.0400 (0.0010, 0.2035)Sakorafas et al. 2000 0.0702 (0.0491, 0.0968)

0.1481 (0.1008, 0.2069)0.1900 (0.1184, 0.2807)0.1750 (0.0734, 0.3278)

Makowiec et al. 2004 0.2203 (0.1616, 0.2887)0.1900 (0.1184, 0.2807)

Agarwal et al. 2008 0.2166 (0.1549, 0.2893)Keck et al. 2009 0.1505 (0.0848, 0.2397)

Raina et al. 2009 0.1538 (0.0436, 0.3487)Pribramska et al. 2009 0.0251 (0.0169, 0.0359)

Chooklin and Hranat 2009 0.2000 (0.0573, 0.4366)Shalimar, S. et al. 2011 0.0398 (0.0184, 0.0742)

Gonzelez et al. 2011 0.1102 (0.0616, 0.1780)Rebours et al. 2012 0.3193 (0.2369, 0.4110)

Muddana et al. 2012 0.1394 (0.0991, 0.1886)Vyas et al. 2012 0.1379 (0.0734, 0.2285)

0.2500 (0.0727, 0.5238)Sisman et al. 2012 0.1719 (0.0890, 0.2868)Harris et al. 2013 0.0122 (0.0083, 0.0174)

Jakchairoongruang and Arjhansiri 2013 0.0139 (0.0004, 0.0750)0.1059 (0.0496, 0.1915)


Sisman et al. 2014 0.2000 (0.1110, 0.3177)


De León et al. 2012


Malíková et al. 2002Mortelé et al. 2001Dörffel et al. 2000

Rogers and Klatt 1989

Marra-López et al. 2013

(b)

Figure 3: Continued.



0.0 0.1 0.2 0.3

Combined 0.0269 (0.0140, 0.0438)Gross 1958 0.0080 (0.0002, 0.0438)

0.0032 (0.0009, 0.0081)Bernades et al. 1992 0.0113 (0.0023, 0.0326)

0.0317 (0.0117, 0.0678)0.1000 (0.0279, 0.2366)0.1400 (0.0787, 0.2237)

Pribramska et al. 2009 0.0035 (0.0009, 0.0088)0.0236 (0.0049, 0.0675)0.0840 (0.0410, 0.1491)0.0069 (0.0040, 0.0111)0.0370 (0.0137, 0.0789)


Rebours et al. 2012Harris et al. 2013Easler et al. 2014

Nordback et al. 1989


Gonzelez et al. 2011

Malíková et al. 2002Mortel e et al. 2004

(c)

Figure 3: (a) Forest plots showing the prevalence of portal vein thrombosis (PVT) in pancreatitis. (b) Forest plots showing the prevalence ofsplenic vein thrombosis (SlpVT) in pancreatitis. (c) Forest plots showing the prevalence of mesenteric vein thrombosis (MVT) in pancreatitis.


0.0 0.2 0.4 0.6 0.8

Combined 0.1660 (0.0998, 0.2450)Rogers and Klatt 1989 0.1528 (0.0788, 0.2569)

0.0026 (0.0005, 0.0077)Tsushima et al. 1999 0.0400 (0.0010, 0.2035)

0.2381 (0.1793, 0.3053)0.1900 (0.1184, 0.2807)0.3250 (0.1857, 0.4913)0.4600 (0.3598, 0.5626)0.0433 (0.0323, 0.0567)

Chooklin and Hranat 2009 0.2000 (0.0573, 0.4366)0.1575 (0.0989, 0.2327)

Rebours et al. 2012 0.4063 (0.2370, 0.5936)Muddana et al. 2012 0.1633 (0.1198, 0.2150)

Vyas et al. 2012 0.2529 (0.1658, 0.3575)Harris et al. 2013 0.0183 (0.0134, 0.0245)

Jakchairoongruang and Arjhansiri. 2013 0.0139 (0.0004, 0.0750)Easler et al. 2014 0.1358 (0.0871, 0.1984)

Talukdar et al. 2014 0.0736 (0.0386, 0.1251)0.6207 (0.5364, 0.6999)





Britton et al. 2014


Mortel e et al. 2001

Pribramska et al. 2009

(a)


0.0 0.2 0.4 0.6 0.8Combined 0.0796 (0.0240, 0.1638)

0.0582 (0.0294, 0.1017)0.0500 (0.0061, 0.1692)0.1300 (0.0711, 0.2120)0.0026 (0.0005, 0.0076)0.0787 (0.0384, 0.1400)0.0081 (0.0050, 0.0126)0.0494 (0.0216, 0.0950)0.0184 (0.0038, 0.0528)0.6207 (0.5364, 0.6999)


Harris et al. 2013Easler et al. 2014

Talukdar et al. 2014



Britton et al. 2014



(b)




0.0 0.2 0.4 0.6

Combined 0.1038 (0.0635, 0.1526)0.1528 (0.0788, 0.2569)0.0400 (0.0010, 0.2035)0.1481 (0.1008, 0.2069)0.1900 (0.1184, 0.2807)0.1750 (0.0734, 0.3278)0.1900 (0.1184, 0.2807)0.0251 (0.0169, 0.0359)0.2000 (0.0573, 0.4366)0.1102 (0.0616, 0.1780)0.1394 (0.0991, 0.1886)0.1379 (0.0734, 0.2285)0.0122 (0.0083, 0.0174)0.0139 (0.0004, 0.0750)0.1173 (0.0721, 0.1771)0.0552 (0.0256, 0.1022)


Rogers and Klatt 1989Tsushima et al. 1999

Chooklin and Hranat 2009

Muddana et al. 2012Vyas et al. 2012

Harris et al. 2013Jakchairoongruang and Arjhansiri 2013

Easler et al. 2014Talukdar et al. 2014






(c)

Proportion meta-analysis plot [random effects]

0.0 0.1 0.2 0.3

Combined 0.0258 (0.0118, 0.0451)

0.0026 (0.0005, 0.0077)

0.0317 (0.0117, 0.0678)

0.1000 (0.0279, 0.2366)

0.1400 (0.0787, 0.2237)

0.0035 (0.0009, 0.0088)

0.0236 (0.0049, 0.0675)

0.0069 (0.0040, 0.0111)

0.0370 (0.0137, 0.0789)


Harris et al. 2013

Easler et al. 2014




Malíková et al. 2002



(d)

Figure 4: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in acute pancreatitis (AP). (b) Forest plots showingthe prevalence of portal vein thrombosis (PVT) in acute pancreatitis (AP). (c) Forest plots showing the prevalence of splenic vein thrombosis(SlpVT) in acute pancreatitis (AP). (d) Forest plots showing the prevalence of mesenteric vein thrombosis (MVT) in acute pancreatitis (AP).

pancreatitis (CP), hereditary pancreatitis (HP), orautoimmune pancreatitis (AIP).Theparticipantswithunderlying malignancy, cirrhosis, trauma, abdominalsurgery unrelated to ongoing pancreatitis, pregnancy,intra-abdominal infections, primary myeloprolifera-tive disorders, or other pancreatic diseases or pan-creatitis and resultant SVT were not deliberatelyexcluded.

