Analysis of Peripheral Blood Cells Due to Adults Posthepatitic Cirrhotic Portal Hypertension and Their Postoperative Prognosis

Patients with splenomegaly due to posthepatitic cirrhotic portal hypertension usually experience severe gastrointestinal hemorrhage, hypersplenism and hepatocarcinoma, and should receive surgical operations. Multiple factors influencing the postoperative prognosis exist [1], and peripheral cytopenias are one of these important factors. Peripheral cytopenias indicate that the blood cell count in blood sample from the peripheral vein is lower than normal, i.e., the leukocyte (WBC) count is <4.0×109/L, the erythrocyte (RBC) count is <4.0×1012/L or the platelet (PLT) count is <100×109/L when first got into the hospital. In this study, data were collected from 366 patients with splenomegaly due to posthepatitic cirrhotic portal hypertension from January 1993 to June 2013, and the constituent ratio of peripheral cytopenias and its influence on the postoperative prognosis were analyzed.

blood cell count increase and recovery, improvement in liver function, no severe postoperative complications, and meeting the criteria for being discharged from the hospital. On the other hand, dead meant that the patients died during hospitalization, or that the patients in critical condition died one week after early discharge from the hospital, as requested by the relatives. All others were considered improved. Comparison of the therapeutic effect between each mono-lineage cytopenia group is shown in Table 1. Comparison of the therapeutic effect between mono-lineage cytopenia and bi-lineage and comparisons of the therapeutic effect between the mono-lineage cytopenia and bi-lineage cytopenias, the mono-lineage cytopenia and multi-lineage cytopenias are shown in Tables 2 and 3, respectively.
The decrease in PLT was the major factor influencing the postoperative prognosis compared with decreases in WBC, RBC and HB (Table 4); in this case, there was significant difference (P<0.005), while decreases in WBC, RBC and HB showed no significant difference (P>0.05).

Discussion
In this study, approximately 10% of patients with splenomegaly due to posthepatitic cirrhotic portal hypertension had normal peripheral blood cell counts, while 90% had peripheral cytopenia [2], of which 70% had multi-lineage cytopenias and 30% had mono-lineage cytopenias. Table 1 shows that only the RBC group demonstrated a significant difference (P<0.05) in the intra-group comparison among the mono-lineage cytopenia groups. According to Tables 2 and 3, there were significant differences (P<0.05) in the therapeutic effects between mono-lineage cytopenias and multi-lineage cytopenias, indicating that the more severe the cytopenia, the worse the therapeutic results appeared to be.
For the multi-lineage cytopenias, a multiple linear regression analysis was applied, and results revealed that thrombocytopenia was the major factor (P<0.005) influencing the therapeutic effect, while leukopenia, erythropenia and decreased hemoglobin showed no statistical significance, and should not be considered. Erythropenia showed significant differences in the intra-group comparison of monolineage cytopenias, but no difference compared to other mono-lineage cytopenia groups. This was possibly due to the small sample size in the mono-lineage cytopenia groups. Leukopenia showed no significant difference in the univariate analysis or the multivariate analysis, and had no influence on the therapeutic results. For example, 2 patients recovered and were discharged from the hospital though their leukocyte count was lower than 1×10 9 /L; this may have been because they had no serious postoperative infection. Theoretically, anemia is related to the prognosis, but in this research it showed no statistical significance in the univariate analysis or the multivariate analysis; the reason for   this may have been because the blood transfusions before and during operation had a favorable effect on the blood condition. Although thrombocytopenia had no statistical significance in the univariate analysis, in the multiple linear regression analysis it was indicated to be the most important influential factor with the increase in case load.
Thrombocytopenia is a significant and common complication in posthepatitic cirrhotic portal hypertension [3,4]; it is related to not only retention of blood cell in the spleen, blood cell aggregation and enhanced phagocytosis of macrophages [5], but also HBV infection, and compensation and regulation of marrow [6]. Djordevic et al. [7,8]. Proposed that extreme thrombocytopenia was life-threatening. A PLT count of <30×10 9 /L can cause variceal hemorrhaging in the distal esophagus and gastric fundus, and intraoperative and postoperative massive wound hemorrhaging, which can be life-threatening. Therefore, PLT transfusions should be performed before an operation to increase the PLT count to 50×10 9 /L to ensure the safety of the patient. Cui et al. [9] reported that PLT transfusions combined with plasma fibrinogen transfusions led to better results. In some cases, after transfusion of 12-24 units of PLT, the PLT count did not increase obviously, or decreased to the previous lowest count after 1-2 days. These types of patients are suitable for splenectomy [10]. Mastuura et al. [11] suggested that the excessive postoperative PLT count was also a life-threatening factor, so the condition of the patient should be closely monitored [12,13] when there is excessive platelet count, appropriate treatment should be administrated immediately.
In 1907, Chauffard proposed the term 'hypersplenism' for the first time [14]. After further research, in 1949, Doan [15] proposed the criteria for hypersplenism: 1. enlarged spleen 2. mono-lineage or multi-lineage cytopenias 3. normal or proliferative bone marrow 4. disappearance of the pathological changes in the blood components after splenectomy. While these four criteria are indispensable for the diagnosis of hypersplenism, peripheral cytopenia and an increase and recovery in blood cell count after a splenectomy are the major criteria for assessing hypersplenism due to cirrhotic portal hypertension. This is because splenomegaly in itself is a necessary criterion for the cirrhotic portal hypertension.
Grading hypersplenism is very difficult as there are mono-lineage cytopenias, bilineage cytopenia or pancytopenia, and even in the pancytopenia; thus, it is difficult to meet the criteria for grading. On the other hand, there are many causes for cytopenias in cirrhotic portal hypertension; therefore, it is very difficult to identify which type of cytopenia is caused by hypersplenism preoperatively. Thus, only cytopenias can be graded. In the present study, the cases were scored and graded based on the accumulated scores. The scoring criteria used in this study were: 1. Analytical results of multiple linear regression: F value obtained from multiple linear regression equation was 7.993 (P<0.005), indicating that multiple linear regression was applicable. The equation Ŷ=1.395 + 0.151PLT indicated that thrombocytopenia was the major influential factor for postoperative prognosis. Therefore, according to the severity of the thrombocytopenia, 1 to 3 points was scored. 2. Intra-group comparison of erythropenia showed a significant difference (P<0.05), so an RBC count ≤ 3×10 12 /L was scored as 1 point. 3. According to clinical experience, leukopenia can cause severe infection and lead to undesirable effects. A WBC of count ≤ 2×10 9 /L was scored as 1 point, though leukopenia showed no statistical significance in either the univariate analysis or multivariate analysis. A total score of <2 points indicated mild cytopenia, 2-3 points indicated medium cytopenia and >3 points indicated severe cytopenia. If cytopenias are caused by hypersplenism, this grading standard could also be used for grading hypersplenism or as a reference [16].
Cytopenia grading could facilitate clinical practice in various aspects, including assessing the disease condition, representation and academic communication, communication with patients and their relatives to resolve or avoid medical disputes, choosing a suitable treatment plan (for example, splenectomy is suitable for severe cytopenia or hypersplenism) and taking preventive methods before an operation [16,17] to increase the curative rate.