Anticoagulation for Splanchnic Vein Thrombosis in Moderate-Severe Acute Pancreatitis: In-Hospital Outcomes from a Prospective Cohort Study.

Background: Splanchnic vein thrombosis (SVT) is a common complication of acute pancreatitis (AP), but the role of anticoagulation (AC) during acute hospitalization remains unclear. We aimed to evaluate the impact of in-hospital AC on SVT recanalization and bleeding risk. Methods: We conducted a single-center prospective cohort study (2023-2026) including patients with moderate-severe AP and CT-confirmed SVT. The primary outcome was SVT recanalization at discharge; secondary outcome was in-hospital bleeding complications. Results: Among the 258 included patients, 89 (34.5%) received AC. The median AC duration was 42 days (range 1-83). SVT recanalization did not differ between AC and non-AC groups (15.7% vs. 16.6%, p = 0.862). Bleeding risk was significantly higher with AC (27.0% vs. 9.5%, p < 0.001), driven predominantly by clinically significant hemoglobin decline (7.9% vs. 1.2%, p = 0.015), while major bleeding did not differ significantly between groups. Among the anticoagulated patients, those with recanalization had a higher rate of necrosectomy (78.6% vs. 53.3%, p = 0.080). Conclusions: In this observational cohort, in-hospital AC was not associated with improved short-term SVT recanalization but was associated with a higher incidence of bleeding complications, driven predominantly by clinically significant hemoglobin decline. These observations require confirmation in randomized trials.