(2) All cohort and case-control studies were eligible,regardless of the retrospective or prospective natureof the study; case reports were excluded.

(3) Reviews, comments, or letters on the relationship ofpancreatitis and SVT were excluded.

(4) Animal studies were also excluded.(5) There was no publication date or publication status

restrictions.

(6) There were no language restrictions.(7) The number of participants in any included study was

beyond 10.

2.2. Search Strategy. TheMEDLINE and EMBASE databaseswere searched using a search strategy from their inceptionto July 2014. Search items combined keywords and med-ical subject heading terms (MeSH) were listed as follows:(“pancreatitis” (MeSH Terms) or “pancreatitis” (All Fields))and ((“portal vein” (MeSH Terms) or (“portal” (All Fields)and “vein” (All Fields)) or “portal vein” (All Fields)) and(“thrombosis” (MeSH Terms) or “thrombosis” (All Fields)))or ((“splenic vein” (MeSH Terms) or (“splenic” (All Fields)and “vein” (All Fields)) or “splenic vein” (All Fields)) and(“thrombosis” (MeSH Terms) or “thrombosis” (All Fields)))or ((“mesenteric veins” (MeSH Terms) or (“mesenteric”(All Fields) and “veins” (All Fields)) or “mesenteric veins”



0.0 0.2 0.4 0.6 0.8Combined 0.116 (0.085, 0.151)


0.038 (0.012, 0.086)Bernades et al. 1992 0.132 (0.093, 0.178)

Lin et al. 1997 0.056 (0.018, 0.125)0.053 (0.033, 0.080)

Takase et al. 1997 0.417 (0.152, 0.723)Arotcarena et al. 1999 0.148 (0.118, 0.182)

Sakorafas et al. 2000 0.070 (0.049, 0.097)Pimentel et al. 2003 0.031 (0.004, 0.108)

0.220 (0.162, 0.289)Agarwal et al. 2008 0.217 (0.155, 0.289)

0.151 (0.085, 0.240)Chowdhury et al. 2011 0.055 (0.015, 0.134)

Shalimar et al. 2011 0.040 (0.018, 0.074)0.322 (0.226, 0.431)0.172 (0.089, 0.287)0.106 (0.050, 0.192)0.030 (0.010, 0.068)0.200 (0.111, 0.318)



Friess et al. 1997

Makowiec et al. 2004

Keck et al. 2009

Rebours et al. 2012Sisman et al. 2012

Sisman et al. 2014Castineira-Alvarino et al. 2013

Marra-Lopez et al. 2013

(a)


0.00 0.02 0.04 0.06 0.08

Combined 0.035 (0.023, 0.048)

0.015 (0.002, 0.053)

0.038 (0.018, 0.068)

0.040 (0.018, 0.074)

0.030 (0.010, 0.068)


Bernades et al. 1992

Shalimar et al. 2011



(b)


0.0 0.2 0.4 0.6 0.8

Combined 0.128 (0.087, 0.176)0.051 (0.034, 0.073)0.220 (0.115, 0.360)0.015 (0.002, 0.053)0.083 (0.053, 0.123)0.056 (0.018, 0.125)0.417 (0.152, 0.723)0.070 (0.049, 0.097)0.220 (0.162, 0.289)0.217 (0.155, 0.289)0.151 (0.085, 0.240)0.172 (0.089, 0.287)0.106 (0.050, 0.192)0.200 (0.111, 0.318)


Roesch et al. 1981Hofer et al. 1987

Bernades et al. 1992Lin et al. 1997

Takase et al. 1997Sakorafas et al. 2000

Agarwal et al. 2008


Makowiec et al. 2004

Keck et al. 2009Sisman et al. 2012

Sisman et al. 2014Marra-Lopez et al. 2013

(c)




0.00 0.02 0.04 0.06

Combined 0.0123 (0.0039, 0.0254)

0.0075 (0.0002, 0.0412)

0.0113 (0.0023, 0.0326)




(d)

Figure 5: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in chronic pancreatitis (CP). (b) Forest plots showingthe prevalence of portal vein thrombosis (PVT) in chronic pancreatitis (CP). (c) Forest plots showing the prevalence of splenic vein thrombosis(SlpVT) in chronic pancreatitis (CP). (d) Forest plots showing the prevalence of mesenteric vein thrombosis (MVT) in chronic pancreatitis(CP).

(All Fields) or (“mesenteric” (All Fields) and “vein” (AllFields)) or “mesenteric vein” (All Fields)) and (“thrombosis”(MeSH Terms) or “thrombosis” (All Fields))). The last searchwas performed on July 29, 2014. The reference lists of theincluded articles were further hand-searched to identify anyadditional relevant studies. When the same data were foundin more than one publication, only the studies with morecomplete data andmore extensive interval of enrolment wereincluded in the meta-analysis. Full-texts were found by threeinvestigators (Wenda Xu, Xingshun Qi, and Chunping Su).

2.3. Data Extraction. Using a predefined protocol, twoinvestigators (Wenda Xu and Xingshun Qi) independentlyreviewed the titles and abstracts of all references to identifystudies for inclusion in the analysis. Dealing with disagree-ment between the two reviewers, a consensus was achievedthrough discussion among all of the reviewers. A schematicdiagram depicting reference flow is shown through the sys-tematic review process. Additionally, a data extraction sheetwas generated that included authors, publication year, studydesign, country where the study was conducted, period ofenrolment, inclusion and exclusion criteria, type of diseases(AP, CP,HP, or AIP), total sample size, demographic data (ageand gender), number of patientswith PVT, SplV, orMVT, andproportion of patients with PVT, SplV, or MVT, respectively.

2.4. Evaluation of Study Quality. Quality assessment of stud-ies was carried out independently by two reviewers (WendaXu and Xingshun Qi). Discrepancies of interpretation andcomprehension were resolved by consensus. The higherquality studies should fulfill the following predeterminedcriteria.

(1) Country where the study was conducted, intervalof enrolment, inclusion and exclusion criteria, andparticipant characteristics (age, gender) were clearlyrecorded.

(2) Pancreatitis was diagnosed on the basis of history,clinical manifestations, elevated serum lipase andamylase, imaging detection by ultrasonography (US),endoscopic ultrasonography (EUS), computed to-mography (CT), magnetic resonance imaging (MRI),or endoscopic retrograde cholangiopancreatography(ERCP), and/or typical histopathology.

2.5. Data Synthesis and Statistical Analysis. Theproportion ofpancreatitis patients with SVT in each study was combinedto give a pooled prevalence of SVT for all studies. With thismethod, the pooled prevalence of PVT, SplV, and MVT wascalculated. Furthermore, according to the type of pancreatitisand continents (Europe, America, and Asia), the pooledprevalence of SVT, PVT, SplV, and MVT was also created.The number and crude proportion of participants withSVT recorded by each study were used to pool the overallproportion, using the DerSimonian-Laird random-effectsmethod. Between-study heterogeneity was assessed by usingthe 𝐼2 index (𝐼2 > 50% was considered having substantialheterogeneity) and the Chi-squared test (𝑃 < 0.01 was con-sidered representing significant statistical heterogeneity) [4].Individualized random effectsmeta-analyses were performedto estimate percentages and 95% confidence intervals (CIs)for all endpoints queried. Analyses were conducted usingStatsDirect statistical software version 2.7.8 (StatsDirect Ltd,Sale, Cheshire, UK).

3. Results

3.1. Description of the Included Studies. In the initial searchstrategy, a total of 947 studies were selected. Among them, 714studies were retrieved by removing duplicate research. Twoadditional unique references were found through referencelists of an original article and a review, respectively [5, 6].One study as object of related comment was also identified[7]. Total of 44 studies were included in the meta-analysis



0.0 0.1 0.2 0.3 0.4

Combined 0.12 (0.03, 0.27)

McElroy and Christiansen 1972 0.19 (0.07, 0.39)

Sibert 1978 0.07 (0.02, 0.15)


(a)


0.0 0.1 0.2 0.3 0.4

Combined 0.066 (0.007, 0.178)

0.115 (0.024, 0.302)

0.028 (0.003, 0.097)


McElroy and Christiansen 1972

Sibert 1978

(b)


0.0 0.1 0.2 0.3

Combined 0.058 (0.021, 0.112)

0.077 (0.009, 0.251)

0.042 (0.009, 0.117)



Sibert 1978

(c)

Figure 6: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in hereditary pancreatitis (HP). (b) Forest plotsshowing the prevalence of portal vein thrombosis (PVT) in hereditary pancreatitis (HP). (c) Forest plots showing the prevalence of splenicvein thrombosis (SlpVT) in hereditary pancreatitis (HP).

(Figure 1). Additionally, five studies recorded by the samestudy team in different publications were excluded [8–12]and one study which concerned the same patients by thesame first author in different publications was also excluded[13]. Another study was excluded because the number ofparticipants was <10 [14]. Twenty-two of 44 studies were

conducted in Europe [6, 15–35], fourteen in America [2, 5, 7,36–46], and eight in Asia [47–54]. Among 10441 participants,874 patients with SVTwere screened.These patients included197 patients with PVT, 525 with SplV, and 72 with MVT. Thedetailed characteristics of these included studies were shownin Table 1.


Table1:Overviewof

inclu

dedstu

dies.

Authors(pu

blication

year)

Type

ofresearch

Cou

ntry

Intervalof

enrolm

ent

Eligibilitycriteria

Type

ofdisease(AP,CP

,HP,or

AIP)

Num

bero

ftotal

samples

SVT

PVT

SlpV

TMVT

Meanage

(range

years)

Female/

male

Sism

anetal.

(2014)

[19]

Retro

spectiv

ecoho

rtstu

dyTu

rkey

2007–2011

NA

CP65

13NA

13NA

NA

14/51

Britton

etal.

(2014)

[18]

Retro

spectiv

ecoho

rtstu

dyUK

1998–2012

Exclu

sioncriteria

:46cases

weree

xcludedfro

mthefi

nal

analysisas

imagingrepo

rts

maden

ocommento

nthe

portalveno

ussyste

m.

AP

145

9090

NA

NA

56.1

NA

Talukd

aretal.

(2014)

[47]

Prospective

coho

rtstu

dyIndia

August2011

toOctob

er2012

Inclu

sioncriteria

:patients

over

18yrsw

ithap

rimary

diagno

sisoffirstepiso

deofAP

from

August2011to

Octob

er2012,and

prospectively

follo

wed

fora

tleastsix

mon

thsa

fterd

ischargeo

rtill

death;exclu

sioncriteria

were

(1)recurrent

AP;

(2)p

atient

who

didno

tgetaC

Tscan.

AP

163

123

9NA

NA

40/12

3

Easle

retal.

(2014)

[38]

Prospective

study

USA

June

2003

andAp

ril2010

Inclu

sioncriteria

:SAP

patie

ntsw

howerea

dmitted

with

theirfi

rstA

Pattack;

exclu

sioncriteria

:patients

with

ahistoryof

APor

CP.

AP

162

228

196

55±20

78/84

Castineira

-Alvarinoet

al.

(2013)

[20]

Prospective

study

Spain

Since2

007

Inclu

sioncriteria

:patients

with

age<

18yearsa

tind

exvisit

totheC

Pou

tpatient

clinic;exclu

sioncriteria

:patie

ntsw

hocle

arlymod

ified

thed

ietb

eforethe

indexvisit

weree

xcluded.

CP168

55

NA

NA

44(17–76)

40/12

8


Table1:Con

tinued.

Authors(pu

blication

year)

Type

ofresearch

Cou

ntry

Intervalof

enrolm

ent

Eligibilitycriteria

Type

ofdisease(AP,CP

,HP,or

AIP)

Num

bero

ftotal

samples

SVT

PVT

SlpV

TMVT

Meanage

(range

years)

Female/

male

Sueroetal.

(2013)

[21]

Retro

spectiv

estu

dySpain

NA

NA

AIP

256

NA

NA

NA

(17–79)

2/23

Marra-Lop

ezetal.

(2013)

[22]

Prospective

coho

rtstu

dySpain

2011–

2013

Inclu

sioncriteria

:CPpatie

nts

defin

edby

M-ANNHEIM.

CP85

9NA

9/85

NA

59.38

17/68

Harris

etal.

(2013)

[2]

Retro

spectiv

estu

dyUSA

Janu

ary1996

toDecem

ber

2006

Inclu

sioncriteria

:an

institu

tional(Mayoclinic)

database

search

was

done

usingthek

eyterm

sacute

pancreatitisa

ndsuperio

rmesenteric

vein

thrombo

sis(SMVT),portalvein

thrombo

sis(PVT),and

splenicv

einthrombo

sis(SplVT)

from

Janu

ary1996

toDecem

ber2

006;exclu

sion

criteria

:(1)patie

ntsw

ithprecipitatin

gfactorsfor

thrombo

sis(abd

ominal

surgeryun

related

toon

going

pancreatitis,trauma,

pregnancy,cirrho

sis,

intra-abdo

minalinfections,

pancreaticcancer,and

prim

arymyeloproliferativ

edisorders)weree

xcluded.(2)

Allcaseso

fchron

icpancreatitisw

erea

lsoexclu

ded.

AP

2454

4520

3017

NA

NA

Jakchairo

ongruang

andArjh

ansir

i(2013)

[48]

Retro

spectiv

estu

dyTh

ailand

Janu

ary1,

2005

and

April

30,2010

Exclu

sioncriteria

:sixhu

ndred

andeightp

atientsw

ere

exclu

dedfro

mthes

tudy

popu

latio

nbecauseo

fthe

followingreason

s:itwas

not

thefi

rstepisode

ofacute

pancreatitis,theinitia

lCTwas

notp

erform

ed,there

aren

oavailableC

Tim

ages

onou

rPictures

Archiving

and

Com

mun

ications

Syste

m(PAC

S),orp

atient

was

imaged

with

onlyun

enhanced

CT.

AP

721

NA

1/72

NA

47.7

(6–89)

33/39


Table1:Con

tinued.

Authors(pu

blication

year)

Type

ofresearch

Cou

ntry

Intervalof

enrolm

ent

Eligibilitycriteria

Type

ofdisease(AP,CP

,HP,or

AIP)

Num

bero

ftotal

samples

SVT

PVT

SlpV

TMVT

Meanage

(range

years)

Female/

male

Ishikawae

tal.(2012)

[49]

Retro

spectiv

estu

dyJapan

July2003

and

Octob

er2010

Inclu

sioncriteria

:patients

who

mettheInternatio

nal

Con

sensus

Diagn

ostic

Criteria

(ICD

C)forA

IP.

AIP

541

1NA

NA

63.2±13.5

(28–86)

6/48

Sism

anetal.

(2012)

[24]

Retro

spectiv

estu

dyTu

rkey

2007–2011

Exclu

sioncriteria

:patients

who

received

previous

H.

pylorieradicationtre

atment

andwho

arew

ithany

malignancyweree

xcluded.

CP64

11NA

11NA

NA

NA

DeL

eonetal.

(2012)

[25]

Retro

spectiv

estu

dySpain

NA

NA

AIP

164

NA

4NA

46.6

(17–73)

1/15

Vyas

etal.

(2012)

[23]

Retro

spectiv

estu

dyUK

NA

NA

AP

8722

NA

12NA

NA

35/52

Mud

dana

etal.

(2012)

[39]

Prospective

study

USA

2003–2010

NA

AP

251

41NA

35NA

51.5±19

123/128

Rebo

urse

tal.

(2012)

[17]

Prospective

single-center

study

France

2000–200

9

Inclu

dedcriteria

:allof

thein-

orou

tpatientsw

ithrecurrent

acuteo

rchron

icalcoho

licpancreatitisa

ndfollo

wed

prospectively

basedon

astandardized

protocol,

inclu

ding

ayearly

physical

exam

inationandas

earchfor

exocrin

epancreatic

insufficiency,diabetes,and

cholestasis

;excludedcriteria

:(1)cirr

hosis;(2)

patie

ntsw

howerelosttofollo

w-upin

2009.

APor

CP119

4114

3810

NA

19/10

0

Gon

zeleze

tal.

(2011)[15]

Retro

spectiv

estu

dyUK

Janu

ary1,

2008,and

Decem

ber3

1,2009

Exclu

dedcriteria

:patients

with

chronicp

ancreatitis,

know

nmalignancy,cirrho

sis,

orestablish

edpo

rtal

hypertensio

n.

AP

127

2010

143

53.5

(36–

81)

118/9

Shalim

aretal.

(2011)[36]

Prospective

study

USA

NA

Inclu

sioncriteria

:patients

with

CPaft

eran

inform

edconsentand

ethicalclearance;

exclu

sioncriteria

:NA.

CP226

9NA

9NA

NA

48/17

8

Hug

gettetal.

(2011)[16]

Prospective

study

UK

2004–2010

Inclu

sioncriteria

:patients

with

AIP

andwith

amedian

follo

w-upfro

mdiagno

sisof

32mon

ths(rang

e0–76)

AIP

527

NA

NA

NA

59(26–

85)

11/41


Table1:Con

tinued.

Authors(pu

blication

year)

Type

ofresearch

Cou

ntry

Intervalof

enrolm

ent

Eligibilitycriteria

Type

ofdisease(AP,CP

,HP,or

AIP)

Num

bero

ftotal

samples

SVT

PVT

SlpV

TMVT

Meanage

(range

years)

Female/

male

Chow

dhuryetal.

(2011)[50]

Retro

spectiv

estu

dyIndia

Janu

ary2005

and

Decem

ber

2009

Inclu

sioncriteria

:children

diagno

sedwith

chronic

pancreatitis(on

imaging

study).

CP73

4NA

NA

NA

NA

22/51

Choo

klin

andHranat

(200

9)[26]

Retro

spectiv

estu

dyUkraine

NA

NA

AP

204

NA

4NA

NA

3/17

Vege

etal.

(200

9)[37]

Retro

spectiv

estu

dyUSA

1989–2007

Exclu

sioncriteria

:patients

with

preexisting

portal

hypertensio

nweree

xcluded.

AP

1155

503

294

NA

NA

Keck

etal.

(200

9)[27]

Retro

spectiv

estu

dyGermany

InGermany:

2001–2005;in

USA

:1995–2005

Exclu

dedcriteria

:three

patie

ntsw

hose

predom

inant

lesio

nwas

onlyav

erydilated

pancreaticdu

ctandwho

were

thus

selected

forlateral

pancreaticojeju

nosto

my.

CP93

14NA

14NA

NA

31/62

Rainae

tal.

(200

9)[5]

Retro

spectiv

estu

dyUSA

1998–2007

Exclu

sioncriteria

:three

other

malignancies(gastric

cancer,

ther

ecurrenceo

fgastric

adenocarcino

ma,and

pancreaticadenocarcino

ma).

AIP

264

NA

4NA

62.5

(23–86)

9/17

Agarw

aletal.

(2008)

[51]

Retro

spectiv

estu

dyIndia

Janu

ary1996

and

Decem

ber

2005

NA

CP157

34NA

34NA

NA

NA

Morteleetal.

(200

4)[40]

Retro

spectiv

estu

dyUSA

17-m

onth

perio

dNA

AP

100

4613

1914

51(12–80)

47/53

Makow

iece

tal.

(200

4)[28]

Prospective

study

Germany

1994–2001

Exclu

sioncriteria

:12patie

nts

with

portalhypertensio

nand

9patie

ntsu

nderwent

splen

ectomywith

outsplenic

vein

thrombo

sis.

CP177

NA

NA

39NA

NA

NA

Pimenteletal.

(2003)

[41]

Retro

spectiv

estu

dyBrazil

1989–2002

NA

CP64

2NA

NA

NA

NA

14/50

Malıkovae

tal.

(2002)

[29]

Retro

spectiv

estu

dyCz

ech

Repu

blic

NA

NA

AP

40NA

27

4NA

NA

Morteleetal.

(2001)[42]

Retro

spectiv

estu

dyUSA

April

1996

andAu

gust

1997

NA

AP

100

19NA

19NA

NA

47/53

Gastroenterology Research and Practice 13Ta

ble1:Con

tinued.

Authors(pu

blication

year)

Type

ofresearch

Cou

ntry

Intervalof

enrolm

ent

Eligibilitycriteria

Type

ofdisease(AP,CP

,HP,or

AIP)

Num

bero

ftotal

samples

SVT

PVT

SlpV

TMVT

Meanage

(range

years)

Female/

male

Sakorafase

tal.

(200

0)[43]

Prospective

study

USA

1976–1997

NA

CP484

34NA

34NA

NA

NA

Dorffeletal.

(200

0)[30]

Prospective

study

Germany

38mon

ths

Inclu

dedcriteria

:definite

diagno

sisof

acutep

ancreatitis

asdetected

byultrason

ograph

y(U

S)andCT

,ele

vatedserum

lipasea

ndam

ylase,compatib

leclinical

picture,on

seto

fpain

symptom

snot

morethan3

days

before

admiss

ion,

nohisto

ryof

pancreatitis,andno

deficienciesinantithrom

bin

III,proteinC,

andproteinS.

AP

189

4511

286

43(19

–80)

49/14

0

Arotcarenae

tal.

(1999)[31]

Prospective

study

France

April

1993

toAp

ril1996

NA

CP494

73NA

NA

NA

NA

NA

Tsushimae

tal.

(1999)[52]

Retro

spectiv

estu

dyJapan

April

1993

andAu

gust

1997

Inclu

dedcriteria

:patientsw

ithAPun

derw

entinitia

labdo

minalCT

with

in3days

after

theo

nsetof

symptom

sandreceived

atleasto

neadditio

nalC

Texam

ination

thereafte

r;Ex

cludedcriteria

:caseso

ftraum

aticor

posto

perativ

epancreatitis

AP

251

NA

1NA

53.4±20.8

(25–83)

7/18

Takase

etal.

(1997)[54]

Prospective

study

Japan

Duringthe

past10

years

Exclu

sioncriteria

:6patie

nts

underw

ent

pancreatod

uodenectom

yor

biop

sywith

outthe

splenic

vein

specim

ens

CP12

5NA

5NA

48.8

0/12

Friessetal.

(1997)[32]

Retro

spectiv

estu

dyGreece

NA

NA

CP397

21NA

NA

NA

NA

NA

Linetal.

(1997)[53]

Prospective

study

Taiwan

1976–1996

NA

CP90

5NA

5NA

NA

NA

Bernades

etal.

(1992)[6]

Prospective

long

itudinal

Stud

yFrance

Janu

ary1980

andMarch

1990

Inclu

sioncriteria

:patients

who

metthec

riteriaof

CPand

who

hadbeen

follo

wed-up

durin

gob

servation;

exclu

sion

criteria

:patientsw

ithcirrho

sis.

CP266

3510

223

40.5

(6–77)

35/231

Nordb

acketal.(1989)

[35]

Retro

spectiv

estu

dyFinland

1972–1986

NA

APor

CP1268

62

24

NA

NA


Table1:Con

tinued.

Authors(pu

blication

year)

Type

ofresearch

Cou

ntry

Intervalof

enrolm

ent

Eligibilitycriteria

Type

ofdisease(AP,CP

,HP,or

AIP)

Num

bero

ftotal

samples

SVT

PVT

SlpV

TMVT

Meanage

(range

years)

Female/

male

RogersandKlatt

(1989)[44

]

Retro

spectiv

eautopsy

case-con

trol

study

USA

Janu

ary1958

and

Decem

ber

1987

Inclu

sioncriteria

:cases

were

inclu

dedforstudy

ifacute

pancreatitisw

asthe

immediateor

contrib

uting

causeo

fdeath

andthep

ortal

veno

ussyste

m(bothsplenic

andpo

rtalveins)was

exam

ined

completely

atautopsy.Ex

clusio

ncriteria

:patie

ntsw

eree

xcludedfro

mstu

dyifthereh

adbeen

asplenectom

yor

ifchronic

pancreatitisw

aspresent

microscop

ically.

AP

7211

NA

11NA

NA

20/52

Hofer

etal.

(1987)[45]

Prospective

study

USA

1975–1985

NA

CP50

11NA

11NA

50(13–75)

24/26

Roesch

etal.

(1981)[33]

Retro

spectiv

estu

dyGermany

NA

NA

CP531

27NA

27NA

42.5

49/482

Sibert(19

78)[34]

Retro

spectiv

estu

dyUK

NA

NA

HP

725

23

NA

NA

NA

McElro

yand

Chris

tiansen

(1972)[46

]

Retro

spectiv

estu

dyUSA

NA

NA

HP

265

32

NA

NA

NA

Gross(1958)

[7]

Prospective

study

USA

1956

NA

APor

CP125

2NA

11

49(6–75)

34/91

NA:the

data

areno

tavailable;AP:

acutepancreatitis;CP

:chron

icpancreatitis;HP:

hereditary

pancreatitis;AIP:autoimmun

epancreatitis;SV

T:splanchn

icvein

thrombo

sis;P

VT:

portalvein

thrombo

sis;SlpVT:

splenicv

einthrombo

sis;M

VT:

mesenteric

vein

thrombo

sis.



0.0 0.2 0.4 0.6 0.8

Combined 0.1457 (0.0607, 0.2592)

Raina et al. 2009 0.1538 (0.0436, 0.3487)

Huggett et al. 2011 0.1346 (0.0559, 0.2579)

0.2500 (0.0727, 0.5238)

Ishikawa et al. 2012 0.0185 (0.0005, 0.0989)

Suero et al. 2013 0.2400 (0.0936, 0.4513)


De Leon et al. 2012

(a)


0.0 0.2 0.4 0.6

Combined 0.20 (0.10, 0.33)

Raina et al. 2009 0.15 (0.04, 0.35)

0.25 (0.07, 0.52)


De Leon al. 2012

(b)

Figure 7: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in autoimmune pancreatitis (AIP). (b) Forest plotsshowing the prevalence of splenic vein thrombosis (SlpVT) in autoimmune pancreatitis (AIP).

3.2. Quality of the Included Studies. The involved countriesof all studies could be found. Interval of enrolment wasunavailable in ten of the 44 studies. Twenty-one studieshad no eligibility criteria; eight of the remaining 23 studieshad detailed inclusion and exclusion criteria. Demographicdata were completely recorded in nineteen studies. Thepancreatitis diagnostic criteria were not elaborate in ninestudies only with abstracts and one study with full-test.

3.3. Prevalence of SVT in Pancreatitis. A meta-analysis ofinvolved studiesmeeting eligibility criteria showed the preva-lence of SVT in patients with pancreatitis, ranging from 0.5%to 62.1% (Figure 2). A pooled prevalence was 13.6% (95%CI: 10.2%–17.4%) with a statistically significant heterogeneityamong studies (𝐼2 = 96.2%, 95% CI: 95.7%–96.6%, 𝑃 <0.001).

3.4. Prevalence of PVT, SplVT, and MVT in Pancreatitis. Sev-enteen studies reported the prevalence of PVT in patientswith pancreatitis, ranging from 0.2% to 62.1% (Figure 3(a)).A pooled prevalence was 6.2% (95% CI: 32.9%–10.7%) witha statistically significant heterogeneity among studies (𝐼2 =

97.1%, 95% CI: 96.6%–97.6%, 𝑃 < 0.001). The analysisof patients with SplVT in pancreatitis showed that theprevalence ranged from0.2% to 41.7% (Figure 3(b)). Apooledprevalencewas 11.2% (95%CI: 8.1%–14.7%)with a statisticallysignificant heterogeneity among studies (𝐼2 = 95.2%, 95% CI:94.4%–95.8%, 𝑃 < 0.001). Eleven studies were selected toanalyze the prevalence of MVT in pancreatitis, ranging from0.3% to 14% (Figure 3(c)). The pooled prevalence was 2.7%(95% CI: 1.4%–4.4%) and the heterogeneity remained (𝐼2 =89.3%, 95% CI: 83.2%–92.5%).

3.5. Prevalence of SVT in AP and CP. Eighteen studiesreported the prevalence of SVT in AP, ranging from 0.3% to62.1% (Figure 4(a)). The pooled prevalence was 16.6% (95%CI: 10.0%–24.5%) with a statistically significant heterogeneityamong studies (𝐼2 = 98%, 95% CI: 97.7%–98.2%, 𝑃 < 0.001).Nine studies reported the prevalence of PVT in AP, rangingfrom 0.3% to 62.1% (Figure 4(b)). The pooled prevalence was8.0% (95% CI: 2.4%–16.4%) with a statistically significantheterogeneity among studies (𝐼2 = 98.2%, 95% CI: 97.8%–98.5%, 𝑃 < 0.001). Fifteen studies reported the prevalenceof SplVT in AP, ranging from 1.2% to 20% (Figure 4(c)).



0.0 0.2 0.4 0.6 0.8Combined 0.169 (0.107, 0.242)

Sibert 1978 0.069 (0.023, 0.155)Roesch et al. 1981 0.051 (0.034, 0.073)

Nordback et al. 1989 0.005 (0.002, 0.010)Bernades et al. 1992 0.132 (0.093, 0.178)

Friess et al. 1997 0.053 (0.033, 0.080)Arotcarena et al. 1999 0.144 (0.114, 0.178)

Dörffel et al. 2000 0.238 (0.179, 0.305)0.325 (0.186, 0.491)

Makowiec et al. 2004 0.220 (0.162, 0.289)Keck et al. 2009 0.151 (0.085, 0.240)

Chooklin and Hranat 2009 0.200 (0.057, 0.437)Huggett et al. 2011 0.135 (0.056, 0.258)

Gonzelez et al. 2011 0.157 (0.099, 0.233)Rebours et al. 2012 0.345 (0.260, 0.437)

Vyas et al. 2012 0.253 (0.166, 0.357)0.250 (0.073, 0.524)

Sisman et al. 2012 0.172 (0.089, 0.287)0.106 (0.050, 0.192)

Suero et al. 2013 0.240 (0.094, 0.451)0.030 (0.010, 0.068)

Britton et al. 2014 0.621 (0.536, 0.700)Sisman et al. 2014 0.200 (0.111, 0.318)



Marra-Lopez et al. 2013

De Leon al. 2012


(a)


0.0 0.2 0.4 0.6 0.8

Combined 0.0846 (0.0163, 0.1990)0.0278 (0.0034, 0.0968)0.0016 (0.0002, 0.0057)0.0376 (0.0182, 0.0680)0.0582 (0.0294, 0.1017)0.0500 (0.0061, 0.1692)0.0787 (0.0384, 0.1400)0.1176 (0.0658, 0.1895)0.0298 (0.0097, 0.0681)0.6207 (0.5364, 0.6999)


Sibert 1978Nordback et al. 1989Bernades et al. 1992


Gonzelez et al. 2011Rebours et al. 2012

Britton et al. 2014Castineira-Alvarino et al. 2013


(b)


0.0 0.2 0.4 0.6 0.8

Combined 0.1352 (0.0756, 0.2086)0.0417 (0.0087, 0.1170)0.0508 (0.0338, 0.0731)0.0016 (0.0002, 0.0057)0.0827 (0.0526, 0.1225)0.1481 (0.1008, 0.2069)0.1750 (0.0734, 0.3278)0.2203 (0.1616, 0.2887)0.1505 (0.0848, 0.2397)0.2000 (0.0573, 0.4366)0.1102 (0.0616, 0.1780)0.3193 (0.2369, 0.4110)0.1379 (0.0734, 0.2285)0.2500 (0.0727, 0.5238)0.1719 (0.0890, 0.2868)0.1059 (0.0496, 0.1915)0.2000 (0.1110, 0.3177)


Sibert 1978Roesch et al. 1981

Nordback et al. 1989Bernades et al. 1992


Makowiec et al. 2004Keck et al. 2009

Chooklin and Hranat 2009Gonzelez et al. 2011Rebours et al. 2012

Vyas et al. 2012

Sisman et al. 2012

Sisman et al. 2014Marra-Lopez et al. 2013

De Leon al. 2012


(c)




0.0 0.1 0.2 0.3

Combined 0.0324 (0.0098, 0.0676)

0.0032 (0.0009, 0.0081)

0.0113 (0.0023, 0.0326)

0.0317 (0.0117, 0.0678)

0.1000 (0.0279, 0.2366)

0.0236 (0.0049, 0.0675)

0.0840 (0.0410, 0.1491)






Rebours et al. 2012


(d)

Figure 8: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in Europe. (b) Forest plots showing the prevalenceof portal vein thrombosis (PVT) in Europe. (c) Forest plots showing the prevalence of splenic vein thrombosis (SlpVT) in Europe. (d) Forestplots showing the prevalence of mesenteric vein thrombosis (MVT) in Europe.

The pooled prevalence was 10.4% (95% CI: 6.3%–15.3%) witha statistically significant heterogeneity among studies (𝐼2 =94.8%, 95% CI: 93.3%–95.8%, 𝑃 < 0.001). Eight studiesreported the prevalence of MVT in pancreatitis, rangingfrom 0.3% to 14.0% (Figure 4(d)). The pooled prevalencewas 2.6% (95% CI: 1.2%–4.5%) with a statistically significantheterogeneity among studies (𝐼2 = 90.4%, 95% CI: 83.9%–93.6%, 𝑃 < 0.001).

Twenty studies reported the prevalence of SVT in CP,ranging from 3% to 41.7% (Figure 5(a)). The pooled preva-lence was 11.6% (95% CI: 8.5%–15.1%) with a statisticallysignificant heterogeneity among studies (𝐼2 = 89.5%, 95% CI:85.6%–91.9%, 𝑃 < 0.001). Four studies reported the preva-lence of PVT in CP, ranging from 1.5% to 4% (Figure 5(b)).The pooled prevalence was 3.5% (95% CI: 2.3%–4.8%) andthere was no statistical heterogeneity between the two studies(𝐼2 = 0%, 95% CI: 0%–67.9%, 𝑃 = 0.5947). Thirteenstudies reported the prevalence of SplVT in CP, rangingfrom 1.5% to 41.7% (Figure 5(c)). The pooled prevalence was12.8% (95% CI: 8.7%–17.6%) with a statistically significantheterogeneity among studies (𝐼2 = 88.8%, 95% CI: 83%–91.9%, 𝑃 < 0.001). Two studies reported the prevalence ofMVT in pancreatitis, ranging from0.8% to 1.1% (Figure 5(d)).The pooled prevalence was 1.2% (95% CI: 0.4%–2.5%). Therewas no statistical heterogeneity between the two studies (𝑃 =0.8506).

3.6. Prevalence of SVT in HP and AIP. Only two studiesreported the prevalence of SVT in HP, ranging from 7% to19% (Figure 6(a)). The pooled prevalence was 12.2% (95%CI: 3.0%–26.5%) and there was no statistical heterogene-ity between the two studies (𝑃 = 0.0914). Two studiesreported the prevalence of PVT in HP, ranging from 2.8%to 11.5% (Figure 6(b)). The pooled prevalence was 6.6% (95%CI: 0.7%–17.8%) and there was no statistical heterogeneitybetween the two studies (𝑃 = 0.1056). Two studies reportedthe prevalence of SplVT in HP, ranging from 4.2% to 7.7%

(Figure 6(c)).Thepooled prevalencewas 5.8% (95%CI: 2.1%–11.2%) and there was no statistical heterogeneity between thetwo studies (𝑃 = 0.437). There was no data on the prevalenceof MVT in HP.

Five studies reported the prevalence of SVT in AIP, rang-ing from 1.9% to 25% (Figure 7(a)). The pooled prevalencewas 14.6% (95% CI: 6.1%–25.9%) and there was no statisticalheterogeneity between the two studies (𝐼2 = 71.4%, 95% CI:0%–86.7%, 𝑃 = 0.0074). Two studies reported the prevalenceof SplVT in AIP, ranging from 15% to 25% (Figure 7(b)).The pooled prevalence was 20.2% (95% CI: 9.8%–33.2%) andthere was no statistical heterogeneity between the two studies(𝑃 = 0.4388). Only one study reported that the prevalence ofPVT in AIP was 1.9%.There was no data on the prevalence ofMVT in AIP.

3.7. Prevalence of SVT in Pancreatitis in Different Continent.The involved countries of all studies could be divided intothree continents (Europe, America, andAsia).The incidencesof SVT in pancreatitis were different among three continents.In Europe, twenty-two studies reported the prevalence ofpancreatitis patients with SVT, ranging from 0.5% to 62.1%(Figure 8(a)). The pooled prevalence was 16.9% (95% CI:10.7%–24.2%) with a statistically significant heterogeneityamong studies (𝐼2 = 97%, 95% CI: 96.6%–97.4%, 𝑃 <0.001). Nine studies reported the prevalence of PVT inpancreatitis, ranging from 0.2% to 62.1% (Figure 8(b)). Thepooled prevalence was 8.5% (95% CI: 1.6%–19.9%) with astatistically significant heterogeneity among studies (𝐼2 =98.1%, 95% CI: 97.7%–98.4%). Sixteen studies reported theprevalence of SplVT in pancreatitis, ranging from 0.2% to31.9% (Figure 8(c)). The pooled prevalence was 13.5% (95%CI: 7.6%–20.9%) with a statistically significant heterogeneityamong studies (𝐼2 = 96.2%, 95% CI: 95.3%–96.8%, 𝑃 <0.001). Six studies reported the prevalence of MVT in pan-creatitis, ranging from 0.3% to 10% (Figure 8(d)). The pooledprevalence was 3.2% (95% CI: 1.0%–6.8%) with a statistically



0.0 0.2 0.4 0.6 0.8

Combined 0.115 (0.070, 0.168)Gross 1958 0.016 (0.002, 0.057)

McElroy and Christiansen 1972 0.192 (0.066, 0.394)Hofer et al. 1987 0.220 (0.115, 0.360)

Rogers and Klatt 1989 0.153 (0.079, 0.257)Sakorafas et al. 2000 0.070 (0.049, 0.097)

0.190 (0.118, 0.281)Pimentel et al. 2003 0.031 (0.004, 0.108)

0.460 (0.360, 0.563)Raina et al. 2009 0.154 (0.044, 0.349)

0.043 (0.032, 0.057)Shalimar et al. 2011 0.040 (0.018, 0.074)

Muddana et al. 2012 0.163 (0.120, 0.215)Harris et al. 2013 0.018 (0.013, 0.024)Easler et al. 2014 0.136 (0.087, 0.198)





(a)


0.0 0.1 0.2 0.3 0.4

Combined 0.0372 (0.0125, 0.0742)

0.1154 (0.0245, 0.3015)

0.1300 (0.0711, 0.2120)

0.0026 (0.0005, 0.0076)

Harris et al. 2013 0.0081 (0.0050, 0.0126)

Easler et al. 2014 0.0494 (0.0216, 0.0950)





(b)


0.0 0.1 0.2 0.3 0.4

Combined 0.0922 (0.0552, 0.1374)0.0080 (0.0002, 0.0438)0.0769 (0.0095, 0.2513)0.2200 (0.1153, 0.3596)0.1528 (0.0788, 0.2569)0.0702 (0.0491, 0.0968)0.1900 (0.1184, 0.2807)0.1900 (0.1184, 0.2807)0.1538 (0.0436, 0.3487)0.0251 (0.0169, 0.0359)0.0398 (0.0184, 0.0742)0.1394 (0.0991, 0.1886)0.0122 (0.0083, 0.0174)0.1173 (0.0721, 0.1771)


Gross 1958McElroy and Christiansen 1972

Hofer et al. 1987Rogers and Klatt 1989

Sakorafas et al. 2000

Raina et al. 2009

Shalimar et al. 2011Muddana et al. 2012

Harris et al. 2013Easler et al. 2014

Mortel e et al. 2004Mortel e et al. 2001


(c)




0.00 0.05 0.10 0.15 0.20 0.25

Combined 0.0239 (0.0074, 0.0495)

0.0080 (0.0002, 0.0438)

0.1400 (0.0787, 0.2237)

0.0035 (0.0009, 0.0088)

0.0069 (0.0040, 0.0111)

0.0370 (0.0137, 0.0789)


Gross 1958

Harris et al. 2013

Easler et al. 2014



(d)

Figure 9: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in America. (b) Forest plots showing the prevalence ofportal vein thrombosis (PVT) in America. (c) Forest plots showing the prevalence of splenic vein thrombosis (SlpVT) in America. (d) Forestplots showing the prevalence of mesenteric vein thrombosis (MVT) in America.

significant heterogeneity among studies (𝐼2 = 88.8%, 95% CI:77.4%–93.1%, 𝑃 < 0.001).

In America, fourteen studies reported the prevalence ofSVT in pancreatitis, ranging from 1.6% to 46% (Figure 9(a)).The pooled prevalence was 11.5% (95% CI: 7.0%–16.8%) witha statistically significant heterogeneity among studies (𝐼2 =95.7%, 95% CI: 94.6%–96.5%, 𝑃 < 0.001). Five studiesreported the prevalence of PVT in pancreatitis, ranging from0.3% to 13% (Figure 9(b)). The pooled prevalence was 3.7%(95% CI: 1.3%–7.4%) with a statistically significant hetero-geneity among studies (𝐼2 = 93.2%, 95% CI: 87.6%–95.6%,𝑃 < 0.001).Thirteen studies reported the prevalence of SplVTin pancreatitis, ranging from 0.8% to 22% (Figure 9(c)). Thepooled prevalence was 9.2% (95% CI: 5.5%–13.7%) with astatistically significant heterogeneity among studies (𝐼2 =94.8%, 95% CI: 93.2%–95.9%, 𝑃 < 0.001). Five studiesreported the prevalence of MVT in pancreatitis, rangingfrom 0.4% to 14% (Figure 9(d)). The pooled prevalence was2.4% (95% CI: 0.7%–5.0%) with a statistically significantheterogeneity among studies (𝐼2 = 91.7%, 95% CI: 83.6%–94.8%, 𝑃 < 0.001).

In Asia, eight studies reported the prevalence of SVTin pancreatitis, ranging from 1.4% to 41.7% (Figure 10(a)).The pooled prevalence was 8.5% (95% CI: 3.7%–15.1%) witha statistically significant heterogeneity among studies (𝐼2 =84.2%, 95% CI: 68.5%–90.3%, 𝑃 < 0.001). Two studiesreported the prevalence of PVT in pancreatitis, ranging from1.8% to 1.9% (Figure 10(b)). The pooled prevalence in twostudies was 2.3% (95% CI: 0.7%–4.6%). Six studies reportedthe prevalence of SplVT in pancreatitis, ranging from 1.4% to41.7% (Figure 10(c)). The pooled prevalence was 10.1% (95%CI: 3.6%–19.5%) with a statistically significant heterogeneityamong studies (𝐼2 = 87.8%, 95%CI: 74.5%–92.6%,𝑃 < 0.001).There was no data on the prevalence of MVT in pancreatitisin Asia.

4. Discussion

Theprevious publishedmeta-analysis that assessed the preva-lence of SVT in patients with pancreatitis almost focusedon AP, CP, HP, or AIP alone without systematic search.The prevalence varied from 1% to 24% in previous studiesaccording to the type of pancreatitis and imaging techniqueused (US, EUS, CT, MRI, or ERCP) [30, 40, 55]. However,our study was remarkably different from the previous ones, asfollows. (1) In the previous studies, most of them were single-center studies with a limited enrollment period and targetpopulation. By comparison, our meta-analysis included allstudies conducted from 1958 to 2014 and 10560 patientswith pancreatitis. Furthermore, we made a distinction on thesource of patients according to the continents. (2) As we haveknown, SVT involves PVT, SplVT, and MVT. In contrast tothe previous studies, we have paid more attention on theprevalence of PVT, SplVT, and MVT in pancreatitis. (3) Ourresearch reported the prevalence of SVT on the basis of thedifferent types of pancreatitis including AP, CP, HP, and AIP.However, there was no similar record in the previous studies.

Pancreatitis is associated with a variety of vascular com-plications including SVT. Clinically, SVT in pancreatitis isbecoming common with the advancement of imaging tech-nique. In the current systematic review andmeta-analysis, wedemonstrated that 13.6% of pancreatitis had SVT, 6.2% hadPVT, 11.2% had SplVT, and 2.7% had MVT. The prevalenceof SVT in pancreatitis showed some regional differences.We found that the prevalence of SVT in pancreatitis inEurope reached 16.9%, which was the highest among thethree continents. Moreover, the prevalence of PVT, SplVT,and MVT in pancreatitis in Europe was higher than thatin America or in Asia, respectively. We can find from theinvolved studies that the results came from nine countries ofEurope, which were more than those from four of Asia and



0.0 0.2 0.4 0.6 0.8

Combined 0.0854 (0.0370, 0.1513)Takase et al. 1997 0.4167 (0.1517, 0.7233)

Lin et al. 1997 0.0556 (0.0183, 0.1249)Tsushima et al. 1999 0.0400 (0.0010, 0.2035)

Agarwal et al. 2008 0.2166 (0.1549, 0.2893)Chowdhury et al. 2011 0.0548 (0.0151, 0.1344)

Ishikawa et al. 2012 0.0185 (0.0005, 0.0989)Jakchairoongruang and Arjhansiri 2013 0.0139 (0.0004, 0.0750)

Talukdar et al. 2014 0.0736 (0.0386, 0.1251)


(a)


0.00 0.02 0.04 0.06 0.08 0.10

Combined 0.0225 (0.0071, 0.0463)

Ishikawa et al.2012 0.0185 (0.0005, 0.0989)

Talukdar et al.2014 0.0184 (0.0038, 0.0528)


(b)


0.0 0.2 0.4 0.6 0.8

Combined 0.1011 (0.0357, 0.1946)

Takase et al. 1997 0.4167 (0.1517, 0.7233)

Lin et al. 1997 0.0556 (0.0183, 0.1249)

Tsushima et al. 1999 0.0400 (0.0010, 0.2035)

Agarwal et al. 2008 0.2166 (0.1549, 0.2893)

Jakchairoongruang and Arjhansiri 2013 0.0139 (0.0004, 0.0750)

Talukdar et al. 2014 0.0552 (0.0256, 0.1022)


(c)

Figure 10: (a) Forest plots showing the prevalence of splanchnic vein thrombosis (SVT) in Asia. (b) Forest plots showing the prevalence ofportal vein thrombosis (PVT) in Asia. (c) Forest plots showing the prevalence of splenic vein thrombosis (SlpVT) in Asia.

two of America. Compared with Asia, the prevalence of SVTin pancreatitis was 11.5% higher than that of 8.5% in Asia, butthe prevalence of SplVT was a little lower in America.

Previous studies that reported the vascular complica-tions of pancreatitis showed different prevalence of SVTin pancreatitis regardless of the type of pancreatitis. Thismeta-analysis demonstrated that the prevalence of SVT inAP was 16.6% higher than previous studies with a reportedincidence of 1-2% [1]. The reason was that previous studiestook PVT, SplVT, and MVT inclusion of SVT as numerator.

The controversy also exists about the prevalence of SplVT inCP. The old series reported that the prevalence of SplVT inpatients with CP varied between 2.5% and 25% [6, 51, 56, 57].Our results showed 12.8% CP with SplVT, which was similarto that from a recent report by Butler et al. [58]. However,there was no detailed description on the prevalence of SVT inHP and AIP. Our results showed that the prevalence of SVTwas 12.2% and 14.6% in HP and AIP, respectively. All of thesecould enrich the whole research on the prevalence of SVT inpancreatitis.


5. Limitation

Our study has several limitations. Firstly, the heterogeneityof available data from various years’ studies was significant.Depending on advanced imaging technique, the majorityof asymptomatic patients with SVT could be involved inresearch groups. Therefore, only the random-effects modelwas applied in our meta-analysis to generate a more conser-vative estimate of the proportion. Secondly, there are differentresults between Western and Asian countries. Besides thedifference in the population race, lifestyle, and diagnosticlevel, the number of countries involved in the research isdifferent. America included two countries and four countrieswere from Asia. Thirdly, there is no related research on theprevalence of SVT in HP and AIP. The final results may benot so typical.

6. Conclusion

This systematic review and meta-analysis attempt to quantifythe incidence of SVT in pancreatitis according to the differ-ent forms of pancreatitis and regional distribution. Furtherstudies are needed to analyze the relationship betweennaturalhistory, clinical significance, long-term outcomes, and theprevalence of SVT in pancreatitis. The rate of SVT associatedgastrointestinal bleeding and the security and reasonabilityof anticoagulation therapy on thrombosis are all neededto develop complete, large, multicentre, and collaborativestudies.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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